8/13/2019 Medicine - Lab Coat Pockets

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Oral Presentation Guidelines Framing statementChief concern/ ID / One Liner

o This is a 60 year old F with a history of (up to 3 relevant things) whopresents [from where? If relevant] with shortness of breath, admitted for

CHF exacerbation

HPI(includerelevantROS, PMHx, etc. here)o Baseline/ USOHdescribe status of PMH items from CCo Now: pt was in this state until ___ ago, when they developed ____

Past Historyo 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 FamHxo SocHxincl. functional status(ADLs / IADLs) and cognitive status

ROS(relevant)Physical Exam

o Vital Signs(with ranges as needed)o General Appearancegive a good descriptive picture of the patiento Rest of exam by system

Labs / Data: CBC, BMPCMP, LFTs, U/A, micro, Imaging (simple complex)o Group related (e.g. WBC & diff, Hbg / MCV, Na/Cl/bicarb & AG

Assessment / Plano Summary: CC + p/w SOB, found to have (hx, PE, Data), admittedo Problem #1 -_______

Subjective / Objectivebrief summary to set up for Assessment

If Dx unknown: 2-3 item DDx; most likely, reasoning If Dx known: assess if better, worse, same

Plan: Workup(for each item on DDx) Treatment plan

o Problem #2 - _______o For problems, remember social issues, functional status, dispo

The follow-up presentation:

1. 8-10 word headlinereminder of who the patient is (or one-liner)2. Problem list

a. Problem #1: _______i. Overnight events / updatesii. Current PE

iii. Assessment / Planb. Problem #2: _______

The Interview, Clinical Reasoning, DDx

Start by getting a full list of concerns Frame the situationwhats important Keep a running DDx / questions to ask / PE exam maneuvers to do

o VITAMIN Co Most commono Worst-case scenario

VITAMIN C:

Vascular Infection Trauma Autoimmune Metabolic / Medications Idiopathic Neoplastic Congenital