Purpose Learner-centered approach to case presentation Allows the student to take an active role Designed to develop the ability to organize patient information in a meaningful way Guide the stu dent in their oral patient presentations in the clinical S ummarize N arrow A nalyze P robe P lan S elec...
This template should only be used to organize your oral presentation, IT SHOULD NOT BE
SUBMITTED.
SUMMARIZE
Using a patient seen in the practicum setting, summarize the H&P into an organized and
concise format. The presentation should be a maximum of 5-7min.
Hi, my name is Annie. For my SNAPPS presentation I will be discussing diarrhea.
CC
HPI statement 32-year-old obese Hispanic female presents with a chief complaint of
using diarrhea and concerns for recurrent C-diff and possible pregnancy. She
OLDCARTS does report that one of her 3 children had the same GI symptoms a week
data or two ago but no one else around her has been sick. She denies recent
travel, changes in diet, antibiotic use, or exposure to unfiltered water. She
is sexually active and does not desire any more children. Because of her
nausea she has skipped a pill or two out of her birth control pack but
doubled up the next day. Her last menstrual period was one month ago and
states she is due to start her period anytime. She does report dysuria x 1
episode yesterday
O — onset of the acute symptoms of N/V, diarrhea, and fever was on
Sunday which is 6 days ago as the appointment was on Friday
L — location is all over her abdomen, but the upper abdomen is worse
D — some of the symptoms are intermittent (like the diarrhea) and some
are consistent like the malaise and nausea
C — on Sunday the characteristics included upset stomach, nausea, and
fever. On Monday she had an upset stomach, nausea, and diarrhea.
Vomiting stopped on Wednesday. On Thursday and today (Friday) she had
soft bowel movements with mucus in it. The mucus is her biggest concern
because she had C-diff in the past with mucus.
A — aggravating factors include eating and standing up for too long
R — she cannot identify any factors that relieve the symptoms
T — treatments she has tried include tums and Pepto-Bismol with no effect
S — the severity has lessened. At the beginning of the illness she was
unable to take care of her children at all and spent most of her time in the
bathroom. Now she is able to get herself to the doctor by herself.
Pertinent ROS Constitutional: No current fever, chills, or body aches
Respiratory & Cardiovascular: No symptoms
Gastrointestinal: per the history of present illness and note that she has had her gall
bladder removed but still has her appendix.
Genitourinary: per the history of present illness
Hematology/Lymphatics: No swollen lymph glands
Neurologic: No headache.
Pertinent PE Vitals & Measurements
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