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    Medicine - Lab Coat Pockets

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    skeebs23
    The document provides guidelines for oral patient presentations, including framing the case with a one-liner introduction, presenting the history of present illness and relevant medical history, examining the patient and reporting relevant findings, considering differentials, assessments, and treatment plans. Key elements are an opening statement, problem list, interview and clinical reasoning, past history, exam, labs/imaging, assessment and plan.

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    Medicine - Lab Coat Pockets

    Uploaded by

    skeebs23
    141 views1 page
    The document provides guidelines for oral patient presentations, including framing the case with a one-liner introduction, presenting the history of present illness and relevant medical history, examining the patient and reporting relevant findings, considering differentials, assessments, and treatment plans. Key elements are an opening statement, problem list, interview and clinical reasoning, past history, exam, labs/imaging, assessment and plan.

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    For the wards

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    The document provides guidelines for oral patient presentations, including framing the case with a one-liner introduction, presenting the history of present illness and relevant medical history, examining the patient and reporting relevant findings, considering differentials, assessments, and treatment plans. Key elements are an opening statement, problem list, interview and clinical reasoning, past history, exam, labs/imaging, assessment and plan.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    141 views1 page

    Medicine - Lab Coat Pockets

    Uploaded by

    skeebs23
    The document provides guidelines for oral patient presentations, including framing the case with a one-liner introduction, presenting the history of present illness and relevant medical history, examining the patient and reporting relevant findings, considering differentials, assessments, and treatment plans. Key elements are an opening statement, problem list, interview and clinical reasoning, past history, exam, labs/imaging, assessment and plan.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    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 whats 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

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