clinical case presentation format

The Ultimate Patient Case Presentation Template for Med Students

• April 6, 2024
• / Reviewed by: Amy Rontal, MD

Knowing how to deliver a patient presentation is one of the most important skills to learn on your journey to becoming a physician. After all, when you’re on a medical team, you’ll need to convey all the critical information about a patient in an organized manner without any gaps in knowledge transfer.

One big caveat: opinions about the correct way to present a patient are highly personal and everyone is slightly different. Additionally, there’s a lot of variation in presentations across specialties, and even for ICU vs floor patients.

My goal with this blog is to give you the most complete version of a patient presentation, so you can tailor your presentations to the preferences of your attending and team. So, think of what follows as a model for presenting any general patient.

Here’s a breakdown of what goes into the typical patient presentation.

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7 Ingredients for a Patient Case Presentation Template

1. the one-liner.

The one-liner is a succinct sentence that primes your listeners to the patient.

A typical format is: “[Patient name] is a [age] year-old [gender] with past medical history of [X] presenting with [Y].

2. The Chief Complaint

This is a very brief statement of the patient’s complaint in their own words. A common pitfall is when medical students say that the patient had a chief complaint of some medical condition (like cholecystitis) and the attending asks if the patient really used that word!

An example might be, “Patient has chief complaint of difficulty breathing while walking.”

3. History of Present Illness (HPI)

The goal of the HPI is to illustrate the story of the patient’s complaint. I remember when I first began medical school, I had a lot of trouble determining what was relevant and ended up giving a lot of extra details. Don’t worry if you have the same issue. With time, you’ll learn which details are important. 

The OPQRST Framework

In the beginning of your clinical experience, a helpful framework to use is OPQRST:

Describe when the issue started, and if it occurs during certain environmental or personal exposures.

P rovocative

Report if there are any factors that make the pain better or worse. These can be broad, like noting their shortness of breath worsened when lying flat, or their symptoms resolved during rest. 

Relay how the patient describes their pain or associated symptoms. For example, does the patient have a burning versus a pressure sensation? Are they feeling weakness, stiffness, or pain?

R egion/Location

Indicate where the pain is located and if it radiates anywhere.

Talk about how bad the pain is for the patient. Typically, a 0-10 pain scale is useful to provide some objective measure.

Discuss how long the pain lasts and how often it occurs.

A Case Study

While the OPQRST framework is great when starting out, it can be limiting. Let’s take an example where the patient is not experiencing pain and comes in with altered mental status along with diffuse jaundice of the skin and a history of chronic liver disease. You will find that certain sections of OPQRST do not apply. In this event, the HPI is still a story, but with a different framework. Try to go in chronological order. Include relevant details like if there have been any changes in medications, diet, or bowel movements.

Pertinent Positive and Negative Symptoms

Regardless of the framework you use, the name of the game is pertinent positive and negative symptoms the patient is experiencing. I’d like to highlight the word “pertinent.” It’s less likely the patient’s chronic osteoarthritis and its management is related to their new onset shortness of breath, but it’s still important for knowing the patient’s complete medical picture. A better place to mention these details would be in the “Past Medical History” section, and reserve the HPI portion for more pertinent history. As you become exposed to more illness scripts, experience will teach you which parts of the history are most helpful to state. Also, as you spend more time on the wards, you will pick up on which questions are relevant and important to ask during the patient interview.   By painting a clear picture with pertinent positives and negatives during your presentation, the history will guide what may be higher or lower on the differential diagnosis. Some other important components to add are the patient’s additional past medical/surgical history, family history, social history, medications, allergies, and immunizations.

The HEADSSS Method

Particularly, the social history is an important time to describe the patient as a complete person and understand how their life story may affect their present condition. One way of organizing the social history is the HEADSSS method: – H ome living situation and relationships – E ducation and employment – A ctivities and hobbies – D rug use (alcohol, tobacco, cocaine, etc.) Note frequency of use, and if applicable, be sure to add which types of alcohol consumption (like beer versus hard liquor) and forms of drug use. – S exual history (partners, STI history, pregnancy plans) – S uicidality and depression – S piritual and religious history   Again, there’s a lot of variation in presenting social history, so just follow the lead of your team. For example, it’s not always necessary/relevant to obtain a sexual history, so use your judgment of the situation.

4. Review of Symptoms

Oftentimes, most elements of this section are embedded within the HPI. If there are any additional symptoms not mentioned in the HPI, it’s appropriate to state them here.

5. Objective

Vital signs.

Some attendings love to hear all five vital signs: temperature, blood pressure (mean arterial pressure if applicable), heart rate, respiratory rate, and oxygen saturation. Others are happy with “afebrile and vital signs stable.” Just find out their preference and stick to that. 

