As a major project in this course, you will deliver a grand rounds presentation. General Guidelines 1. Your Grand Rounds presentation should not be just a presentation of a patient encounter—it should be a teaching presentation based on a case that you were involved with. 2. In Week 1, you will be assigned the week in which you will be expected to present your case. (Week 3, 5, 7, or 9) 3. Create a minimum of three high level learning objectives for this presentation. (What do you want the learners to know after they view your presentation?) There are multiple web sources on how to write learning objectives using Bloom's taxonomy online. Click here for an example or conduct your own search. 4. Your case will start with a complete SOAP note (on the approved template)—then major research and discussion of the disease process are presented. 5. Your case will also include an extended SOAP note. Click here for guidelines on what should be included in the extended SOAP note. 6. A minimum of five test questions should be created and posted with your presentation. a. The test questions will focus on appropriate intellectual activities ranging from simple recall (no more than one question), problem solving, critical thinking, reasoning, and evaluation. b. There are multiple Internet sources on how to write test questions. 7. Part of your role in presenting involves moderating the responses to your case and fielding questions. 8. A minimum of five scholarly sources should be used for your presentation. (Course texts can count for one source only; if using data from websites you must go back to the literature source for the information—no secondary sources are allowed.) 9. In weeks when you are not the presenter, you are to contribute to the case either through your patient experience or through your readings. As a participant, you should support your statements with evidence. As a recap, your Grand Rounds presentation must include: 1. Three learning objectives that must be clearly written and presented 2. A complete SOAP on the approved template. 3. Extended SOAP note 4. At least five test questions 5. A minimum of five scholarly resources Keep in mind the following guidelines while taking part in this assignment: • For those who are presenting, post your presentations to the Discussion Area by Day 3 of the week in which you are a presenter. Begin facilitating the discussion and continue to lead it throughout the week. • For those who are participants in a week, begin participating by Day 3 of that week and continue until the end of the week. You are responsible for participating in at least two presentations. For the presenters: The Grand Rounds presentation should consist of a patient scenario that you experienced in your clinical setting and should follow the guidelines provided above. Your goal is to present your case as a teaching presentation and lead a discussion throughout the week. Here are some tips for facilitating the discussion: • To prepare for your presentation, rehearse the key points and findings of your research and think about points you can make to initiate the discussion and keep it going. • Develop questions you can ask to initiate the discussion and keep it going. • As you approach the end of the discussion period, ask participants to: o Summarize the discussion o Draw conclusions from the collective group discussion Keep the presentation interesting, professional, and focused on the topic. APA format is expected, and references should be cited. SOAP Note Example Below is an example of a complete SOAP note that includes a complete physical examination. Look under each of the headings to note where information should be included. If the note documents an acute or episodic visit, the note will include only the SOAP portions that are specific to the complaint. For example, if a patient presents with an eye infection, the SOAP note would include the chief complaint and any pertinent medical history of the complaint. The review of systems would include anything that is pertinent to the complaint. The exam will include the HEENT (always include CV and Respiratory) and any other pertinent systems. The assessment and plan are the same. Name: Date: Time: Age: Sex: SUBJECTIVE CC: Reason given by the patient for seeking medical care “in quotes” HPI: Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or past diagnostic testing related to present illness. Medications: (list with reason for med ) PMH Allergies: Medication Intolerances: Chronic Illnesses/Major traumas Hospitalizations/Surgeries “Have you ever been told that you have: Diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems or kidney disease or psychiatric diagnosis?” Family History Does your mother, father or siblings have any medical or psychiatric illnesses? Anyone diagnosed with: lung disease, heart disease, htn, cancer, TB, DM, or kidney disease. Social History Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, marijuana. Safety status ROS General Weight change, fatigue, fever, chills, night sweats, energy level Cardiovascular Chest pain, palpitations, PND, orthopnea, edema Skin Delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles Respiratory Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB Eyes Corrective lenses, blurring, visual changes of any kind Gastrointestinal Abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools Ears Ear pain, hearing loss, ringing in ears, discharge Genitourinary/Gynecological Urgency, frequency burning, change in color of urine. Contraception, sexual activity, STDS Fe: last pap, breast, mammo, menstrual complaints, vaginal discharge, pregnancy hx Male: prostate, PSA, urinary complaints Nose/Mouth/Throat Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, throat pain Musculoskeletal Back pain, joint swelling, stiffness or pain, fracture hx, osteoporosis Breast SBE, lumps, bumps or changes Neurological Syncope, seizures, transient paralysis, weakness, paresthesia, black out spells Heme/Lymph/Endo HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance Psychiatric Depression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dx OBJECTIVE Weight BMI Temp BP Height Pulse Resp General Appearance Healthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Slightly somber affect at first, then brighter later. Skin Skin is brown, warm, dry, clean and intact. No rashes or lesions noted. HEENT Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair. Cardiovascular S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema. Respiratory Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally. Gastrointestinal Abdomen obese; BS active in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly. Breast Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin. Genitourinary Bladder is non-distended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink and nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT. Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness. No adnexal masses or tenderness. Ovaries are non-palpable. (Male: testes palpable, no masses or lesions, no hernia, no uretheral discharge.) (Rectal as appropriate: no evidence of hemorrhoids, fissures, bleeding or masses—Males: prostrate is smooth, non-tender and free from nodules, is of normal size, sphincter tone is firm). Musculoskeletal Full ROM seen in all 4 extremities as patient moved about the exam room. Neurological Speech clear. Good tone. Posture erect. Balance stable; gait normal. Psychiatric Alert and oriented. Dressed in clean slacks, shirt and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately. Lab Tests Urinalysis – pending Urine culture – pending Wet prep - pending Special Tests ASSESSMENT FINDINGS AND PLAN o Diagnosis o Plan:  Further testing  Medication  Education  Non-medication treatments

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