8/14/2019 Oral Case Presentation Protocol
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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."
8/14/2019 Oral Case Presentation Protocol
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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