Students will provide an oral case presentation of an acute care patient case via video.
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.
The oral case presentation should follow the SOAP format:
Visit type (H&P, progress note, or consult)
The purpose of the visit (CC and HPI – use OLDCARTS)
Pertinent histories (PMH, PSH, PFH, PSH, etc.)
Medication and Allergies
Pertinent Review of Systems (ROS)
Vital Signs and pertinent physical exam elements
Provide a differential dx of at least 3 diagnoses (2 differentials plus the working diagnosis)
Final (Working) Diagnosis
Treatment Plan
Patient Education
Disposition and Prognosis
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).
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)
You will use the screen share setting to record yourself.
The presentation should be no longer than 15 minutes.
This is a video presentation. Review the instructions on how to export the presentation with your narration as a video.
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
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