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  • Oral Case Presentation Protocol

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    This document provides a protocol for presenting clinical cases orally. It recommends including: 1) An introduction with the patient's name, age, gender, chief complaint and timeline. 2) A history of present illness detailing symptoms and their progression. 3) Relevant portions of the patient's past medical, medication, allergy and social histories. 4) Physical exam findings pertinent to the differential diagnosis. 5) Diagnostic test results and assessment, including a differential diagnosis.

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    This document provides a protocol for presenting clinical cases orally. It recommends including: 1) An introduction with the patient's name, age, gender, chief complaint and timeline. 2) A history of present illness detailing symptoms and their progression. 3) Relevant portions of the patient's past medical, medication, allergy and social histories. 4) Physical exam findings pertinent to the differential diagnosis. 5) Diagnostic test results and assessment, including a differential diagnosis.

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    50 views2 pages

    Oral Case Presentation Protocol

    Uploaded by

    merediss
    This document provides a protocol for presenting clinical cases orally. It recommends including: 1) An introduction with the patient's name, age, gender, chief complaint and timeline. 2) A history of present illness detailing symptoms and their progression. 3) Relevant portions of the patient's past medical, medication, allergy and social histories. 4) Physical exam findings pertinent to the differential diagnosis. 5) Diagnostic test results and assessment, including a differential diagnosis.

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    MichiganStateUniversityCollegeofHumanMedicine ClinicalSkillsOralCasePresentationProtocol Oralcasepresentationsvaryaccordingtothepurposeofthepresentation,theaudience,the settingandtheamountoftimeallotted.DonotjustreadawrittenH&PorSOAPnote.Tryto includeonlytheinformationthatisrelevanttotheassessmentandplan,realizingthatasa preclinicalstudentyoumaynotknowwhatinformationismostrelevantandwhatinformation issuperfluous.Youmayleaveoutsubsectionsthatdonotcontainanyinformationthatis relevanttotheassessment.However,alwayspresentthehistory,physicalexamination, diagnosticdataifavailable,assessment,andplan. Thisprotocolincludesthecontentareasusuallyincludedinanoralcasepresentationfora patientwhoisnewlyadmittedtothehospitalorseenforthefirsttimeintheoffice.Case presentationsonroundsinthehospitalwouldgenerallybemuchshorterandincludeabrief summaryofthepatient'shistoryfollowedbynewinformationobtainedinthelast24hours.For furtherguidanceandexamples,referto:Smith,pp.227233and APracticalGuidetoClinicalMedicine,athttp://meded.ucsd.edu/clinicalmed/oral.

    al.htm 1. Introduction:Theintroductionsetsthestagebybrieflysummarizing: i. Whothepatientis(age,gender,sometimesmajordiseasesoroccupation) ii. Whytheycamein(thechiefcomplaintand/orotherhealthissuesaddressedat thevisit) iii. Brieftimecourse(usingeitherdateofonsetordayspriortopresentation) iv. Sourceofthehistoryandreliability(onlyincludedifunabletoobtainadequate historyfromthepatient) Hereareafewexamples: i. "Mrs.Oliverisa48yearoldwomanwhowaswelluntilJuly2whenshe developedfatigue,diarrhea,andheadache.Thesourceofthehistoryisthe patient,whosereliabilityisquestionableduetosomeconfusion,andoldhospital records." ii. "Mr.Witherspoonisa69yearoldmanwithseverebrittletypeIIDiabetes Mellituswhopresentedtotheemergencydepartmentcomplainingof approximately12hoursofconfusion.Thesourceofthehistoryisthepatient's niece,whoiswithhim,andoldhospitalrecords."

    2. HistoryofPresentIllness(HPI) A. Describethechronologicalaccountofeventssincetheonsetoftheproblem. Providesignificantdetailsofsymptoms,includingsymptomdimensions(PPQRST)as appropriate. B. Includepertinentpositivesandnegativesonly.Thismayincludeinformationfrom anyportionofthehistory,i.e.,pastmedicalorsurgicalhistory,medications, allergies,familyorsocialhistory,andreviewofsystems,thatmayrelatetothe specificdiagnostichypothesesyouareconsidering. 3. PastMedicalHistory(PMH) A. ChronicDiseases B. Significantmedicalillnesses C. Hospitalizations D. Surgeries E. HealthMaintenance 4. Medications 5. Allergies 6. SocialHistory(SOCIALHX) 7. FamilyHistory(FAMHX) 8. ReviewofSystems(ROS) 9. PhysicalExamination A. Generalappearance B. Vitalsigns C. Fortherestoftheexamination,includepertinentpositives(abnormalfindings) andnegatives(normalfindingsthatrelatetothedifferentialdiagnosis)only. 10. DiagnosticData(testresults,usuallylaboratoryandradiology) 11. Assessment(usuallyadifferentialdiagnosis,thatis,alistofpossiblediagnoses) 12. Plan

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