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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