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Oral Presentation Guidelines

 “Framing statement”  Chief concern / ID / “One Liner”
o “This is a 60 year old F with a history of (up to 3 relevant things) who presents [from where? If relevant] with shortness of breath, admitted for CHF exacerbation”

 HPI (include relevant ROS, PMHx, etc. here)
o o Baseline / USOH – describe status of PMH items from CC Now: pt was in this state until ___ ago, when they developed ____

The follow-up presentation: 1. 8-10 word “headline” – reminder of who the patient is (or one-liner) 2. Problem list a. “Problem #1: _______” i. Overnight events / updates ii. Current PE iii. Assessment / Plan b. “Problem #2: _______”

The Interview, Clinical Reasoning, DDx
   Start by getting a “full” list of concerns Frame the situation – what’s important Keep a running DDx / questions to ask / PE exam maneuvers to do o VITAMIN C o Most common o Worst-case scenario

 Past History o PMHx / PSurgHx
List new items; give state / severity (last FEV1, uses 2L O2 for COPD) For writeup; list previously mentioned items w/o description too o Meds (doses, indications, etc) o Allergies / Intolerance (describe rxn)  

o FamHx o SocHx – incl. functional status (ADLs / IADLs) and cognitive status  ROS (relevant)  “Physical Exam” o Vital Signs (with ranges as needed) o General Appearance – give a good descriptive picture of the patient o Rest of exam by system  Labs / Data: CBC, BMP CMP, LFTs, U/A, micro,  Imaging (simple  complex)
o Group related (e.g. WBC & diff, Hbg / MCV, Na/Cl/bicarb & AG

VITAMIN C:  Vascular  Infection  Trauma  Autoimmune  Metabolic / Medications  Idiopathic  Neoplastic  Congenital

 “Assessment / Plan” o Summary: CC + “p/w SOB, found to have (hx, PE, Data), admitted…” o “Problem #1 - _______”  Subjective / Objective – brief summary to set up for…  Assessment
  If Dx unknown: 2-3 item DDx; most likely, reasoning If Dx known: assess if better, worse, same Workup (for each item on DDx) Treatment plan

 Plan:
 

o “Problem #2 - _______” o For problems, remember social issues, functional status, dispo