Physical Exam  

This is one of the most important parts of the patient presentation for any specialty. It paints a picture of how the patient looks and can guide acute management like in the case of a rigid abdomen. As discussed in the HPI section, typically you should report pertinent positives and negatives. When you’re starting out, your attending and team may prefer for you to report all findings as part of your learning. For example, pulmonary exam findings can be reported as: “Regular chest appearance. No abnormalities on palpation. Lungs resonant to percussion. Clear to auscultation bilaterally without crackles, rhonchi, or wheezing.” Typically, you want to report the physical exams in a head to toe format: General Appearance, Mental Status, Neurologic, Eyes/Ears/Nose/Mouth/Neck, Cardiovascular, Pulmonary, Breast, Abdominal, Genitourinary, Musculoskeletal, and Skin. Depending on the situation, additional exams can be incorporated as applicable.

Now comes reporting pertinent positive and negative labs. Several labs are often drawn upon admission. It’s easy to fall into the trap of reading off all the labs and losing everyone’s attention. Here are some pieces of advice: 

You normally can’t go wrong sticking to abnormal lab values. 

One qualification is that for a patient with concern for acute coronary syndrome, reporting a normal troponin is essential. Also, stating the normalization of previously abnormal lab values like liver enzymes is important.

Demonstrate trends in lab values.

A lab value is just a single point in time and does not paint the full picture. For example, a hemoglobin of 10g/dL in a patient at 15g/dL the previous day is a lot more concerning than a patient who has been stable at 10g/dL for a week.

Try to avoid editorializing in this section.

Save your analysis of the labs for the assessment section. Again, this can be a point of personal preference. In my experience, the team typically wants the raw objective data in this section. This is also a good place to state the ins and outs of your patient (if applicable). In some patients, these metrics are strictly recorded and are typically reported as total fluid in and out over the past day followed by the net fluid balance. For example, “1L in, 2L out, net -1L over the past 24 hours.”

6. Diagnostics/Imaging

Next, you’ll want to review any important diagnostic tests and imaging. For example, describe how the EKG and echo look in a patient presenting with chest pain or the abdominal CT scan in a patient with right lower quadrant abdominal pain. Try to provide your own interpretation to develop your skills and then include the final impression. Also, report if a diagnostic test is still pending.

7. Assessment/Plan

This is the fun part where you get to use your critical thinking (aka doctor) skills! For the scope of this blog, we’ll review a problem-based plan. It’s helpful to begin with a summary statement that incorporates the one-liner, presenting issue(s)/diagnosis(es), and patient stability. Then, go through all the problems relevant to the admission. You can impress your audience by casting a wide differential diagnosis and going through the elements of your patient presentation that support one diagnosis over another.  Following your assessment, try to suggest a management plan. In a patient with congestive heart failure exacerbation, initiating a diuresis regimen and measuring strict ins/outs are good starting points. You may even suggest a follow-up on their latest ejection fraction with an echo and check if they’re on guideline-directed medical therapy. Again, with more time on the clinical wards you’ll start to pick up on what management plan to suggest. One pointer is to talk about all relevant problems, not just the presenting issue. For example, a patient with diabetes may need to be put on a sliding scale insulin regimen or another patient may require physical/occupational therapy. Just try to stay organized and be comprehensive.

A Note About Patient Presentation Skills

When you’re doing your first patient presentations, it’s common to feel nervous. There may be a lot of “uhs” and “ums.”

Here’s the good news: you don’t have to be perfect! You just need to make a good faith attempt and keep on going with the presentation.

With time, your confidence will build. Practice your fluency in the mirror when you have a chance. No one was born knowing medicine and everyone has gone through the same stages of learning you are!

Practice your presentation a couple times before you present to the team if you have time. Pull a resident aside if they have the bandwidth to make sure you have all the information you need. 

One big piece of advice: NEVER LIE. If you don’t know a specific detail, it’s okay to say, “I’m not sure, but I can look that up.” Someone on your team can usually retrieve the information while you continue on with your presentation.

Example Patient Case Presentation Template

Here’s a blank patient case presentation template that may come in handy. You can adapt it to best fit your needs.   One-Liner:   Chief Complaint:   History of Present Illness:   Past Medical History: Past Surgical History: Family History: Social History: Medications: Allergies: Immunizations:   ROS:   Objective:   Vital Signs : Temp ___ BP ___ /___ HR ___ RR ___ O2 sat ___   Physical Exam:

General Appearance:

Mental Status:

Neurological:

Eyes, Ears, Nose, Mouth, and Neck:

Cardiovascular:

Genitourinary:

Musculoskeletal:

Most Recent Labs:

Previous Labs:

Diagnostics/Imaging:

Impression/Interpretation:

Assessment/Plan:

One-line summary:

#Problem 1:

Assessment:

#Problem 2:

Final Thoughts on Patient Presentations

I hope this post demystified the patient presentation for you. Be sure to stay organized in your delivery and be flexible with the specifications your team may provide.   Something I’d like to highlight is that you may need to tailor the presentation to the specialty you’re on. For example, on OB/GYN, it’s important to include a pregnancy history. Nonetheless, the aforementioned template should set you up for success from a broad overview perspective.   Stay tuned for my next post on how to give an ICU patient presentation. And if you’d like me to address any other topics in a blog, write to me at [email protected] ! Looking for more (free!) content to help you through clinical rotations? Check out these other posts from Blueprint tutors on the Med School blog:

