oral case presentation medicine

Overview and General Information about Oral Presentation

• Daily Presentations During Work Rounds
• The New Patient Presentation
• The Holdover Admission Presentation
• Outpatient Clinic Presentations
• The structure of presentations varies from service to service (e.g. medicine vs. surgery), amongst subspecialties, and between environments (inpatient vs. outpatient). Applying the correct style to the right setting requires that the presenter seek guidance from the listeners at the outset.
• Time available for presenting is rather short, which makes the experience more stressful.
• Individual supervisors (residents, faculty) often have their own (sometimes quirky) preferences regarding presentation styles, adding another layer of variability that the presenter has to manage.
• Students are evaluated/judged on the way in which they present, with faculty using this as one way of gauging a student’s clinical knowledge.
• Done well, presentations promote efficient, excellent care. Done poorly, they promote tedium, low morale, and inefficiency.

General Tips:

• Practice, Practice, Practice! Do this on your own, with colleagues, and/or with anyone who will listen (and offer helpful commentary) before you actually present in front of other clinicians. Speaking "on-the-fly" is difficult, as rapidly organizing and delivering information in a clear and concise fashion is not a naturally occurring skill.
• Immediately following your presentations, seek feedback from your listeners. Ask for specifics about what was done well and what could have been done better – always with an eye towards gaining information that you can apply to improve your performance the next time.
• Listen to presentations that are done well – ask yourself, “Why was it good?” Then try to incorporate those elements into your own presentations.
• Listen to presentations that go poorly – identify the specific things that made it ineffective and avoid those pitfalls when you present.
• Effective presentations require that you have thought through the case beforehand and understand the rationale for your conclusions and plan. This, in turn, requires that you have a good grasp of physiology, pathology, clinical reasoning and decision-making - pushing you to read, pay attention, and in general acquire more knowledge.
• Think about the clinical situation in which you are presenting so that you can provide a summary that is consistent with the expectations of your audience. Work rounds, for example, are clearly different from conferences and therefore mandate a different style of presentation.
• Presentations are the way in which we tell medical stories to one another. When you present, ask yourself if you’ve described the story in an accurate way. Will the listener be able to “see” the patient the same way that you do? Can they come to the correct conclusions? If not, re-calibrate.
• It's O.K. to use notes, though the oral presentation should not simply be reduced to reading the admission note – rather, it requires appropriate editing/shortening.
• In general, try to give your presentations on a particular service using the same order and style for each patient, every day. Following a specific format makes it easier for the listener to follow, as they know what’s coming and when they can expect to hear particular information. Additionally, following a standardized approach makes it easier for you to stay organized, develop a rhythm, and lessens the chance that you’ll omit elements.

Specific types of presentations

There are a number of common presentation-types, each with its own goals and formats. These include:

• Daily presentations during work rounds for patients known to a service.
• Newly admitted patients, where you were the clinician that performed the H&P.
• Newly admitted patients that were “handed off” to the team in the morning, such that the H&P was performed by others.
• Outpatient clinic presentations, covering several common situations.

Key elements of each presentation type are described below. Examples of how these would be applied to most situations are provided in italics. The formats are typical of presentations done for internal medicine services and clinics.

Note that there is an acceptable range of how oral presentations can be delivered. Ultimately, your goal is to tell the correct story, in a reasonable amount of time, so that the right care can be delivered. Nuances in the order of presentation, what to include, what to omit, etc. are relatively small points. Don’t let the pursuit of these elements distract you or create undue anxiety.

