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)