• How I Balanced My Clinical Rotations with Shelf Exam Studying
• How (and Why) to Use a Qbank to Prepare for USMLE Step 2
• How to Study For Shelf Exams: A Tutor’s Guide

About the Author

Hailing from Phoenix, AZ, Neelesh is an enthusiastic, cheerful, and patient tutor. He is a fourth year medical student at the Keck School of Medicine of the University of Southern California and serves as president for the Class of 2024. He is applying to surgery programs for residency. He also graduated as valedictorian of his high school and the USC Viterbi School of Engineering, obtaining a B.S. in Biomedical Engineering in 2020. He discovered his penchant for teaching when he began tutoring his friends for the SAT and ACT in the summer of 2015 out of his living room. Outside of the academic sphere, Neelesh enjoys surfing at San Onofre Beach and hiking in the Santa Monica Mountains. Twitter: @NeeleshBagrodia LinkedIn: http://www.linkedin.com/in/neelesh-bagrodia

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Top 7 Medical Case Presentation Templates with Samples and Examples

Sarojit Hazra

How does information expand beyond essential recollection? Facts alone can diminish in value over time. Context and implementation are crucial to form deep connections and roots. Here comes the role of case studies for clinical personnel in the medical field.

In the always-growing healthcare industry, medical case presentation is essential as it is a suggestion for new researchers. A medical case study is a report where a medical practitioner shares a patient's case. It comprises every detail related to patients. It is beneficial for describing a new medical condition, management options, or treatment for diseases.

Medical case presentations contribute significantly to the evolution of medical knowledge and research.

Case study analysis is essential for every business or industry, like the medical industry. It helps in managing the twists and turns of the industry. Want to take some ideas? Have a look at SlideTeam’s blog Case Analysis Templates .

Let us highlight some significant benefits of medical case presentation:

• Case study presentations are extremely good at depicting realistic clinical frameworks.
• It helps to enhance student participation alongside the joy of learning.
• These are ideal for sharing the latest information on the clinical landscape.
• It promotes critical thinking.
• It can also make better clinical outcomes.

If you are in the healthcare sector, another important tool is the medical dashboard. For a deeper insight, quickly take a look at Medical dashboard Templates .

Each of the slides is 100% editable and customizable. The 100% customizable nature of the templates allows you to edit your presentations. The content-ready slides give you the much-needed structure. Below, let’s explore a wide array of ready to use, content ready medical case presentation templates fit for your organization.

Template 1: Case Study on Blockchain Application in Healthcare: Medical Staff Credential Verification

Blockchain is becoming a potential solution to verify medical credentials. Though these are open to the public, they can be restricted through permissions. Are you finding it difficult to understand and implement? SlideTeam introduces this PPT Template that highlights how to operationalize medical staff verification process using blockchain technology. It explains that healthcare-based systems can also be used to verify the credentials of medical staff. Solutions-based blockchain to track the experiences of medical professionals. The PPT slides are designed with suitable icons, designs, graphs and other relevant material. Grab it quickly and draft your case study as per the client’s requirements.

Click to Download

Template 2: Cost Benefits IOT Digital Twins Implementation Use Cases in the Medical Domain

This PPT template is designed to focus on the use cases in the medical domain, including research and development, diagnosis, surgery, medical equipment, etc. The slide offers a brief description of the mentioned use cases to understand the scenario better. Use it as an essential tool and captivate your audience. Get it Now!

Template 3: Major Use Cases for Tracking Medical Assets Asset Tracking and Management IoT 

Want to simplify medical complexities? The asset tracking solution is here to accompany you. It enables the medical sector to locate patients, clinicians, and medications more accurately and quickly. IoT development has made this task much more accessible by guiding you through every significant aspect of a medical asset-tracking solution. Introducing our slide exhibiting use cases of medical tools that can be tracked with IoT technology . Medical assets, including medical tools, medical equipment tracking, medications , etc., are shown in the layout with their use cases and impacts. Each topic is depicted in separate tables with appropriate icons.

Template 4: AIoT Healthcare Applications in Medical Imaging

AIoT is making the medical sector smarter and wiser to improve data management and human-machine interaction. When AIoT is applied to healthcare, enables virtual monitoring and accurate diagnosis of patients to develop a personalized patient experience. Here, we introduce our premium PPT Templates showcasing applications of Artificial Intelligence of Things (AIoT) in radiology. You can provide detailed information about remote diagnosis , personalized treatment , and real-time monitoring. Adapt it now to increase your presentation threshold and educate your audience.

Template 5: Case Study of Leading Medical Devices Manufacturing Organization

An array of disruptive themes is shaping the medical device industry, and cloud computing is one of them. Soon, cloud computing will have a more significant impact on this industry. So, for your convenience, we are presenting our slide covering a case study of blue cloud with lending medical devices manufacturing organization. It covers significant topics like client objective, problem, our solution, and results chronologically. Consisting of three essential stages, this template is excellent for educating and enticing your audience.