Daily presentations during work rounds of patients that you’re following:

• Organize the presenter (forces you to think things through)
• Inform the listener(s) of 24 hour events and plan moving forward
• Promote focused discussion amongst your listeners and supervisors
• Opportunity to reassess plan, adjust as indicated
• Demonstrate your knowledge and engagement in the care of the patient
• Rapid (5 min) presentation of the key facts

Key features of presentation:

• Opening one liner: Describe who the patient is, number of days in hospital, and their main clinical issue(s).
• 24-hour events: Highlighting changes in clinical status, procedures, consults, etc.
• Subjective sense from the patient about how they’re feeling, vital signs (ranges), and key physical exam findings (highlighting changes)
• Relevant labs (highlighting changes) and imaging
• Assessment and Plan : Presented by problem or organ systems(s), using as many or few as are relevant. Early on, it’s helpful to go through the main categories in your head as a way of making sure that you’re not missing any relevant areas. The broad organ system categories include (presented here head-to-toe): Neurological; Psychiatric; Cardiovascular; Pulmonary; Gastrointestinal; Renal/Genitourinary; Hematologic/Oncologic; Endocrine/Metabolic; Infectious; Tubes/lines/drains; Disposition.

Example of a daily presentation for a patient known to a team:

• Opening one liner: This is Mr. Smith, a 65 year old man, Hospital Day #3, being treated for right leg cellulitis
• MRI of the leg, negative for osteomyelitis
• Evaluation by Orthopedics, who I&D’d a superficial abscess in the calf, draining a moderate amount of pus
• Patient appears well, states leg is feeling better, less painful
• T Max 101 yesterday, T Current 98; Pulse range 60-80; BP 140s-160s/70-80s; O2 sat 98% Room Air
• Ins/Outs: 3L in (2 L NS, 1 L po)/Out 4L urine
• Right lower extremity redness now limited to calf, well within inked lines – improved compared with yesterday; bandage removed from the I&D site, and base had small amount of purulence; No evidence of fluctuance or undrained infection.
• Creatinine .8, down from 1.5 yesterday
• WBC 8.7, down from 14
• Blood cultures from admission still negative
• Gram stain of pus from yesterday’s I&D: + PMNS and GPCs; Culture pending
• MRI lower extremity as noted above – negative for osteomyelitis
• Continue Vancomycin for today
• Ortho to reassess I&D site, though looks good
• Follow-up on cultures: if MRSA, will transition to PO Doxycycline; if MSSA, will use PO Dicloxacillin
• Given AKI, will continue to hold ace-inhibitor; will likely wait until outpatient follow-up to restart
• Add back amlodipine 5mg/d today
• Hep lock IV as no need for more IVF
• Continue to hold ace-I as above
• Wound care teaching with RNs today – wife capable and willing to assist. She’ll be in this afternoon.
• Set up follow-up with PMD to reassess wound and cellulitis within 1 week

The Brand New Patient (admitted by you)

