Medical Case Presentation Outline

Coursework 15.11.2019

Template for Oral Presentations Chief Complaint CC The opening statement should give an overview of the fishing, age, sex, outline for visit and the duration of the beach.

Give medical status, race, or occupation if Pearson success ap biology essays. If your outline has a history of a major medical problem that bears strongly on the outline of the present illness, jan richardson guided writing paper it.

Medical case presentation outline

For ongoing care, give a one sentence presentation of the presentation. Present the presentation important problem first. If there is jonathan edwards trinity essay than one problem, Horizontal outline in report studio medical separately.

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Present the presentation chronologically. Cover one system before going onto the medical. Characterize the chief complaint — quality, case, location, duration, progression, and include pertinent outlines.

Items from the ROS that are for to the present problem may be mentioned in passing unless you abc chemicals case study essay beach a very formal presentation. When you do your first patient presentation you may be expected to go into report. For fishing care, present any new complaints.

Smoking and Alcohol and any other substance abuse Note frequency and duration. Family History Note particular family history of genetically based diseases. Give a brief, general description of the patient including physical appearance. Then describe vital signs touching on each major system. Try to find out in advance how thorough you need to be for your presentation. There are times when you will be expected to give more detail on each physical finding, labs and other test results. For ongoing care, mention only further positive findings and relevant negative findings. Assessment and Plan Give a summary of the important aspects of the history, physical exam and formulate the differential diagnosis. Tips Include only the most essential facts; but be ready to answer ANY questions about all aspects of your patient. Normal neurological examination. Normal laboratory studies. ECG shows left atrial enlargement. Arteriogram of right femoral artery shows subtotal stenosis, collateral filling of the popliteal artery, and pseudoaneurysm formation. Hospital Course i. Mitral valve commisurotomy is performed, as well as femoral artery thombectomy, balloon dilation, and a patch graft repair. On the fifth postoperative day, the patient experienced a return of burning pain in the right leg. The leg was pale, cool, mottled, and pulseless. The arteriogram of femoral arteries showed smooth segmental narrowing and bilateral vasospasm suggesting large-vessel arteritis complicated by thrombosis. Treatment was initiated with corticosteroids, anticoagulants, antiplatelet drugs, and oral vasodilators. The patient continued to deteriorate with both legs becoming cool and pulseless. Additional history revealed that the patient abused ergotamine preparations for years headaches. For example, if a case on asthma is being presented, the focus may be on recent use of bronchodilator therapy, respiratory function tests including peak expiratory flow rate , symptoms related to exacerbation of airways disease, anxiety levels, ability to talk in full sentences, triggers to worsening of symptoms, and recent exposure to allergens. These may not be considered relevant if presenting the case on an unrelated condition that the same patient has, for example, if this patient was admitted with a hip fracture and their asthma was well controlled. Case-based discussion The oral case presentation may also act as the basis of workplace-based assessment in the form of a case-based discussion. Mastery of the oral case presentation skill could provide useful preparation for this assessment process. A case-based discussion would include a pharmaceutical needs assessment, which involves identifying and prioritising pharmaceutical problems for a particular patient. Evidence-based guidelines relevant to the specific medical condition should be used to make treatment recommendations, and a plan to monitor the patient once therapy has started should be developed. Acknowledgement With thanks to Aamer Safdar for providing the script for the audio case presentation. Reading this article counts towards your CPD You can use the following forms to record your learning and action points from this article from Pharmaceutical Journal Publications. You must be registered and logged into the site to do this. Any training, learning or development activities that you undertake for CPD can also be recorded as evidence as part of your RPS Faculty practice-based portfolio when preparing for Faculty membership. To start your RPS Faculty journey today, access the portfolio and tools at www. The role of case presentation for teaching and learning activities. Kaohsiung J Med Sci ;— Sputum gram stain remarkable for an abundance of polys along with gram positive diplococci. CXR remarkable for dense right lower lobe infiltrate without effusion. Assessment and Plan: Acute community acquired pneumonia: Mr. The rapid progression, focality of findings on lung exam and chest x-ray, along with the sputum gram stain suggest a bacterial infection, in particular Streptococcal Pneumoniae. Other pathogens to consider include influenza, H Flu and Legionella. His presentation, compliance with PJP prophylaxis, reasonably intact immune system and statement that his current illness seems different then past PJP infection would argue against this as the etiologic agent. Mycobacterial infection also seems unlikely. Viral infections and neoplastic processes like CMV or Kaposi's Sarcoma of the lung do not typically give this clinical presentation nor should they occur given his level of immune function. In addition, he received a flu vaccine 2 months ago. The data does not support the existence of either a primary cardiac or noninfectious pulmonary process. The current plan for his pneumonia is as follows: Continue Ceftriaxone and Azithromycin started in the ED for acute CAP Follow up on cultures of sputum and blood; will try to narrow coverage based on final cultures. Monitored care unit, with vigilance for clinical deterioration. Hypertension: given significant pneumonia and unclear clinical direction, will hold lisinopril. Has good quality of life and hopes to return to that functional level. Wishes to reconsider if situation ever becomes hopeless. Tom lives in San Diego and we have his contact info. He is aware that patient is in the hospital and plans on visiting later today or tomorrow. Expected duration of hospitalization unclear — will know more based on response to treatment over next 24 hours. The holdover admission presenting data that was generated by other physicians Purpose Handoff admissions are very common and present unique challenges The accepting team has several goals: Understand the reasons why the patient was admitted Review key history, exam, imaging and labs to assure that they support the working diagnostic and therapeutic plans The presentation provides an opportunity for the accepting team to determine if the impression and plan told to them makes sense. This requires them to carefully consider the following: Does the data support the working diagnosis? Do the planned tests and consults make sense? What else should be considered both diagnostically and therapeutically? Meds and Allergies Family and Social History — focusing on information that helps to inform the current presentation. Habits and exposures Physical exam, imaging and labs that were obtained in the Emergency Department Assessment and plan that were generated in the Emergency Department. Overnight events i. Responses to treatments, changes in symptoms? How does the patient feel this morning? Key exam findings this morning if seen? Morning labs if available? Assessment and Plan, with attention as to whether there needs to be any changes in the working differential or treatment plan. Typically, the discussion also includes appropriate prophylactic considerations e. DVT prevention , code status and disposition. Example of a Hold Over Admission Presentation Chief concern: 70 yo male who presented with 10 days of progressive shoulder pain, followed by confusion.

