Oral Case Presentation Benchmarks, Lecture notes of Surgical Pathology

Download Oral Case Presentation Benchmarks and more Lecture notes Surgical Pathology in PDF only on Docsity! Oral Case Presentation Benchmarks _____ _ On completion of Foundations of Clinical Medicine, students should be able to perform an accurate, complete and well organized comprehensive oral case presentation for a new clinic or hospital patient, and adapt the case presentation to the clinical setting. A comprehensive OCP includes these sections: Identifying information & chief concern Name & age Known medical problems highly relevant to the chief concern (< 4) Chief concern and duration of symptoms History of present illness Background: Health at the time of symptom onset and details of any chronic illness directly related to the chief concern. Details of the presenting problem: Beginning at symptom onset and proceeding sequentially. Predisposing conditions & risk factors Pertinent negatives Optional: Hospital course or evaluation to date Past medical history All active medical problems and any other problems relevant to evaluation or ongoing management. Summarize for each major, active problem: diagnosis, current treatment, control, and complications Medications & allergies Prescribed medications and doses Non-prescription medications and complementary therapies Drug allergies and the type of reaction Habits and risk factors Substance use not already covered in HPI Social history Summary of social influences on your patient’s health and health care: living situation, social support, occupation and avocation, any financial or other concerns Physical exam General appearance and vital signs Name each organ system in order and report all pertinent exam findings, both normal and abnormal:  Comprehensive exam of system(s) relevant to chief concern  Other findings (normal or abnormal) that will help your listener answer a clinical question Report all abnormal findings Summary statement Restate the ID, and summarize the key features from the history and exam Assessment Format determined by clinical context Plan Format determined by clinical context PURPOSE AND FORMAT OF EACH SECTION The purpose of the oral case presentation is: • To concisely communicate the findings of your history and exam to other members of your team • To formulate and address the clinical questions important to your patient's care Identifying Information and Chief Concern (ID/CC) Purpose: Sets the stage and gives a brief synopsis of the patient’s major problem. Format: -Identify the patient by name and age -Include no more than four medical problems (sometimes there are zero) that are highly relevant to the chief concern. List only the diagnoses here, and elaborate on them in the HPI or PMH. -Report the chief concern and duration of symptoms Template: “Mr. _____ is a ____ year-old man with a history of _______ who presents with  _______ of ______ duration.” Example: “Mr. T is a 32 year old man with Crohn's disease who presents with bloody diarrhea of 3 days duration.” History of Present Illness (HPI) Purpose: Provides a complete account of the presenting problem, including information from the past medical history, family history and social history related to that problem. Format: The HPI should occupy 1/3 to 1/2 of your total presentation time.  The content of the HPI in the oral case presentation is the same as the HPI in the write up. Template: A 5-paragraph format is one common structure for the HPI. Use this structure for your case presentations for patients seen in college tutorials. Your preceptors may ask you to adapt this structure in different clinical contexts. Paragraph 1: Background Characterize the patient’s health at the time current symptoms began. If the presenting concern is related to a chronic illness, give a brief summary of the illness, including when it was diagnosed, treatment, complications, and how well it is controlled. Example: “Mr. T was in his usual state of good health, with well controlled Crohn's disease, until three days prior to admission. He was first diagnosed with Crohn's in 2011, when he presented with diarrhea, abdominal pain, and weight loss. He was treated with steroids and then infliximab, and his symptoms have been well controlled, with one to two bowel movements per day. He had had no recent flares or hospitalizations before this week." Report all pertinent physical examination findings, both normal and abnormal:  Complete exam of the organ system(s) relevant to the chief concern  Other findings (normal or abnormal) that help your listener answer a clinical question. Use concise but complete descriptions of positive findings. Report all abnormal findings regardless of organ system. If the examination of a system NOT relevant to the chief concern was normal, you may say “Normal”. 