Case Study and Evidence-Based Guideline Presentations

With approval from the faculty, the student will select a patient to present in class.  The student will create a recorded PowerPoint presentation and post the presentation in he discussion board.  Presentations should be about 15 – 20 minutes long.  The student will include discussion question/s for the class to respond to.

Students should present a case study in a SOAP format (see guide).  Topics for presentation should include:

  • Annual visit – Health promotion and screening
  • Patients with low severity problem; with no comorbidities or uncomplicated comorbidities.  Examples of disease conditions:
  • Dermatology disorders
  • ENT disorders
  • Lung disorders: acute bronchitis
  • CV Disorders: HTN, hyperlipidemia
  • Endocrine: Thyroid disorders
  • Neuro: headaches, migraine
  • MS: back pain, OA
  • GU: UTI, STD

Subjective

Chief Complaint (CC). The opening statement should give an overview of the patient, age, sex, reason for visit and the duration of the complaint.  If the patient has a history of a major medical problem that bears strongly on the understanding of the present illness, include it.  

History of Present Illness (HPI). Present the most important problem first. If there is more than one problem, treat each separately. Present the information chronologically.  Cover one system before going onto the next. Characterize the chief complaint – quality, severity, location, duration, progression, and include pertinent negatives.

Review of Systems (ROS). Include only the pertinent systems.  Most of the ROS is incorporated in the HPI.

Past Medical and Surgical History (PM/SH). Discuss other past medical history that bears directly on the current medical problem.  

Allergies/Medications. Present all current medications along with dosage, route and frequency.

Social/Work History. Smoking, alcohol and recreational drug use.  Home, environment, work status and sexual history (if pertinent).  

Family History.  Note particular family history of genetically based diseases.  

Objective

Physical Exam. Include a focused assessment.  Include all significant abnormal findings and any normal findings that contribute to the diagnosis.

Labs/Other Tests. Review laboratory or diagnostic tests done with results.

Assessment

Working Diagnosis/Differential Diagnoses.

Provide a summary of the important aspects of the history, physical exam, lab/diagnostic tests and formulate the differential diagnoses and working diagnosis.

Plan

Discuss the actual management of the patient including pharmacologic and non- pharmacologic management.  Discuss the follow up plan for the patient, if necessary.

Clinical Guidelines Discussion

  1. Review the classic presentation and key findings in the physical exam in patients with this diagnosis, including what your patient may not have exhibited.
  2.  Identify and discuss the latest guideline for the diagnosis. 
  3. What are the appropriate tests to make the diagnosis (if applicable)? If not done, discuss why.
  4. Based on guidelines, was the treatment appropriate? Are there any other treatment options?  If the patient was not treated based on the guidelines, what was the rationale? 
  5. Identify the “red flags” for this diagnosis.
  6. Provide 5 certification type question related to the diagnosis.  Provide a rationale for the answers.

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