Week 6: Online Class Activity 2
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Case Presentation
For this activity we will focus on presenting patients in addition to assessing clinical reasoning. Students will select a patient from the clinical setting that presents with a complaint consistent with the topical content for the course week.
Presentations need to follow SOAP format with reflections. Address the following:
- Subjective (S) =chief complaint or reason patient presented for treatment with pertinent historical information including PMH, Medication, Allergies, PSH, SH, and ROS.
- Objective (O) =exam findings relevant to chief complaint or reason for visit including any diagnostic tests [labs or imaging] done at the point of care.
- Assessment (A) = most probable diagnosis include at least 2 differential diagnoses for acute problem [new problem] and status of any chronic conditions listed in order of priority.
- Plan (P) =include all appropriate treatment as well as a written prescription and management of all diagnoses addressed during visit including patient education, health promotion and disease prevention [age appropriate].
- Document the current CPT billing codes for an office visit (level of service) and testing conducted during the office visit.
- Reflections- what did you learn, and would you do anything differently (if any)
Expert Solution Preview
The case presentation activity requires students to select a patient from a clinical setting and present their case using the SOAP format, along with reflections. The SOAP format includes subjective, objective, assessment, and plan sections, as well as documentation of billing codes. Here is an example of how a student could answer each part of the activity:
1. Subjective (S): The patient presented with a chief complaint of chest pain. Relevant historical information includes a past medical history (PMH) of hypertension, a medication history including lisinopril for blood pressure control, allergies to penicillin, a surgical history (PSH) of appendectomy, social history (SH) of being a smoker, and a review of systems (ROS) that reveals no other concerning symptoms.
2. Objective (O): On physical examination, the patient’s vital signs were stable, with a blood pressure of 120/80 mmHg, heart rate of 80 beats per minute, and oxygen saturation of 98%. Auscultation of the chest revealed normal heart sounds and clear lung fields bilaterally. EKG was done at the point of care and showed sinus rhythm without any ST-segment changes.
3. Assessment (A): The most probable diagnosis for this patient’s acute problem of chest pain is stable angina. Differential diagnoses to consider include gastroesophageal reflux disease (GERD) and musculoskeletal chest pain. For chronic conditions, the patient’s hypertension is the only listed condition, which is stable and currently well-controlled.
4. Plan (P): The appropriate treatment for stable angina includes lifestyle modifications, such as smoking cessation and diet changes, as well as medication management with nitroglycerin for symptom relief and beta-blockers for long-term control. A written prescription for nitroglycerin and guidance on its use will be provided to the patient. In terms of disease prevention, the patient will be educated on the importance of blood pressure control and the need for regular follow-up.
5. CPT billing codes for an office visit and testing conducted during the office visit would depend on the complexity and level of service provided. For example, an office visit may be coded as CPT 99213 (Level 3) for a low to moderate complexity visit. Additional codes for testing, such as an EKG, would be assigned based on the specific procedures performed.
6. Reflections: Through this case presentation, I have learned about the importance of considering both acute and chronic conditions when evaluating a patient’s complaint. I have also gained a better understanding of the management approach for stable angina, including lifestyle modifications and medication therapy. If I had the opportunity to do anything differently, I would perhaps explore further differential diagnoses to ensure thorough consideration of all possibilities.
By following the SOAP format and addressing each section of the case presentation activity, students will be able to effectively present their patient’s case and demonstrate their clinical reasoning skills.
