What do you think is going on based on the clinical case scenario?

***EXAMPLE Powerpoint attached, please use it for template***

CLINICAL CASE SCENARIO
A 5-year-old male patient presents to your clinic for ear pain. His mother reports he was in good spirits and energetic until about 5 days ago when he developed an upper respiratory infection (URI) consisting of clear nasal discharge and cough. The mother reports that he has been lethargic and stopped drinking fluids about 48 hours before he developed a temperature of 102.1°F and started complaining that his right ear hurt. The mother denies nausea, vomiting, diarrhea, headache, or change in urine output. The mother reports that the patient’s sleep was interrupted due to his complaints of right ear pain. She noticed that he tugged at his right ear frequently while remaining minimally interested in playing with his toys earlier in the day. Today, his vitals are as follows: weight 40.5 lbs, height 43.0 inches, BP 100/70, HR 100, RR 26, and Temperature is 102F.

Diagnosis: Acute Otitis Media (Right ear)

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 POWERPOINT ATTACHED FOR GUIDANCE.

SUBJECTIVE (S): Describes what the patient reports about their condition.
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.
Patient Profile: Activities of Daily Living (age-appropriate): (include feeding, sleeping, bathing, dressing, chores, etc.), Changes in daycare/school/after-school care, Sports/physical activity, and Developmental History: (provide a history of development over the child’s lifespan. If a child is 1y/o or younger, provide birth history also)
HRB (Health-related behaviors):
ROS (Review of Systems): Asking about problems by organ system systematically from head-to-toe. Included classic associated symptoms (this includes pertinent negatives and positives).

OBJECTIVE: Physical findings you observe or find on the exam.
1. Age, gender, general appearance
2. Vitals – HR, BP, RR, Temp, BMI, Height & Percentile; Weight & Percentile, Include the Growth Chart
3. Physical Exam: note pertinent positives and negatives (refer to the textbook for classic findings related to present complaint and the diagnosis you believe the patient has)
4. Lab Section – what results do you have?
5. Studies/Radiology/Pap Results Section – what results do you have?

RISK FACTORS: List risk factors for the acute and chronic conditions

ASSESSMENT: What do you think is going on based on the clinical case scenario? This is based on the case. You are to list the acute diagnosis and three differential diagnoses, in order of what is likely, possible, and unlikely (include supporting information that helped you to arrive at these differentials). You must include the ICD-10 codes, the definition for the acute and differential diagnoses, and the pertinent positives and negatives of each diagnosis.
You are to also list any chronic conditions with the ICD-10 codes.

NATIONAL CLINICAL GUIDELINES: List the guidelines you will use to guide your treatment and management plan

TREATMENT & MANAGEMENT PLAN: Number problems (E.g. 1. HTN, 2. DM, 3. Knee sprain), use bullet points, and include A – F below for each diagnosis and G – H after you’ve addressed all conditions.

***Once again, please follow example powerpoint attached as a template-set slides up the same way***

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