In this foundational talk. Dr. Zaafran discusses the case presentation and the components of an effective clinical communication.

The following topics are discussed

Case Presentation

1. Timing
2. Reciting the case
3. Using the notes

Module Overview

• Chief complaint
• History of the present illness
• Past medical history
• Medications
• Medication allergies
• Social history
• Family history
• Review of systems (specify only pertinent positive and negative findings) • Physical Exam
• Labs and Tests
• Assessment and Plan

Physical Examination

• Vitals (Be sure to write 24 hour ranges) • Blood Pressure
  • Heart Rate
  • Respiratory Rate
  • O2 Saturation • Temperature • Pain (+/-)

• Generalized

• Focused

• General- Normal Appearance vs. lethargic, disheveled

• HEENT- PEERLA

• Chest- nl d1, s2 RRR no m/r/g

• Lungs- CTA B

• Abdomen- soft, non distended, bowel sounds regular on ascultation • Extremties- no edema, lesions, breaks, etc.

• Neuro- A & O x 4 (Person, place, time, situation) CN II-XII intact

Laboratory Results and Studies

Assessment and Plan

Cases