To prepare:

• Review this week’s Learning Resources and consider the insights they provide. Also review the Kaltura Media Uploader resource provided via the Help button located in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
• Select a patient from your clinical experience that presents with significant comorbidities. This should not be a patient with a single, straightforward condition, such as an ear infection, nor should it be a wellness visit. Create a focused SOAP note for this patient using the template in the Resources. All SOAP notes must be signed and each page must be initialed by your preceptor. When you submit your SOAP Note, you should include the complete SOAP Note as a Word document and pdf/images of each page that is initialed and signed by your preceptor.
  Please Note: Electronic signatures are not accepted. If both files are not received by the due date, faculty will deduct points per the Walden Late Policies.
• Based on this patient case, and using the focused SOAP note as a reference, develop a case study presentation that includes the history of present illness (HPI), appropriate positive and negative physical exam findings, past medical and surgical history, diagnostic results, diagnosis including differentials that were ruled out, and treatment plan.
• Your presentation should also include objectives for your audience (see the resource on Bloom’s Taxonomy), at least three possible discussion questions/prompts for your classmates to respond to, and at least five scholarly resources to support your diagnostic reasoning and treatment plan.
• Ensure that you have the appropriate lighting and equipment to record the presentation.

Video Assignment for this week’s presenters:

Record yourself presenting the complex case study for your clinical patient. In your presentation:

• Dress professionally with a lab coat and present yourself in a professional manner.
• Display your photo ID at the start of the video when you introduce yourself.
• Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information).
• State 3-4 objectives for the presentation that are targeted, clear, use appropriate verbs from Bloom’s taxonomy, and address what the audience will know or be able to do after viewing.
• Present the full complex case study. Include the history of present illness, appropriate positive and negative physical exam findings, past medical and surgical history, diagnostic results, diagnosis including differentials that were ruled out, and treatment plan.
• Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.
• Pose three questions or discussion prompts, based on your presentation, that your colleagues can respond to after viewing your video.
• Be succinct in your presentation, and do not exceed 8 minutes.

A note on grading: 

• Presenters: Review the Grand Rounds Presenter Rubric attached to this discussion to ensure you meet the scoring criteria.
• Participants: Review the Grand Rounds Participant Rubric located on the following Week 4 Assignment 1 page to ensure you meet the scoring criteria. Note the Week 4 Assignment 1 page is for viewing the participant rubric only. Your response should be posted in the forum of this page.

ANSWER  

T.S., 96, Male, Caucasian

S

CC “ER follow up”

HPI

T.S. is a 96 y/o Caucasian male with significant PMH of diastolic and systolic heart failure, hypertension, hyperlipidemia, myocardial infarction one year ago, and COPD who presents to the clinic for an ER follow up. Three days ago he was seen and treated for Afib RVR rate of 120-130s with shortness of breath and dizziness and was discharged with Cardizem 30mg PO daily and Eliquis 5mg PO BID and instructed to follow up with his PCP to manage his medications and care.……..please click the icon below to access entire answer at $10