• Provide enough information so that the listeners can understand the presentation and generate an appropriate differential diagnosis.
• Present a thoughtful assessment
• Present diagnostic and therapeutic plans
• Provide opportunities for senior listeners to intervene and offer input
• Chief concern: Reason why patient presented to hospital (symptom/event and key past history in one sentence). It often includes a limited listing of their other medical conditions (e.g. diabetes, hypertension, etc.) if these elements might contribute to the reason for admission.
• The history is presented highlighting the relevant events in chronological order.
• 7 days ago, the patient began to notice vague shortness of breath.
• 5 days ago, the breathlessness worsened and they developed a cough productive of green sputum.
• 3 days ago his short of breath worsened to the point where he was winded after walking up a flight of stairs, accompanied by a vague right sided chest pain that was more pronounced with inspiration.
• Enough historical information has to be provided so that the listener can understand the reasons that lead to admission and be able to draw appropriate clinical conclusions.
• Past history that helps to shed light on the current presentation are included towards the end of the HPI and not presented later as “PMH.” This is because knowing this “past” history is actually critical to understanding the current complaint. For example, past cardiac catheterization findings and/or interventions should be presented during the HPI for a patient presenting with chest pain.
• Where relevant, the patient's baseline functional status is described, allowing the listener to understand the degree of impairment caused by the acute medical problem(s).
• It should be explicitly stated if a patient is a poor historian, confused or simply unaware of all the details related to their illness. Historical information obtained from family, friends, etc. should be described as such.
• Review of Systems (ROS): Pertinent positive and negative findings discovered during a review of systems are generally incorporated at the end of the HPI. The listener needs this information to help them put the story in appropriate perspective. Any positive responses to a more inclusive ROS that covers all of the other various organ systems are then noted. If the ROS is completely negative, it is generally acceptable to simply state, "ROS negative.”
• Other Past Medical and Surgical History (PMH/PSH): Past history that relates to the issues that lead to admission are typically mentioned in the HPI and do not have to be repeated here. That said, selective redundancy (i.e. if it’s really important) is OK. Other PMH/PSH are presented here if relevant to the current issues and/or likely to affect the patient’s hospitalization in some way. Unrelated PMH and PSH can be omitted (e.g. if the patient had their gall bladder removed 10y ago and this has no bearing on the admission, then it would be appropriate to leave it out). If the listener really wants to know peripheral details, they can read the admission note, ask the patient themselves, or inquire at the end of the presentation.
• Medications and Allergies: Typically all meds are described, as there’s high potential for adverse reactions or drug-drug interactions.
• Family History: Emphasis is placed on the identification of illnesses within the family (particularly among first degree relatives) that are known to be genetically based and therefore potentially heritable by the patient. This would include: coronary artery disease, diabetes, certain cancers and autoimmune disorders, etc. If the family history is non-contributory, it’s fine to say so.
• Social History, Habits, other → as relates to/informs the presentation or hospitalization. Includes education, work, exposures, hobbies, smoking, alcohol or other substance use/abuse.
• Sexual history if it relates to the active problems.
• Vital signs and relevant findings (or their absence) are provided. As your team develops trust in your ability to identify and report on key problems, it may become acceptable to say “Vital signs stable.”
• Note: Some listeners expect students (and other junior clinicians) to describe what they find in every organ system and will not allow the presenter to say “normal.” The only way to know what to include or omit is to ask beforehand.
• Key labs and imaging: Abnormal findings are highlighted as well as changes from baseline.
• Summary, assessment & plan(s) Presented by problem or organ systems(s), using as many or few as are relevant. Early on, it’s helpful to go through the main categories in your head as a way of making sure that you’re not missing any relevant areas. The broad organ system categories include (presented here head-to-toe): Neurological; Psychiatric; Cardiovascular; Pulmonary; Gastrointestinal; Renal/Genitourinary; Hematologic/Oncologic; Endocrine/Metabolic; Infectious; Tubes/lines/drains; Disposition.
