Patient Case Presentation Inpatient OSU Internal Medicine 1.

The patient case should be presented using the following format. This should be typewritten and is expected to be handed in. The presentation should not be merely read from the handout, but more of a story telling approach. The patient case should take no longer than 10-1 minutes. Chief Complaint !r"s# $$$$$$$$$$$$$$$$$ is a $$$$$$ year old $$$$$$$ $$$$$$$ who "initials# "age# "race# "sex# %resented to the hospital with a chief complaint of $$$$$$$$$$$$$$$$$$$$$$$. The Chief Complaint is a brief statement of the why the patient sought medical attention, stated in the patients own words. No medical term or diagnosis is used. History of Present Illness The HPI is amore complete description of the patients symptoms(s . !eneral features included in the HPI are" #ate of onset Precise location Nature of onset, se$erity, and duration %ffect of any treatment #egree of interference with daily acti$ities

Past Medical History The P&H includes serious illness, chronic diseases, surgical procedures, and in'uries the patient has e(perienced. &inor complaints may be omitted. Family History The )H includes the age and health of parents, siblings, and children. *ges and cause of death should be recorded for deceased relati$es. +nly include data that is pertinent to the patient case. Social History The ,H included not only the social characteristics of the patient, but also the en$ironmental factors and beha$iors that may contribute to the de$elopment of disease. Items included are marital status, number of children, educational bac-ground, occupation, dietary habits, use of tobacco, alcohol, or other drugs. Medication History The &H should include current medications prior to admission. This includes prescription and non.prescription medications. Include name and dosing information for each. Allergies *llergies to drugs, foods, pets and en$ironmental factors should be included. *n accurate description of the reaction that occurred should be presented.

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Review of Systems and Physical !am In the /+,, the e(aminer 0uestions the patient about the presence of symptoms that are pertinent to each body system. +nly the pertinent positi$e and negati$e findings may be recorded. The general sections for the P% are listed below. It is only necessary to list the findings that are 1remar-able.2 !eneral appearance 3ital signs ,-in 4ungs Cardio$ascular *bdomen !enital5/ectal %(tremities Neurological H%%NT"head, eyes, ears, nose, throat Admission "a#s The results of lab tests should be recorded. )or handout purposes, these may be listed in table form. 4ist all lab results but comment only on those that are abnormal or pertinent to the case. Admitting Impressions 6ased on the abo$e information, what are the admitting impressions5problems5diseases. #e$elop a problem list according to the acuity and significance of the patients conditions. Hospital Co$rse Pro$ide a detailed but concise description of the patients hospital course. This can be done in a day.to.day format or by each problem. 6e sure to include pertinent changes in medications, lab $alues, symptoms, etc. Case S$mmary Pro$ide a brief summary of the chief complaint and the treatment pro$ided. 4ist other problems associated with hospitali7ation (no details '. (fter the patient presentation, the student should be prepared to discuss all aspects of the patient case. )mphasis will be placed on the understanding of the drug therapy for each problem and de*eloping clinical +udgment with respect to optimal drug therapy. ,. The student should be prepared to gi*e a 1 -'0 minute re*iew-discussion of the ma+or problem-disease-reason for admission. ( complete understanding of each problem-disease state is expected. .. The student should e*aluate the rele*ant primary literature and apply the information to the patient-problem. (t least 1-' primary literature references should be included in each case discussion. . ( typewritten handout is re/uired for each component of number ', ,, and . abo*e.

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