Template 6: IoT Technology Use Case for Medical Treatment

IoT, or the Internet of Things, is gaining significance across industries, and the medical sector is no exception. It has taken medical treatment to a new level. This custom-built PowerPoint Template exhibits the use of IoT technology in domains of the healthcare industry. It provides a digital solution for patient treatment. The key elements are primary care, acute care, virtual hospital, etc., which are depicted along with descriptions, benefits, and additional comments. Each illustration is highlighted, colored and has a relevant icon for instantaneous identification. 

Template 7: IoT Medical Healthcare Technology Use Cases

The transformation of healthcare into digital healthcare has resulted in the rise of IoMT, or medical IoT . It refers to connected devices in medical healthcare and has become one of the fastest-growing industries in the IoT market. It would help if you dived deeper to manage, monitor, and preserve IoT devices in medical healthcare. This PPT presentation demonstrates uses of IoT Medical Healthcare Technology in monitoring patient health. Moreover, the slide includes remote patient monitoring, reduced waiting time, identifying chronic diseases, and drug management. Download this template design and present your case study with ultimate professionalism.

HEALTH CONSULTATION WILL BE QUICKER, SAFER AND SECURE

Case studies have a great history as an educational tool for clinicians. These are highly beneficial for nurturing deeper insights and learning. Access to such visually appealing and comprehensively presented Top 7 Medical Case Presentation Templates enables medical professionals to quickly present their patients' case studies. Be it tracking of medical assets, application of IoT in the clinical field, IoT medical healthcare technology uses, and so on, these templates serve as essential equipment in implementing all.

P.S. For perfection and success, you should dig into SlideTeam's fantastic blog, Medical Report Templates .

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Clinical Case Study Presentation Template

Number of slides: 10

A clinical case study is a report where medical practitioners share a patient’s case. Generally, clinical case studies are valuable tools for medical research as they provide detailed information on the development of a disease or illness in particular individuals. Use this PowerPoint template to document extraordinary patient cases and share your findings with the healthcare community. You can also use these slides to report the progress of your patient’s disease and work on the proper treatment alongside your team.

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Free Template for presenting a Clinical Case Study in PowerPoint

Patient’s clinical profile.

Before starting, share the patient’s clinical profile. This slide is great to describe your patient’s clinical history, underlying conditions, and other relevant health information. You can include demographic data and specific facts related to your patient but remember to keep their anonymity.

Clinical Treatment Slide

This is one of the most important sections of your patient’s case study. You’ll find a creative slide to explain the medical treatment stage by stage. You can go deep into the medicines or drugs the patient used and their reaction in different stages of the treatment. This means you’ll be able to cover the evolution of your patient from the beginning and provide detailed insights. 

Medical Team Slide

As in any research, you should acknowledge the professionals that worked with you. So, here’s a slide to showcase the whole medical team involved in the case study. You can add photos and short descriptions of each team member. Make sure to ask for professional images and double-check the spelling of role titles and names.   

Roadmaps for Clinical Case Study Presentations

If you’re wondering how to present a patient case study in PowerPoint, the best way to do so is by taking full advantage of its visual elements. Here you’ll find creative roadmaps, diagrams, and icons

Medical PowerPoint Slides

The Clinical Case Study PowerPoint template has a clean and minimalistic style that makes your work stand out in high-level professional slides.

Medical icons in PowerPoint

You’ll find medical icons on every PowerPoint slide. Use them to organize your information and direct your audience’s attention exactly where you want it to be.

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Presenting a patient is an essential skill that is rarely taught

Clinical presenting is the language that doctors use to communicate with each other every day of their working lives. Effective communication between doctors is crucial, considering the collaborative nature of medicine. As a medical student and later as a doctor you will be expected to present cases to peers and senior colleagues. This may be in the setting of handovers, referring a patient to another specialty, or requesting an opinion on a patient.

A well delivered case presentation will facilitate patient care, act a stimulus for timely intervention, and help identify individual and group learning needs. 1 Case presentations are also used as a tool for assessing clinical competencies at undergraduate and postgraduate level.

Medical students are taught how to take histories, examine, and communicate effectively with patients. However, we are expected to learn how to present effectively by observation, trial, and error.

Principles of presentation

Remember that the purpose of the case presentation is to convey your diagnostic reasoning to the listener. By the end of your presentation the examiner should have a clear view of the patient’s condition. Your presentation should include all the facts required to formulate a management plan.

There are no hard and fast rules for a perfect presentation, rather the content of each presentation should be determined by the case, the context, and the audience. For example, presenting a newly admitted patient with complex social issues on a medical ward round will be very different from presenting a patient with a perforated duodenal ulcer who is in need of an emergency laparotomy.

Whether you’re presenting on a busy ward round or during an objective structured clinical …

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Clinical Case Presentation Template

Present your patient’s history and the impact of medication using this presentation template..

Use high-resolution stock photos, icons, charts and graphs alongside the bullet-point form of text to summarize your patient’s case.

