Purpose: To provide a documentation of the patient’s progress during their hospital course. Obtain only that information needed to help determine the patient’s problem as quickly as possible.
Usually recorded in the medical record S.O.A.P method:
Subjective - symptoms as relayed by the patient, how has their chief complaint improved or changed.
Objective - findings (test results, [...]
Purpose: A case presentation is a verbal report usually presented from one student physician to another, which gives a detailed description of a patient. The same format is used to communicate among physicians for the remainder of one’s career.
Format:
Orientating statement (age, sex, relevant past medical history)
Chief complaint in the patient’s own words
[...]
Introduction: common courtesies-e.g. find out how the child likes to be addressed, spend a few minutes to socialize with family.
The interview:
Age of the patient affects interview style=
Under age 5, most information will be observational and from parent/guardian
Sensitive issues may be avoided with toddler present
Age 5 & over, the child can add greatly to history-you [...]
General Symptoms:
Weight Loss
n Causes may be GI, endocrine, chronic infections, malignancies, depression anorexia nervosa
n Wt loss with high food intake: diabetes, hyperthyroidism, malabsorption or bulimia
Strength
n Fatigue = sense of weariness or loss of energy
Some causes: depression, anxiety, endocrine, infections (mono), anemia
n Weakness = loss of muscular power
n Fever = abnormal increase in body [...]
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