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MichiganStateUniversityCollegeofHumanMedicineClinicalSkillsOralCasePresentationProtocol

Oralcasepresentationsvaryaccordingtothepurposeofthepresentation,theaudience,the

settingand

the

amount

of

time

allotted.

Do

not

just

read

awritten

H&P

or

SOAP

note.

Try

to

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.htm

1. Introduction:Theintroductionsetsthestagebybrieflysummarizing:i. Whothepatientis(age,gender,sometimesmajordiseasesoroccupation)ii. Whytheycamein(thechiefcomplaintand/orotherhealthissuesaddressedat

thevisit)

iii. Brieftimecourse(usingeitherdateofonsetordayspriortopresentation)iv. Sourceofthehistoryandreliability(onlyincludedifunabletoobtainadequate

historyfrom

the

patient)

Hereareafewexamples:

i. "Mrs.Oliverisa48yearoldwomanwhowaswelluntilJuly2whenshedevelopedfatigue,diarrhea,andheadache.Thesourceofthehistoryisthe

patient,whosereliabilityisquestionableduetosomeconfusion,andoldhospital

records."

ii. "Mr.Witherspoonisa69yearoldmanwithseverebrittletypeIIDiabetesMellituswhopresentedtotheemergencydepartmentcomplainingof

approximately

12

hours

of

confusion.

The

source

of

the

history

is

the

patient's

niece,whoiswithhim,andoldhospitalrecords."

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2. HistoryofPresentIllness(HPI)A. Describethechronologicalaccountofeventssincetheonsetoftheproblem.

Providesignificantdetailsofsymptoms,includingsymptomdimensions(PPQRST)as

appropriate.

B. Includepertinentpositivesandnegativesonly. Thismayincludeinformationfromanyportionofthehistory,i.e.,pastmedicalorsurgicalhistory,medications,

allergies,familyorsocialhistory,andreviewofsystems,thatmayrelatetothe

specificdiagnostichypothesesyouareconsidering.

3. PastMedicalHistory(PMH)A. ChronicDiseasesB. SignificantmedicalillnessesC. HospitalizationsD. SurgeriesE. HealthMaintenance

4. Medications5. Allergies6. SocialHistory(SOCIALHX)7. FamilyHistory(FAMHX)8. ReviewofSystems(ROS)9. PhysicalExamination

A. GeneralappearanceB. VitalsignsC. Fortherestoftheexamination,includepertinentpositives(abnormalfindings)

andnegatives(normalfindingsthatrelatetothedifferentialdiagnosis)only.

10.DiagnosticData(testresults,usuallylaboratoryandradiology)11.Assessment(usuallyadifferentialdiagnosis,thatis,alistofpossiblediagnoses)12.Plan