This presentation template offers you the opportunity to present clinical cases to peers and attendings. You can also use it to present patient history and course of treatment during your oral board certification exam.

• Change colors, fonts and more to fit your branding
• Access free, built-in design assets or upload your own
• Visualize data with customizable charts and widgets
• Add animation, interactivity, audio, video and links
• Download in PDF, PPTX, MP4 and HTML5 format
• Share online with a link or embed on your website

Ace clinical case presentation on your next exam with this impactful template, or take a look at our other presentation templates for a better fit.

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Template Specifications

9 Slides, 1366 x 768 pixels – 16:9 Aspect Ratio (HD Presentation Quality)

Customizable

This template can be fully customized. You can edit content, change image(s), apply custom colors, input your own fonts and logo, and more.

Download as a PDF to share with your recipient or generate a shareable link for online sharing.

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How To Present a Patient: A Step-To-Step Guide

Last Updated on June 24, 2022 by Laura Turner

Updated and verified by Dr. Lee Burnett on March 19, 2022.

The ability to deliver oral case presentations is a core skill for any physician. Effective oral case presentations help facilitate information transfer among physicians and are essential to delivering quality patient care. Oral case presentations are also a key component of how medical students and residents are assessed during their training.

At its core, an oral case presentation functions as an argument. It is the presenter’s job to share the pertinent facts of a patient’s case with the other members of the medical care team and establish a clear diagnosis and treatment plan. Thus, the presenter should include details to support the proposed diagnosis, argue against alternative diagnoses, and exclude extraneous information. While this task may seem daunting at first, with practice, it will become easier. That said, if you are unsure if a particular detail is important to your patient’s case, it is probably best to be safe and include it.

Now, let’s go over how to present a case. While I will focus on internal medicine inpatients, the following framework can be applied to patients in any setting with slight modifications.

Oral case presentations are generally made to a medical care team, which can be composed of medical and pharmacy students, residents, pharmacists, medical attendings, and others. As the presenter, you should strive to deliver an interesting presentation that keeps your team members engaged. Here are a few things to keep in mind:

• Be confident: Speak clearly at the loudest volume appropriate to protect patient privacy, vary your tone to emphasize the most important details, and maintain eye contact with members of your team.
• Don’t fidget : Stand up straight and avoid unnecessary, distracting movements.
• Use your notes : You may glance at your notes from time to time while presenting. However, while there is no need to memorize your presentation, there is no better way to lose your team’s attention than to read your notes to them.
• Be honest: Given the importance of presentations in guiding medical care, never guess or report false information to the team. If you are unsure about a particular detail, say so.

The length of your presentation will depend on various factors, including the complexity of your patient, your audience, and your specialty. I have found that new internal medicine inpatients generally take 5-10 minutes to present. Internal medicine clerkship directors seem to agree. In a 2009 survey , they reported a range of 2-20 minutes for the ideal length of student inpatient presentations, with a median of 7 minutes.

While delivering oral case presentations is a core skill for trainees, and there have been attempts to standardize the format , expectations still vary among attending physicians. This can be a frustrating experience for trainees, and I would recommend that you clarify your attending’s expectations at the beginning of each new rotation. However, I have found that these differences are often stylistic, and content expectations are generally quite similar. Thus, developing a familiarity with the core elements of a strong oral case presentation is essential.

How to Present a Patient

You should begin every oral presentation with a brief one-liner that contains the patient’s name, age, relevant past medical history, and chief complaint. Remember that the chief complaint is why the patient sought medical care in his or her own words. An example of an effective opening is as follows: “Ms. X is a 78-year-old female with a past medical history of chronic obstructive pulmonary disease who presents to the hospital after she felt short of breath at home.”

Following the opener, elaborate on why the patient sought medical care. Describe the events that preceded the patient’s presentation in chronological order. A useful mnemonic to use when deciding what to report is OPQRST , which includes: • The Onset of the patient’s symptoms • Any Palliative or Provoking factors that make the symptoms better or worse, respectively • The Quality of his or her symptoms (how he or she describes them) • The Region of the body where the patient is experiencing his or her symptoms and (if the symptom is pain) whether the patient’s pain Radiates to another location or is well-localized • The Severity of the symptoms and any other associated Symptoms • The Time course of the symptoms (how they have changed over time and whether the patient has experienced them before) Additionally, include any other details here that may support your final diagnosis or rule out alternative diagnoses. For example, if you are concerned about a pulmonary embolism and your patient recently completed a long-distance flight, that would be worth mentioning.

The review of systems is sometimes included in the history of present illness, but it may also be separated. Given the potential breadth of the review of systems (a comprehensive list of questions that may be asked can be found here ), when presenting, only report information that is relevant to your patient’s condition.

