CLINICAL CASE SCENARIO
A 4-year-old boy presents to your clinic with a 2-day history of runny nose, productive cough, and wheezing. His mother reports that he had a fever and decreased appetite today. He has no known cardiorespiratory disease, and his immunizations are current. His two younger siblings are recovering from “chest colds.” His physical examination is remarkable for congested nares; clear rhinorrhea, coarse breath sounds in all lung fields and bibasilar end-expiratory wheezes. Today, his vitals are as follows: weight 36 lbs, height 40.3 inches, BP 120/76, HR 100, RR 24, and his temperature is 103.2 F.
Diagnosis – Pneumonia
As you develop your narrated PowerPoint, be sure to address the criteria discussed in the video above and the instructions listed below:
FOLLOW THE TEMPLATE BELOW for the Clinical Case Report – SOAP PowerPoint Assignment:
DO NOT INCLUDE THESE INSTRUCTIONS IN THE POWERPOINT. POINTS WILL BE DEDUCTED. REFER TO THE EXAMPLE CASE REPORT FOR GUIDANCE.
SUBJECTIVE (S): Describes what the patient reports about their condition. For INITIAL visits gather the info below from the clinical scenario and the textbook. DO NOT COPY AND PASTE THE SCENARIO; EXTRACT THE RELEVANT INFORMATION.
Historian (required; unless the patient is 16 y/o and older): document name and relationship of guardian Patient’s Initials + CC (Identification and Chief Complaint): E.g. 6-year-old female here for evaluation of a palmar rash HPI (History of Present Illness): Remember OLD CAARTS (onset, location, duration, character, aggravating/alleviating factors, radiation, temporal association, severity) written in paragraph form PMH (Past Medical History): List any past or present medical conditions, surgeries, or other medical interventions the patient has had. Specify what year they took place MEDs: List prescription medications the patient is taking. Include dosage and frequency if known. Inquire and document any over-the-counter, herbal, or traditional remedies. Allergies: List any allergies the patient has and indicate the reaction. e.g. Medications (tetracycline-> shortness of breath), foods, tape, iodine->rash FH (Family History): List relevant health history of immediate family: grandparents, parents, siblings, or children. e.g. Inquire about any cardiovascular disease, HTN, DM, cancer, or any lung, liver, renal disease, etc… SHx (Social history): document parent’s work (current), educational level, living situation (renting, homeless, owner), substance use/abuse (alcohol, tobacco, marijuana, illicit drugs), firearms in-home, relationship status (married, single, divorced, widowed), number of children in the home (in SF or abroad), how recently pt immigrated to the US and from what country of origin (if applicable), the gender of sexual partners, # of partners in last 6 mo, vaginal/anal/oral, protected/unprotected.