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Power Point Presentation 428

  1. Students will provide an oral case presentation of an acute care patient case via video. Students should choose a patient with a cardiac or pulmonary disorder related to the weekly topics covered in Week 3. Students in a concurrent clinical course with a clinical site will present a patient case seen in the clinical setting. Students not placed in a clinical setting by Week 3 should email the instructor for a case assignment. Please use your WCU email address for all communications.
  2. The oral case presentation should follow the SOAP format:
    1. Visit type (H&P, progress note, or consult)
    2. The purpose of the visit (CC and HPI – use OLDCARTS)
    3. Pertinent histories (PMH, PSH, PFH, PSH, etc.)
    4. Medication and Allergies
    5. Pertinent Review of Systems (ROS)
    6. Vital Signs and pertinent physical exam elements
    7. Provide a differential dx of at least 3 diagnoses (2 differentials plus the working diagnosis)
    8. Final (Working) Diagnosis
    9. Treatment Plan
    10. Patient Education
    11. Disposition and Prognosis
    12. Oral assignments should include verbally articulated evidence-based guideline(s) used to prepare the oral presentation. (For example, the 2022 American Heart Association/American College of Cardiology/Heart Failure Society of America Guidelines for the management of Heart Failure were referenced to prepare this oral presentation).

*Please do not disclose or enter any patient-identifying information except the age/gender of the patient and visit type (H&P, progress note, or consult).

  1. Download the SOAP Note Template and fill it out based on this scenario to guide your oral presentation. No written submission is required for this assignment. (SOAP TEMPLATE ATTACHED TO USES AS A GUIDE)
  2. You will use the screen share setting to record yourself.
  3. The presentation should be no longer than 15 minutes.
  4. This is a video presentation. Review the instructions on how to export the presentation with your narration as a video.
  5. Review the rubric to ensure you address all assignment requirements.

Please see case study for the presentation

A 65 years old former garage mechanic presents with a chief complaint of increased shortness of breath and a change in the quantity and color of his sputum for the past week. The sputum is usually scant and clear. However, recently it has become yellow and continues all day. He has had trouble raising sputum in the past year. He has become progressively short of breath over the last five years. He is now dyspneic at rest. He denies asthma, childhood respiratory problems, allergies and any occupational exposures.

Physical Examination

Obvious respiratory distress with prominent use of accessory muscles.

Temperature 99.5; Blood pressure 140/90; pulse 110; respiratory rate 28.

Head/neck reveal distended neck veins throughout expiration.

Chest reveals increased A-P diameter; reduced chest wall excursion; lungs hyperresonant to percussion; diaphragms low and immobile; auscultation reveals a prolonged expiratory phase with diminished breath sounds and generalized rhonchi.

Heart reveals PMI in epigastrium; heart sounds distant with regular rhythm and no murmurs.

Extremities reveal trace pitting edema of the lower extremities.

Chest x-ray reveals hyperinflation of lungs with an increase in the retrosternal space; low, flattened diaphragms; hyperlucent lung fields with paucity of vascular markings in the periphery but prominent hila and narrow heart silhouette.

EKG reveals low voltage; right axis; peaked P waves and clockwise rotation.

Laboratory reveals WBC 8,500 with normal differential and Hgb 14.7 gm.

ABG’s:

PFT 0100 (RA) 0300 (2 LPM) 0800 (2 LPM) 0800 (RA)

Ph 7.38 7.37 7.42 7.42
Pa02 44 60 62 60
PaC02 58 63 44 36
HC03 (calc) 31 32 30 24
Normal: Ph 7.40+0.05; Pa02 80+10; PaC02 40+4; HCO2 24+2

Rubric

Video Case Presentation

CriteriaRatingsPts

This criterion is linked to a Learning OutcomeClinical Case Presentation

10 pts

Accomplished

Reports subjective and objective data in an organized and professional manner. Obtains all pertinent data with enough detail to be able to formulate correct diagnosis without extraneous data. Includes all important data (subjective or objective).

7.5 pts

Satisfactory

Reports and organizes subjective and objective data in a professional manner that is mainly focused. Obtains most pertinent data with enough detail to be able to formulate correct diagnosis. May collect a few pieces of extraneous data. Misses no important data (subjective or objective).

5 pts

Needs Improvement

Reports subjective and objective data in a manner that is less organized or professional and less focused. Obtains data that are mostly pertinent with enough detail to be able to formulate correct diagnosis. May collect many pieces of extraneous data. Misses one or two pieces of important data (subjective or objective).

2.5 pts

Unsatisfactory

Fails to report subjective and objective data in an organized, professional manner or is not focused. Collects data that does not enable the student to formulate the correct diagnosis. May collect many pieces of extraneous data. Misses significant amounts of important data (subjective or objective) or performs tasks and skills incorrectly.

10 pts

This criterion is linked to a Learning OutcomeClinical Reasoning, Problem-Solving, and Management Skills

30 pts

Accomplished

Synthesizes subjective and objective information in a logical manner and formulates the correct diagnosis and plan that addresses each diagnosis, appropriate dx tests, treatments, pt. education, and referrals. Oral presentation reflects incorporation of current standards of care.

22.5 pts

Satisfactory

Synthesizes subjective and objective in a logical manner and formulates the correct diagnosis and plan that addresses each diagnosis. Plan may be missing one or two minor components from the dx tests, tx, pt. ed, referral or health maintenance). Consults resources (e.g. preceptor & reference materials) appropriately.

15 pts

Needs Improvement

Synthesizes subjective and objective in a manner that leads to an incorrect dx but the differential is correct. Plan fails to address each diagnosis and may be missing two or three minor components from the dx tests, tx, pt. ed, referral or health maintenance). Consults resources (e.g. preceptor & reference materials) appropriately.

7.5 pts

Unsatisfactory

Unable to synthesize subjective and objective data in a manner that leads to correct diagnosis or differential. Plan does not address the diagnosis or may be missing significant components. Does not consult resources (preceptor or references appropriately.

30 pts

This criterion is linked to a Learning OutcomeOrganization and Time Management

10 pts

Accomplished

Oral presentation of patient encounter is well organized and flows. Prognosis and disposition are included. Case presentation is presented within 15 minutes.

7.5 pts

Satisfactory

Patient encounter is mostly organized as far as flow and time management is somewhat well managed. Prognosis and disposition are included. Case presentation is presented within 20 minutes.

5 pts

Needs Improvement

Patient encounter is less organized and does not flow. Prognosis or disposition are missing. Time is not managed well. Case is presented within 25 minutes.

2.6 pts

Unsatisfactory

Patient encounter does not flow and is not organized. Prognosis and disposition are missing. Time is not managed well. Case presentation exceeds 25 minutes.

10 pts

Total Points: 50