The past medical history comes next. This should include the following information: • The patient’s medical conditions, including any that were not highlighted in the opener • Any past surgeries the patient has had and when they were performed • The timing of and reasons for past hospitalizations • Any current medications, including dosages and frequency of administration

The next section should detail the patient’s relevant family history. This should include: • Any relevant conditions that run in the patient’s family, with an emphasis on first-degree relatives

After the family history comes the social history. This section should include information about the patient’s: • Living situation • Occupation • Alcohol and tobacco use • Other substance use You may also include relevant details about the patient’s education level, recent travel history, history of animal and occupational exposures, and religious beliefs. For example, it would be worth mentioning that your anemic patient is a Jehovah’s Witness to guide medical decisions regarding blood transfusions.

Once you have finished reporting the patient’s history, you should transition to the physical exam. You should begin by reporting the patient’s vital signs, which includes the patient’s: • Temperature • Heart rate • Blood pressure • Respiratory rate • Oxygen saturation (if the patient is using supplemental oxygen, this should also be reported) Next, you should discuss the findings of your physical exam. At the minimum, this should include: • Your general impressions of the patient, including whether he or she appears “sick” or not • The results of your: • Head and neck exam • Eye exam • Respiratory exam • Cardiac exam • Abdominal exam • Extremity exam • Neurological exam Additional relevant physical examination findings may be included, as well. Quick note: resist the urge to report an exam as being “normal.” Instead, report your findings. For example, for a normal abdominal exam, you could report that “the patient’s abdomen is soft, non-tender, and non-distended, with normoactive bowel sounds.”

This section includes the results of any relevant laboratory testing, imaging, or other diagnostics that were obtained. You do not have to report the results of every test that was ordered. Before presenting, consider which results will further support your proposed diagnosis and exclude alternatives.

The emergency department (ED) course is classically reported towards the end of the presentation. However, different attendings may prefer to hear the ED course earlier, usually following the history of present illness. When unsure, report the ED course after the results of diagnostic testing. Be sure to include initial ED vital signs and any administered treatments.

You should conclude your presentation with the assessment and plan. This is the most important part of your presentation and allows you to show your team how much you really know. You should include: • A brief summary (1-2 lines) of the patient, the reason for admission, and your likely diagnosis. This should also include information regarding the patient’s clinical stability. While it can be similar to your opener, it should not be identical. An example could be: “Ms. X is a 78-year-old female with a past medical history of chronic obstructive pulmonary disease who presents with shortness of breath in the setting of an upper respiratory tract infection who is now stable on two liters of supplemental oxygen delivered via nasal cannula. Her symptoms are thought to be secondary to an acute exacerbation of chronic obstructive pulmonary disease.” • A differential diagnosis . For students, this should consist of 3-5 potential diagnoses. You should explain why you think each diagnosis is or is not the final diagnosis. Be sure to rule out potentially life-threatening conditions (unless you think your patient has one). For our fictional patient, Ms. X, for example, you could explain why you think she does not have a pulmonary embolism or acute coronary syndrome. For more advanced trainees, the differential can be more limited in scope. • Your plan . On regular inpatient floors, this should include a list of the patient’s medical problems, ordered by acuity, followed by your proposed plan for each. After going through each active medical problem, be sure to mention your choice for the patient’s diet and deep vein thrombosis prophylaxis, the patient’s stated code status, and the patient’s disposition (whether you think they need to remain in the hospital). In intensive care units, you can organize the patient’s medical problems by organ system to ensure that no stone is left unturned (if there are no active issues for an organ system, you may say so).

Presenting Patients Who Have Been in the Hospital for Multiple Days

After the initial presentation, subsequent presentations can be delivered via SOAP note format as follows:

• The  Subjective  section includes details about any significant overnight events and any new complaints the patient has.
• In the  Objective  section, report your physical exam (focus on any changes since you last examined the patient) and any significant new laboratory, imaging, or other diagnostic results.
• The  Assessment  and  Plan  are typically delivered as above. For the initial patient complaint, you do not have to restate your differential diagnosis if the diagnosis is known. For new complaints, however, you should create another differential and argue for or against each diagnosis. Be sure to update your plan every day.

Presenting Patients in Different Specialties

Before you present a patient, consider your audience. Every specialty presents patients differently. In general, surgical and OB/GYN presentations tend to be much quicker (2-3 minutes), while pediatric and family medicine presentations tend to be similar in length to internal medicine presentations. Tailor your presentations accordingly.

Presenting Patients in Outpatient Settings

Outpatients may be presented similarly to inpatients. Your presentation’s focus, however, should align with your outpatient clinic’s specialty. For example, if you are working at a cardiology clinic, your presentation should be focused on your patient’s cardiac complaints.

If your patient is returning for a follow-up visit and does not have a stated chief complaint, you should say so. You may replace the history of present illness with any relevant interval history since his or her last visit.

And that’s it! Delivering oral case presentations is challenging at first, so remember to practice. In time, you will become proficient in this essential medical skill. Good luck!

Kunal Sindhu, MD, is an assistant professor in the Department of Radiation Oncology at the Icahn School of Medicine at Mount Sinai and New York Proton Center. Dr. Sindhu specializes in treating cancers of the head, neck, and central nervous system.