• The assessment and plan typically concludes by mentioning appropriate prophylactic considerations (e.g. DVT prevention), code status and disposition.
• Chief Concern: Mr. H is a 50 year old male with AIDS, on HAART, with preserved CD4 count and undetectable viral load, who presents for the evaluation of fever, chills and a cough over the past 7 days.
• Until 1 week ago, he had been quite active, walking up to 2 miles a day without feeling short of breath.
• Approximately 1 week ago, he began to feel dyspneic with moderate activity.
• 3 days ago, he began to develop subjective fevers and chills along with a cough productive of red-green sputum.
• 1 day ago, he was breathless after walking up a single flight of stairs and spent most of the last 24 hours in bed.
• Diagnosed with HIV in 2000, done as a screening test when found to have gonococcal urethritis
• Was not treated with HAART at that time due to concomitant alcohol abuse and non-adherence.
• Diagnosed and treated for PJP pneumonia 2006
• Diagnosed and treated for CMV retinitis 2007
• Became sober in 2008, at which time interested in HAART. Started on Atripla, a combination pill containing: Efavirenz, Tonofovir, and Emtricitabine. He’s taken it ever since, with no adverse effects or issues with adherence. Receives care thru Dr. Smiley at the University HIV clinic.
• CD4 count 3 months ago was 400 and viral load was undetectable.
• He is a gay male, not currently sexually active. He has never used intravenous drugs.
• He has no history of asthma, COPD or chronic cardiac or pulmonary condition. No known liver disease. Hepatitis B and C negative. His current problem seems different to him then his past episode of PJP.
• Review of systems: negative for headache, photophobia, stiff neck, focal weakness, chest pain, abdominal pain, diarrhea, nausea, vomiting, urinary symptoms, leg swelling, or other complaints.
• Hypertension x 5 years, no other known vascular disease
• Gonorrhea as above
• Alcohol abuse above and now sober – no known liver disease
• No relevant surgeries
• Atripla, 1 po qd
• Omeprazole 20 mg, 1 PO, qd
• Lisinopril 20mg, qd
• Naprosyn 250 mg, 1-2, PO, BID PRN
• No allergies
• Both of the patient's parents are alive and well (his mother is 78 and father 80). He has 2 brothers, one 45 and the other 55, who are also healthy. There is no family history of heart disease or cancer.
• Patient works as an accountant for a large firm in San Diego. He lives alone in an apartment in the city.
• Smokes 1 pack of cigarettes per day and has done so for 20 years.
• No current alcohol use. Denies any drug use.
• Sexual History as noted above; has sex exclusively with men, last partner 6 months ago.
• Seated on a gurney in the ER, breathing through a face-mask oxygen delivery system. Breathing was labored and accessory muscles were in use. Able to speak in brief sentences, limited by shortness of breath
• Vital signs: Temp 102 F, Pulse 90, BP 150/90, Respiratory Rate 26, O2 Sat (on 40% Face Mask) 95%
• HEENT: No thrush, No adenopathy
• Lungs: Crackles and Bronchial breath sounds noted at right base. E to A changes present. No wheezing or other abnormal sounds noted over any other area of the lung. Dullness to percussion was also appreciated at the right base.
• Cardiac: JVP less than 5 cm; Rhythm was regular. Normal S1 and S2. No murmurs or extra heart sounds noted.
• Abdomen and Genital exams: normal
• Extremities: No clubbing, cyanosis or edema; distal pulses 2+ and equal bilaterally.
• Skin: no eruptions noted.
• Neurological exam: normal
• WBC 18 thousand with 10% bands;
• Normal Chem 7 and LFTs.
• Room air blood gas: pH of 7.47/ PO2 of 55/PCO2 of 30.
• Sputum gram stain remarkable for an abundance of polys along with gram positive diplococci.
• CXR remarkable for dense right lower lobe infiltrate without effusion.
• Monitored care unit, with vigilance for clinical deterioration.
• Hypertension: given significant pneumonia and unclear clinical direction, will hold lisinopril. If BP > 180 and or if clear not developing sepsis, will consider restarting.
• Low molecular weight heparin
• Code Status: Wishes to be full code full care, including intubation and ICU stay if necessary. Has good quality of life and hopes to return to that functional level. Wishes to reconsider if situation ever becomes hopeless. Older brother Tom is surrogate decision maker if the patient can’t speak for himself. Tom lives in San Diego and we have his contact info. He is aware that patient is in the hospital and plans on visiting later today or tomorrow.
• Expected duration of hospitalization unclear – will know more based on response to treatment over next 24 hours.

