Download SNAPPS oral presentation and more Summaries Preventive medicine in PDF only on Docsity!
SNAPPS ORAL PRESENTATION TEMPLATE
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. CC Urinary Frequency and urgency HPI statement using OLDCARTS data 42 year old female, presents with burning when urinating, urinary frequency and urgency for the last 3 days. Lower abdominal pain. Pt has a had a history of hypertension and hyperlipidemia. O- (How long) Onset 3 days ago L- ( location) Urinary bladder D- increasing urinary frequency and urgency. Abdominal pain and discomfort. Starting to get worse yesterday. C- (characteristics) Burning sensation when urinating, urinary frequency and urination A ( anything make it worse aggravating factors) Feeling of urgency when urinating R- relieves when urinating T- (Treatments tried) trying to increase water intake, has taken Tylenol to abdominal discomfort Pertinent ROS Constitutional: Denies fever, chills, body aches. Cardiovascular/ Respiratory: Denies, SOB, cough, wheezing, palpitation, or chest pain. Gastrointestinal: positive for lower abdominal pain, negative for blood in a stool, flank pain, or back pain.
Genitourinary: Positive pain upon urination, urgency, and frequency. Denies. Vaginal discharge, odor, itching, positive for blood in urine .Hematology/lymphatics: No swollen lymph glands. Neurologic: Denies confusion, or fatigue, dizziness Pertinent PE
Constitutional: Denies
fever, chills, body
aches.
Cardiovascular/
Respiratory: Denies,
SOB, cough,
wheezing, palpitation,
or
chest pain.
Gastrointestinal:
Denies abdominal
pain, blood in a stool,
General SH is a 42-year-old female who is awake, alert, and oriented, she is not in acute distress; hydrated, nourished, and appropriate weight; she is cooperative and appears the stated age. Skin Warm, dry and intact without rashes or lesions. Appropriate color for ethnicity. Nailbeds pink without cyanosis or clubbing. HEENT / Neck normocephalic and atraumatic Eyes: Conjunctivae is pink negative discharge bilaterally Ears: External ears and canals are non-tender without swelling or erythema; negative discharge from canals; bilateral tympanic membranes are pearly gray negative erythema, bulging, or middle ear effusion. Nose: Nares are patent bilaterally negative discharge Sinuses: No frontal or maxillary tenderness on palpation/ percussion. Throat: negative erythematous posterior pharynx. Neck: negative bilateral anterior cervical lymph node enlargement and negative tenderness, full range of motion without difficulty, trachea is midline; thyroid gland is normal size negative nodules or masses. Cardiovascular negative for tachycardia of 65 bpm, rhythm negative for murmurs, rubs or gallops. Chest / Respiratory Chest: symmetric without deformity. Respiratory: Even unlabored respirations: lung sounds clear to auscultation bilaterally. Abdomen Soft, symmetric, tender in lower quadrant, negative distension. Umbilicus midline without herniation. Bowel sounds present and normoactive for all four quadrants. No masses, to liver or spleen. Genitourinary / Rectal: External exam, vulva normal, pubic area, no rash, Labia left and right no tenderness or lesion, urethra: no prolapse, urethral pain, urethral swelling or urethral lesion. Musculoskeletal / Osteopathic Structural Examination Upright posture, Spinal processes are midline and non-tender, Full range of motion of neck and spine without discomfort. Motor function grip, upper and lower extremities muscles strength 5/5 bilaterally. Sensation is intact bilaterally. Neurologic Awake, alert, and oriented to person, place, and time with normal speech. Psychiatric Appropriate mood and affect. Lymphatic Bilateral anterior cervical lymph node negative for enlargement and tenderness. Negative for occipital, pre and postauricular, submental, supraclavicular, axillary, or inguinal lymph node enlargement or tenderness bilaterally. NARROW Based on the H&P key findings, identify an appropriate differential. UTI (Urinary Tract Infection) Dysuria:
A urinary tract infection is a very common type of infection in your urinary system. It can involve any part of your urinary system. Bacteria, especially E. Coli are the most common causes of UTIs. Pertinent Positives include dysuria, urinary frequency, and dysuria, pain in your side, lower back, and lower abdomen Cystitis this would be the most likely diagnosis for this patient's condition is cystitis. Pertinent positives for these conditions are dysuria, urgency, and frequency. The patients have a history of recurrent UTI Vaginitis Vaginitis is a common condition characterized by inflammation of the vagina, pertinent positives are burning, abdominal discomfort. Pertinent negatives are itching, and abnormal discharge. This condition affects women at various life stages and can be caused by various factors, including infections, hormonal changes, and irritants. Common types of vaginitis include bacterial vaginosis, yeast infections, and trichomoniasis, each with distinct causes and treatments. ANALYZE Analyze the differential by comparing and contrasting the possibilities. Use pertinent positive and negative findings to argue for or against each diagnosis in your differential. Rank your diagnoses in order of most likely to least likely. UTI Cystitis Vaginitis
In the written portion of this assignment, you will present your findings.