2 thoughts on “How To Present a Patient: A Step-To-Step Guide”

To clarify, it should take 5-10 minutes to present (just one) new internal medicine inpatient? Or if the student had 4 patients to work up, it should take 10 minutes to present all 4 patients to the preceptor?

Good question. That’s per case, but with time you’ll become faster.

Comments are closed.

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Guidelines To Writing A Clinical Case Report

What is a clinical case report.

A case report is a detailed report of the symptoms, signs, diagnosis, treatment, and follow-up of an individual patient. Case reports usually describe an unusual or novel occurrence and as such, remain one of the cornerstones of medical progress and provide many new ideas in medicine. Some reports contain an extensive review of the relevant literature on the topic. The case report is a rapid short communication between busy clinicians who may not have time or resources to conduct large scale research.

WHAT ARE THE REASONS FOR PUBLISHING A CASE REPORT?

The most common reasons for publishing a case are the following: 1) an unexpected association between diseases or symptoms; 2) an unexpected event in the course observing or treating a patient; 3) findings that shed new light on the possible pathogenesis of a disease or an adverse effect; 4) unique or rare features of a disease; 5) unique therapeutic approaches; variation of anatomical structures.

Most journals publish case reports that deal with one or more of the following:

• Unusual observations
• Adverse response to therapies
• Unusual combination of conditions leading to confusion
• Illustration of a new theory
• Question regarding a current theory
• Personal impact.

STRUCTURE OF A CASE REPORT[ 1 , 2 ]

Different journals have slightly different formats for case reports. It is always a good idea to read some of the target jiurnals case reports to get a general idea of the sequence and format.

In general, all case reports include the following components: an abstract, an introduction, a case, and a discussion. Some journals might require literature review.

The abstract should summarize the case, the problem it addresses, and the message it conveys. Abstracts of case studies are usually very short, preferably not more than 150 words.

Introduction

The introduction gives a brief overview of the problem that the case addresses, citing relevant literature where necessary. The introduction generally ends with a single sentence describing the patient and the basic condition that he or she is suffering from.

This section provides the details of the case in the following order:

• Patient description
• Case history
• Physical examination results
• Results of pathological tests and other investigations
• Treatment plan
• Expected outcome of the treatment plan
• Actual outcome.

The author should ensure that all the relevant details are included and unnecessary ones excluded.

This is the most important part of the case report; the part that will convince the journal that the case is publication worthy. This section should start by expanding on what has been said in the introduction, focusing on why the case is noteworthy and the problem that it addresses.

This is followed by a summary of the existing literature on the topic. (If the journal specifies a separate section on literature review, it should be added before the Discussion). This part describes the existing theories and research findings on the key issue in the patient's condition. The review should narrow down to the source of confusion or the main challenge in the case.

Finally, the case report should be connected to the existing literature, mentioning the message that the case conveys. The author should explain whether this corroborates with or detracts from current beliefs about the problem and how this evidence can add value to future clinical practice.

A case report ends with a conclusion or with summary points, depending on the journal's specified format. This section should briefly give readers the key points covered in the case report. Here, the author can give suggestions and recommendations to clinicians, teachers, or researchers. Some journals do not want a separate section for the conclusion: it can then be the concluding paragraph of the Discussion section.

Notes on patient consent

Informed consent in an ethical requirement for most studies involving humans, so before you start writing your case report, take a written consent from the patient as all journals require that you provide it at the time of manuscript submission. In case the patient is a minor, parental consent is required. For adults who are unable to consent to investigation or treatment, consent of closest family members is required.

Patient anonymity is also an important requirement. Remember not to disclose any information that might reveal the identity of the patient. You need to be particularly careful with pictures, and ensure that pictures of the affected area do not reveal the identity of the patient.

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Presenting a Clinical Vignette: Deciding What to Present

If you are scheduled to make a presentation of a clinical vignette, reading this article will improve your performance. We describe a set of practical, proven steps that will guide your preparation of the presentation. The process of putting together a stellar presentation takes time and effort, and we assume that you will be willing to put forth the effort to make your presentation successful. This and subsequent articles will focus on planning, preparation, creating visual aids (slides), and presentation skills. The intent of this series of articles is to help you make a favorable impression and reap the rewards, personal and professional, of a job well done.

The process begins with the creation of an outline of the topics that might be presented at the meeting. Your outline should follow the typical format and sequence for this type of communication: history, physical examination, investigations, patient course, and discussion. This format is chosen because your audience understands it and uses it every day. If you have already prepared a paper for publication, it can be a rich source of content for the topic outline.

To get you started, we have prepared a generic outline to serve as an example. Look over the generic outline to get a sense of what might be addressed in your presentation. We realize that the generic outline will not precisely fit all of the types of cases; nevertheless, think about the larger principle and ask yourself, "How can I adapt this to my situation?" In order to help you visualize the type of content you might include in the outline, an example of a topic outline for a clinical vignette is presented.

Introduction

The main purpose of the introduction is to place the case in a clinical context and explain the importance or relevance of the case. Some case reports begin immediately with the description of the case, and this is perfectly acceptable.