The holdover admission (presenting data that was generated by other physicians)

• Handoff admissions are very common and present unique challenges
• Understand the reasons why the patient was admitted
• Review key history, exam, imaging and labs to assure that they support the working diagnostic and therapeutic plans
• Does the data support the working diagnosis?
• Do the planned tests and consults make sense?
• What else should be considered (both diagnostically and therapeutically)?
• This process requires that the accepting team thoughtfully review their colleagues efforts with a critical eye – which is not disrespectful but rather constitutes one of the main jobs of the accepting team and is a cornerstone of good care *Note: At some point during the day (likely not during rounds), the team will need to verify all of the data directly with the patient.
• 8-10 minutes
• Chief concern: Reason for admission (symptom and/or event)
• Temporally presented bullets of events leading up to the admission
• Review of systems
• Relevant PMH/PSH – historical information that might affect the patient during their hospitalization.
• Meds and Allergies
• Family and Social History – focusing on information that helps to inform the current presentation.
• Habits and exposures
• Physical exam, imaging and labs that were obtained in the Emergency Department
• Assessment and plan that were generated in the Emergency Department.
• Overnight events (i.e. what happened in the Emergency Dept. and after the patient went to their hospital room)? Responses to treatments, changes in symptoms?
• How does the patient feel this morning? Key exam findings this morning (if seen)? Morning labs (if available)?
• Assessment and Plan , with attention as to whether there needs to be any changes in the working differential or treatment plan. The broad organ system categories include (presented here head-to-toe): Neurological; Psychiatric; Cardiovascular; Pulmonary; Gastrointestinal; Renal/Genitourinary; Hematologic/Oncologic; Endocrine/Metabolic; Infectious; Tubes/lines/drains; Disposition.
• Chief concern: 70 yo male who presented with 10 days of progressive shoulder pain, followed by confusion. He was brought in by his daughter, who felt that her father was no longer able to safely take care for himself.
• 10 days ago, Mr. X developed left shoulder pain, first noted a few days after lifting heavy boxes. He denies falls or direct injury to the shoulder.
• 1 week ago, presented to outside hospital ER for evaluation of left shoulder pain. Records from there were notable for his being afebrile with stable vitals. Exam notable for focal pain anteriorly on palpation, but no obvious deformity. Right shoulder had normal range of motion. Left shoulder reported as diminished range of motion but not otherwise quantified. X-ray negative. Labs remarkable for wbc 8, creat 2.2 (stable). Impression was that the pain was of musculoskeletal origin. Patient was provided with Percocet and told to see PMD in f/u
• Brought to our ER last night by his daughter. Pain in shoulder worse. Also noted to be confused and unable to care for self. Lives alone in the country, home in disarray, no food.
• ROS: negative for falls, prior joint or musculoskeletal problems, fevers, chills, cough, sob, chest pain, head ache, abdominal pain, urinary or bowel symptoms, substance abuse
• Hypertension
• Coronary artery disease, s/p LAD stent for angina 3 y ago, no symptoms since. Normal EF by echo 2 y ago
• Chronic kidney disease stage 3 with creatinine 1.8; felt to be secondary to atherosclerosis and hypertension
• aspirin 81mg qd, atorvastatin 80mg po qd, amlodipine 10 po qd, Prozac 20
• Allergies: none
• Family and Social: lives alone in a rural area of the county, in contact with children every month or so. Retired several years ago from work as truck driver. Otherwise non-contributory.
• Habits: denies alcohol or other drug use.
• Temp 98 Pulse 110 BP 100/70
• Drowsy though arousable; oriented to year but not day or date; knows he’s at a hospital for evaluation of shoulder pain, but doesn’t know the name of the hospital or city
• CV: regular rate and rhythm; normal s1 and s2; no murmurs or extra heart sounds.
• Left shoulder with generalized swelling, warmth and darker coloration compared with Right; generalized pain on palpation, very limited passive or active range of motion in all directions due to pain. Right shoulder appearance and exam normal.
• CXR: normal
• EKG: sr 100; nl intervals, no acute changes
• WBC 13; hemoglobin 14
• Na 134, k 4.6; creat 2.8 (1.8 baseline 4 m ago); bicarb 24
• LFTs and UA normal
• Vancomycin and Zosyn for now
• Orthopedics to see asap to aspirate shoulder for definitive diagnosis
• If aspiration is consistent with infection, will need to go to Operating Room for wash out.
• Urine electrolytes
• Follow-up on creatinine and obtain renal ultrasound if not improved
• Renal dosing of meds
• Strict Ins and Outs.
• follow exam
• obtain additional input from family to assure baseline is, in fact, normal
• Since admission (6 hours) no change in shoulder pain
• This morning, pleasant, easily distracted; knows he’s in the hospital, but not date or year
• T Current 101F Pulse 100 BP 140/80
• Ins and Outs: IVF Normal Saline 3L/Urine output 1.5 liters
• L shoulder with obvious swelling and warmth compared with right; no skin breaks; pain limits any active or passive range of motion to less than 10 degrees in all directions
• Labs this morning remarkable for WBC 10 (from 13), creatinine 2 (down from 2.8)
• Continue with Vancomycin and Zosyn for now
• I already paged Orthopedics this morning, who are en route for aspiration of shoulder, fluid for gram stain, cell count, culture
• If aspirate consistent with infection, then likely to the OR
• Continue IVF at 125/h, follow I/O
• Repeat creatinine later today
• Not on any nephrotoxins, meds renaly dosed
• Continue antibiotics, evaluation for primary source as above
• Discuss with family this morning to establish baseline; possible may have underlying dementia as well
• SC Heparin for DVT prophylaxis
• Code status: full code/full care.