8. Summary Statement: The first sentences of your assessment Purpose: To synthesize the important history and exam findings, to frame the clinical problem and to lead your listener into your assessment. This is NOT simply a restatement of the ID chief concern. Format: Restate the identifying data and summarize the key features from the patient's history and physical exam. Template: “In, summary, NAME is a AGE year old man who presents with a history of PRESENTING CONCERN (REFINED WITH SEMANTIC QUALIFIERS) AND MAJOR ASSOCIATED SYMPTOMS. His history is notable for ELEMENTS OF THE HPI, PREDISPOSING CONDITIONS AND RISK FACTORS THAT IMPACT YOUR ASSESSMENT. Physical exam is notable for KEY FINDINGS, NORMAL AND ABNORMAL, THAT IMPACT YOUR ASSESSMENT. 9. Assessment Purpose: Address the clinical problem(s) important in this encounter, and demonstrate your clinical reasoning. The clinical problem may range from a new and undiagnosed problem to routine follow-up of a chronic problem. Format: Format may vary based on type of problem. For example: 1. An undiagnosed problem. Your assessment would address the top 3-4 items on the differential diagnosis suggested by your patient’s history and exam findings. Example: The most likely reason for Lily’s rash is eczema. Her skin dryness and pruritis, and her family history of atopy are all consistent with eczema, as is the history of worsening in the winter and after frequent swimming. She also has a classic distribution on the hands and elbow creases. A less likely possibility is scabies, which frequently affects the hands. However, Lily’s skin between the wrists and elbows is spared, which would be atypical for scabies. 2. An exacerbation of a chronic problem. Your assessment would address the most likely reasons for the exacerbation, as suggested by your patient’s history and exam findings. Example: The most likely reason for Mr. C’s CHF exacerbation is medication non- adherence due to both costs and confusion. He reports filling his medications less often than monthly because even the co-pay is expensive, which is confirmed by his pharmacy. Although he manages his own medications, he is unable to accurately describe what each is for, or his dosing schedule. A second possibility is new ischemia; however, he’s had no chest pain or tightness, and initial ECG and enzymes were negative. Finally, a URI could have precipitated this exacerbation, as he had low grade fever, cough, and rhinorrhea last week. However, those symptoms have resolved as his edema and shortness of breath have progressed, making this possibility less likely. 3. Routine follow-up of a chronic problem. Your assessment would address current control of the problem, evidence of complications, and adequacy of current education and treatment. Example: Ms. B’s type 2 diabetes is well controlled, with most recent HgbA1c of 6.8. She reports excellent adherence to diet and exercise, as well as metformin. She has no evidence of retinopathy or neuropathy on exam and urine for microalbumin was negative. 10. Plan Purpose: To outline your next steps in addressing your patient’s clinical problem(s). Format: The plan is usually presented as a bulleted list, and may include interventions in these categories: Diagnostic evaluation Lab tests Imaging Consultation with specialists Therapy Behavior change Medications Counseling Referral to another provider (e.g. physical therapy) Monitoring and follow-up Repeat laboratory tests to monitor response to treatment Routine screening tests Primary care clinic follow-up Education Education about diagnoses done by you Referral to other providers for additional teaching, e.g. diabetes educator, pharmacist Adapting The Comprehensive OCP To Other Contexts Example #1: An outpatient presenting for routine follow-up of a known problem S: Subjective ID/CC: Include ‘scheduled follow up for’ and list problem(s) as well as any additional issues identified during agenda setting. HPI: Start with a brief synopsis of the problem that the patient is being seen for:  Diagnosis  Current treatment  Control  Complications  When the patient was last seen in clinic Status of the known problem since the last visit:  Symptoms/control  Intervening problems  Pertinent positive/negative symptoms PMH: Brief synopsis of other ongoing medical problems Medications and allergies Any changes in PMH/FH/SH since the last visit O: Objective Physical Exam  Vital signs  General appearance  Exam of the pertinent systems ONLY A: Assessment: Start with your summary statement Address current control of the problem(s), evidence of complications, and adequacy of current education and treatment. P: Plan