1. Describing the clinical context and relevance

i. Ergotism is characterized by intense, generalized vasoconstriction of small and large blood vessels. ii. Ergotism is rare and therefore difficult to diagnose. iii. Failure to diagnose can lead to significant morbidity.

Case Presentation

The case report should be chronological and detail the history, physical findings, and investigations followed by the patient's course. At this point, you may wish to include more details than you might have time to present, prioritizing the content later.

i. A 34-year-old female smoker has chronic headaches, dyspnea, and burning leg pain. ii. Clinical diagnosis of mitral valve stenosis is made. iii. She returns in one week because of burning pain in the legs. iv. One month after presentation, cardiac catheterization demonstrates severe mitral valve stenosis. v. Elective mitral valve commisurotomy is scheduled, but the patient is admitted to hospital early because of increased burning pain in her feet and a painful right leg.

2. Physical Examination

i. Normal vital signs. ii. No skin findings. iii. Typical findings of mitral stenosis, no evidence of heart failure. iv. Cool, pulseless right leg. v. Normal neurological examination.

3. Investigations

i. Normal laboratory studies. ii. ECG shows left atrial enlargement. iii. Arteriogram of right femoral artery shows subtotal stenosis, collateral filling of the popliteal artery, and pseudoaneurysm formation.

4. Hospital Course

i. Mitral valve commisurotomy is performed, as well as femoral artery thombectomy, balloon dilation, and a patch graft repair. ii. On the fifth postoperative day, the patient experienced a return of burning pain in the right leg. The leg was pale, cool, mottled, and pulseless. iii. The arteriogram of femoral arteries showed smooth segmental narrowing and bilateral vasospasm suggesting large-vessel arteritis complicated by thrombosis. iv. Treatment was initiated with corticosteroids, anticoagulants, antiplatelet drugs, and oral vasodilators. v. The patient continued to deteriorate with both legs becoming cool and pulseless. vi. Additional history revealed that the patient abused ergotamine preparations for years (headaches). She used 12 tables daily for the past year and continued to receive ergotamine in hospital on days 2, 6, and 7. vii. Ergotamine preparations were stopped, intravenous nitroprusside was begun, and she showed clinical improvement within 2 hours. Nitroprusside was stopped after 24 hours, and the symptoms did not return. viii. The remainder of hospitalization was uneventful.

The main purpose of the discussion section is to articulate the lessons learned from the case. It should describe how a similar case should be approached in the future. It is sometimes appropriate to provide background information to understand the pathophysiological mechanisms associated with the patient's presentation, findings, investigations, course, or therapy.

1. Discussion

i. The most common cause of ergotism is chronic poisoning found in young females with chronic headaches. ii. Manifestations can include neurological, gastrointestinal, and vascular (list each in a table). iii. Ergotamine poisoning induces intense vasospasm, and venous thrombosis may occur from direct damage to the endothelium. iv. Vasospasm is due primarily to the direct vasoconstrictor effects on the vascular smooth muscle. v. Habitual use of ergotamine can lead to withdrawal headaches leading to a cycle of greater levels of ingestion. vi. In addition to stopping ergotamine, a direct vasodilator is usually prescribed. vii. Lesson 1: Physicians should be alert to the potential of ergotamine toxicity in young women with chronic headaches that present with neurological, gastrointestinal, or ischemic symptoms. viii. Lesson 2: The value of a complete history and checking the medication list.

Creating a topic outline will provide a list of all the topics you might possibly present at the meeting. Since you will have only ten minutes, you will prioritize the topics to determine what to keep and what to cut.

How do you decide what to cut? First, identify the basic information in the three major categories that you simply must present. This represents the "must-say" category. If you have done your job well, the content you have retained will answer the following questions:

What happened to the patient? What was the time course of these events? Why did management follow the lines that it did? What was learned?

After you have identified the "must-say" content, identify information that will help the audience better understand the case. Call this the "elaboration" category. Finally, identify the content that you think the audience would like to know, provided there is enough time, and identify this as the "nice-to-know" category.

Preparing a presentation is an iterative process. As you begin to "fit" your talk into the allotted time, certain content you originally thought of as "elaboration" may be dropped to the "nice-to-know" category due to time constraints. Use the following organizational scheme to efficiently prioritize your outline.

Prioritizing Topics in the Topic Outline

1. Use your completed topic outline.

2. Next to each entry in your outline, prioritize the importance of content.

3. Use the following code system to track your prioritization decisions:

A = Must-Say B = Elaboration C = Nice-to-Know

4. Remember, this is an iterative process; your decisions are not final.

5. Review the outline with your mentor or interested colleagues, and listen to their decisions.

Use the Preparing the Clinical Vignette Presentation Checklist to assist you in preparing the topic outline.

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Mental Health Clinical Case

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Treating psychological and psychiatric conditions is quite important, as they affect our health to a large stent. To learn more about them, use this Mental Health Clinical Case presentation and give some info about case reports, using diagrams, tables, maps… Provide details about the patient, diagnosis, treatment or even the diagnosis.

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