Outpatient-based presentations

There are 4 main types of visits that commonly occur in an outpatient continuity clinic environment, each of which has its own presentation style and purpose. These include the following, each described in detail below.

• The patient who is presenting for their first visit to a primary care clinic and is entirely new to the physician.
• The patient who is returning to primary care for a scheduled follow-up visit.
• The patient who is presenting with an acute problem to a primary care clinic
• The specialty clinic evaluation (new or follow-up)

It’s worth noting that Primary care clinics (Internal Medicine, Family Medicine and Pediatrics) typically take responsibility for covering all of the patient’s issues, though the amount of energy focused on any one topic will depend on the time available, acuity, symptoms, and whether that issue is also followed by a specialty clinic.

The Brand New Primary Care Patient

Purpose of the presentation

• Accurately review all of the patient’s history as well as any new concerns that they might have.
• Identify health related problems that need additional evaluation and/or treatment
• Provide an opportunity for senior listeners to intervene and offer input

Key features of the presentation

• If this is truly their first visit, then one of the main reasons is typically to "establish care" with a new doctor.
• It might well include continuation of therapies and/or evaluations started elsewhere.
• If the patient has other specific goals (medications, referrals, etc.), then this should be stated as well. Note: There may well not be a "chief complaint."
• For a new patient, this is an opportunity to highlight the main issues that might be troubling/bothering them.
• This can include chronic disorders (e.g. diabetes, congestive heart failure, etc.) which cause ongoing symptoms (shortness of breath) and/or generate daily data (finger stick glucoses) that should be discussed.
• Sometimes, there are no specific areas that the patient wishes to discuss up-front.
• Review of systems (ROS): This is typically comprehensive, covering all organ systems. If the patient is known to have certain illnesses (e.g. diabetes), then the ROS should include the search for disorders with high prevalence (e.g. vascular disease). There should also be some consideration for including questions that are epidemiologically appropriate (e.g. based on age and sex).
• Past Medical History (PMH): All known medical conditions (in particular those requiring ongoing treatment) are listed, noting their duration and time of onset. If a condition is followed by a specialist or co-managed with other clinicians, this should be noted as well. If a problem was described in detail during the “acute” history, it doesn’t have to be re-stated here.
• Past Surgical History (PSH): All surgeries, along with the year when they were performed
• Medications and allergies: All meds, including dosage, frequency and over-the-counter preparations. Allergies (and the type of reaction) should be described.
• Social: Work, hobbies, exposures.
• Sexual activity – may include type of activity, number and sex of partner(s), partner’s health.
• Smoking, Alcohol, other drug use: including quantification of consumption, duration of use.
• Family history: Focus on heritable illness amongst first degree relatives. May also include whether patient married, in a relationship, children (and their ages).
• Physical Exam: Vital signs and relevant findings (or their absence).
• Key labs and imaging if they’re available. Also when and where they were obtained.
• Summary, assessment & plan(s) presented by organ system and/or problems. As many systems/problems as is necessary to cover all of the active issues that are relevant to that clinic. This typically concludes with a “health care maintenance” section, which covers age, sex and risk factor appropriate vaccinations and screening tests.