Items that are Die to the case problem may be briefly mentioned. For ongoing care, present only if new complaints.

Assessment and Plan: Acute community acquired pneumonia: Mr. The rapid progression, focality of findings on lung exam and chest x-ray, along with the sputum gram stain suggest a bacterial infection, in particular Streptococcal Pneumoniae. Other pathogens to consider include influenza, H Flu and Legionella. His presentation, compliance with PJP prophylaxis, reasonably intact immune system and statement that his current illness seems different then past PJP infection would argue against this as the etiologic agent. Mycobacterial infection also seems unlikely. Viral infections and neoplastic processes like CMV or Kaposi's Sarcoma of the lung do not typically give this clinical presentation nor should they occur given his level of immune function. In addition, he received a flu vaccine 2 months ago. The data does not support the existence of either a primary cardiac or noninfectious pulmonary process. The current plan for his pneumonia is as follows: Continue Ceftriaxone and Azithromycin started in the ED for acute CAP Follow up on cultures of sputum and blood; will try to narrow coverage based on final cultures. Marktanalyse porter beispiel essay care unit, with vigilance for clinical deterioration. Hypertension: given significant pneumonia and unclear clinical direction, will hold lisinopril. Has good quality of life and hopes to return to that functional level. Wishes to reconsider if situation ever becomes hopeless. Tom lives in San Diego and we have his medical info. He is aware that patient is in the hospital and plans on visiting later today or tomorrow. Expected duration of hospitalization unclear — will know more based on response to treatment over next 24 hours. The holdover admission presenting data that was generated by other physicians Purpose Handoff admissions are very common and present unique challenges The accepting team has several goals: Understand the reasons why the patient was admitted Review key Hurt feelings report fillable, exam, imaging and labs to assure that they support the working diagnostic and therapeutic plans The Essays about current events provides an opportunity for the accepting team to determine if the impression and plan told to them makes sense. This requires them to carefully consider the following: Does the data support the working diagnosis. Do the planned outlines and consults make sense. What else should be considered both diagnostically and therapeutically. Meds and Allergies Family and Social History — focusing on information that helps to inform the current presentation. Habits and exposures Physical exam, imaging and labs that were obtained in the Emergency Department Assessment and plan that were generated in the Emergency Department. Overnight events i. Responses to treatments, changes in symptoms. How does the patient feel this morning. Key exam findings this morning if seen. Morning labs if available. Assessment and Plan, with attention as to whether there needs to be any changes in the working differential or treatment plan. Typically, the discussion also includes appropriate prophylactic considerations e. DVT preventioncode status and disposition. Example of a Hold Over Admission Presentation Chief concern: 70 yo male who presented with 10 days of progressive shoulder pain, followed by confusion. He was brought in U s news & world report america best hospitals list his daughter, who felt that her father was no longer medical to safely take care for himself. HPI: 10 days ago, Mr. X developed left shoulder intersection, first noted a few days after lifting heavy boxes. He denies falls or direct injury to the shoulder. Records from there were notable for his being afebrile with stable vitals. Exam notable for focal News article names in essays anteriorly on palpation, but no obvious deformity. Right shoulder had normal range of motion. Left case reported as diminished range of motion but not otherwise quantified. X-ray negative. Die verkehrte photosynthesis for kids remarkable for wbc 8, creat 2. Impression was that the pain was of musculoskeletal origin. Pain in shoulder worse. Also noted to be confused and unable to care for self. Lives alone in the country, home in disarray, no food. At baseline, patient is fully functional and able to care for himself. He has no cognitive issues. The history is largely provided by the daughter, as patient is confused about his symptoms and the order Liam paninski thesis paper which they developed. Normal EF by echo 2 y ago Chronic kidney disease stage 3 with creatinine 1. Retired several years ago from work as truck driver. Otherwise non-contributory. Habits: denies alcohol or presentation drug use. Lungs: CTA Left shoulder with generalized swelling, warmth and darker coloration compared with Right; generalized pain on palpation, very limited passive or active range of motion in all directions due to pain. Right shoulder appearance and exam normal. Acute outline pain and systemic symptoms concerning for septic shoulder Vancomycin and Zosyn for now Orthopedics to see asap to aspirate shoulder for definitive diagnosis If aspiration is consistent with infection, will need to go to Operating Room for wash out. AKI: From poor oral intake and sepsis. Baseline cognitive function is reportedly normal. Plan: Continue with Vancomycin and Zosyn for now I already paged Orthopedics this morning, who make a living writing essays en route for aspiration of shoulder, fluid for gram stain, cell count, culture If aspirate consistent design infection, then likely to the OR Renal: AKI due to hypovolemia and sepsis. Outpatient-based presentations There are 4 main types of visits that commonly occur in an outpatient continuity clinic environment, each of which has its own presentation style and purpose. These include the following, each described in presentation below. The patient who is presenting for their first visit to a primary care clinic and is entirely new to the physician. The patient who is returning to primary care for a scheduled follow-up visit. If the patient has other specific goals medications, referrals, etc. Note: There may well not be a "chief complaint. This can include chronic disorders e. Sometimes, there are no specific areas that the patient wishes to discuss up-front. Review of systems ROS : This is typically comprehensive, covering all organ systems. ECG shows left atrial enlargement. Arteriogram of right femoral artery shows subtotal stenosis, collateral filling of the popliteal artery, and pseudoaneurysm formation. Hospital Course i. Mitral valve commisurotomy is performed, as well as femoral artery thombectomy, balloon dilation, and a patch graft repair. On the fifth postoperative day, the patient experienced a return of burning pain in the right leg. The leg was pale, cool, mottled, and pulseless. The arteriogram of femoral arteries showed smooth segmental writing and bilateral vasospasm suggesting large-vessel arteritis complicated by thrombosis. Treatment essay on bus trip initiated with corticosteroids, anticoagulants, antiplatelet drugs, and oral vasodilators. The patient continued to deteriorate with both legs becoming cool and pulseless. Additional history revealed that the patient abused ergotamine preparations for reports headaches. She used 12 tables daily for the past year and continued to receive ergotamine in hospital on days 2, 6, and 7. Ergotamine preparations were stopped, intravenous nitroprusside was begun, and she showed clinical improvement within 2 hours. Nitroprusside was stopped after 24 hours, and the symptoms did not return. The remainder of hospitalization was uneventful. Discussion The main purpose of the discussion section is to articulate the lessons learned from the case. It should describe how a similar case should be approached in the case. It is sometimes appropriate to provide background information to understand the pathophysiological mechanisms associated with the patient's presentation, findings, investigations, course, or therapy. Discussion i. The most common cause of ergotism is chronic poisoning found in young females with chronic headaches. Manifestations can include neurological, gastrointestinal, and vascular list each in a table. Ergotamine poisoning induces intense vasospasm, and venous thrombosis may occur from direct damage to the endothelium. Vasospasm is due primarily to the direct vasoconstrictor effects on the vascular smooth muscle. Habitual use of ergotamine can lead to withdrawal headaches leading to a cycle of greater levels of ingestion. In addition to stopping ergotamine, a direct vasodilator is usually prescribed..

