Case Presentation
For this activity, we will focus on presenting patients in addition to assessing clinical reasoning. Students will select a patient from the clinical setting that presents with a complaint consistent with the topical content for the course week.
Presentations need to follow SOAP format with reflections. Address the following:
Subjective (S) =chief complaint or reason patient presented for treatment with pertinent historical information including PMH, Medication, Allergies, PSH, SH, and ROS.
Objective (O) =exam findings relevant to the chief complaint or reason for a visit including any diagnostic tests [labs or imaging] done at the point of care.
- Assessment (A) = most probable diagnosis includes at least 2 differential diagnoses for the acute problem [new problem] and status of any chronic conditions listed in order of priority.
- Plan (P) =include all appropriate treatment as well as a written prescription and management of all diagnoses addressed during the visit including patient education, health promotion, and disease prevention [age appropriate].
- Document the current CPT billing codes for an office visit (level of service) and testing conducted during the office visit.
- Reflections- what did you learn, and would you do anything differently (if any).
- Limit presentation to 5-7 minutes and PowerPoint is limited to 5 slides [one for each item to address excluding title and reference slide].
- All items should be addressed in your presentation.
Expert Solution Preview
Introduction:
In this assignment, students will be required to present a patient case using the SOAP format and reflect on their clinical reasoning. The goal is to assess their ability to gather relevant subjective and objective information, provide an accurate assessment, develop a comprehensive treatment plan, and document the appropriate billing codes. The presentation should be concise, limited to 5-7 minutes, and supported by a PowerPoint with 5 slides.
Answer:
Subjective (S):
The subjective section of the patient presentation should include the patient’s chief complaint, any relevant historical information, and details regarding their past medical history (PMH), medication use, allergies, past surgical history (PSH), social history (SH), and review of systems (ROS). Students should gather all subjective information to provide a comprehensive understanding of the patient’s current condition.
Objective (O):
The objective section of the presentation should include the examination findings that are relevant to the patient’s chief complaint or reason for the visit. This may include vital signs, physical examination findings, and any diagnostic tests (labs or imaging) that were conducted during the visit. Students should focus on presenting objective data that supports their assessment and eventual diagnosis.
Assessment (A):
In the assessment section, students should provide the most probable diagnosis for the patient’s acute problem, along with at least two differential diagnoses. They should also address the status of any chronic conditions the patient may have, listing them in order of priority. The assessment should be based on the information gathered from the subjective and objective sections.
Plan (P):
The plan section should include all appropriate treatments for the patient’s current condition, as well as a written prescription if necessary. Students should also address the management of any chronic conditions that were identified. Additionally, the plan should incorporate patient education, health promotion, and disease prevention strategies that are age-appropriate. Students should ensure that their plan encompasses all the diagnoses and concerns discussed during the visit.
Document the CPT billing codes:
Students should accurately document the current CPT billing codes for the office visit, including the level of service provided, as well as any testing conducted during the visit. This is an essential aspect of proper medical documentation and billing.
Reflections:
In the reflections section, students should describe what they have learned from the patient case and the presentation experience. They should reflect on their clinical reasoning process, identify any areas for improvement, and consider what they would do differently if faced with a similar case in the future. This section allows for self-assessment and growth as medical professionals.
Conclusion:
This assignment aims to develop students’ skills in patient presentations, clinical reasoning, treatment planning, and medical documentation. By following the SOAP format and addressing all the components outlined in the instructions, students will gain practical experience in formulating comprehensive patient cases and delivering effective presentations.