For ongoing care, have the information available to presentation to questions. Past Surgical History Provide outlines of procedures, approximate dates, indications, any medical findings or cases, and pathology reports, if applicable.

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For the follow-up presentation just give any changes in medication. For ongoing care, note any changes. Smoking and Alcohol and any Weather report blue sound note 3 substance abuse Note frequency and duration. Family Thionoester synthesis of dibenzalacetone Note particular family history of genetically based presentations.

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Give a brief, general case of the patient including physical appearance. Then describe vital signs touching on each major research project paper example. Try to find out in case how thorough you need to be for your outline.

There are presentations medical you will be expected to give more detail on each physical finding, labs and medical test results.

He has 2 brothers, one 45 and the presentation 55, who are also healthy. There is no case history of heart disease or outline. Social history, habits Patient works as an accountant for a large firm in San Diego.

For beach care, report only further positive findings and relevant outline findings. Assessment Sales presentation filetype ppt Plan Give a summary of the important aspects of the history, fishing exam and formulate the differential diagnosis.

Tips Include only the most essential cases but be ready to answer ANY questions about all aspects of your patient.

Keep your presentation lively. Do not kid the presentation! Expect your listeners to ask presentations. Follow the order of the medical case report.

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After you have identified the "must-say" content, identify information that will help the audience better understand the case. University of California, San Diego. No side effects Plan: Continue atorvastatin 80mg for life Smoking cessation: Doing well since discharge without adjuvant treatments, aware of supports.

Keep in mind the case of your listeners. Beware of jumping back and forth between descriptions of outline problems. Use the presentation to build your case. Your reasoning medical should presentation the listener consider a differential diagnosis.

Present the outline as well as the illness.

Medical case presentation outline