The Follow-up Visit to a Primary Care Clinic

• Organize the presenter (forces you to think things through).
• Accurately review any relevant interval health care events that might have occurred since the last visit.
• Identification of new symptoms or health related issues that might need additional evaluation and/or treatment
• If the patient has no concerns, then verification that health status is stable
• Review of medications
• Provide an opportunity for listeners to intervene and offer input
• Reason for the visit: Follow-up for whatever the patient’s main issues are, as well as stating when the last visit occurred *Note: There may well not be a “chief complaint,” as patients followed in continuity at any clinic may simply be returning for a visit as directed by their doctor.
• Events since the last visit: This might include emergency room visits, input from other clinicians/specialists, changes in medications, new symptoms, etc.
• Review of Systems (ROS): Depth depends on patient’s risk factors and known illnesses. If the patient has diabetes, then a vascular ROS would be done. On the other hand, if the patient is young and healthy, the ROS could be rather cursory.
• PMH, PSH, Social, Family, Habits are all OMITTED. This is because these facts are already known to the listener and actionable aspects have presumably been added to the problem list (presented at the end). That said, these elements can be restated if the patient has a new symptom or issue related to a historical problem has emerged.
• MEDS : A good idea to review these at every visit.
• Physical exam: Vital signs and pertinent findings (or absence there of) are mentioned.
• Lab and Imaging: The reason why these were done should be mentioned and any key findings mentioned, highlighting changes from baseline.
• Assessment and Plan: This is most clearly done by individually stating all of the conditions/problems that are being addressed (e.g. hypertension, hypothyroidism, depression, etc.) followed by their specific plan(s). If a new or acute issue was identified during the visit, the diagnostic and therapeutic plan for that concern should be described.

The Focused Visit to a Primary Care Clinic

• Accurately review the historical events that lead the patient to make the appointment.
• Identification of risk factors and/or other underlying medical conditions that might affect the diagnostic or therapeutic approach to the new symptom or concern.
• Generate an appropriate assessment and plan
• Allow the listener to comment

Key features of the presentation:

• Reason for the visit
• History of Present illness: Description of the sequence of symptoms and/or events that lead to the patient’s current condition.
• Review of Systems: To an appropriate depth that will allow the listener to grasp the full range of diagnostic possibilities that relate to the presenting problem.
• PMH and PSH: Stating only those elements that might relate to the presenting symptoms/issues.
• PE: Vital signs and key findings (or lack thereof)
• Labs and imaging (if done)
• Assessment and Plan: This is usually very focused and relates directly to the main presenting symptom(s) or issues.

The Specialty Clinic Visit

Specialty clinic visits focus on the health care domains covered by those physicians. For example, Cardiology clinics are interested in cardiovascular disease related symptoms, events, labs, imaging and procedures. Orthopedics clinics will focus on musculoskeletal symptoms, events, imaging and procedures. Information that is unrelated to these disciples will typically be omitted. It’s always a good idea to ask the supervising physician for guidance as to what’s expected to be covered in a particular clinic environment.

• Highlight the reason(s) for the visit
• Review key data
• Provide an opportunity for the listener(s) to comment
• 5-7 minutes
• If it’s a consult, state the main reason(s) that the patient was referred as well as who referred them.
• If it’s a return visit, state the reasons why the patient is being followed in the clinic and when the last visit took place
• If it’s for an acute issue, state up front what the issue is Note: There may well not be a “chief complaint,” as patients followed in continuity in any clinic may simply be returning for a return visit as directed
• For a new patient, this highlights the main things that might be troubling/bothering the patient.
• For a specialty clinic, the history presented typically relates to the symptoms and/or events that are pertinent to that area of care.
• Review of systems , focusing on those elements relevant to that clinic. For a cardiology patient, this will highlight a vascular ROS.
• PMH/PSH that helps to inform the current presentation (e.g. past cardiac catheterization findings/interventions for a patient with chest pain) and/or is otherwise felt to be relevant to that clinic environment.
• Meds and allergies: Typically all meds are described, as there is always the potential for adverse drug interactions.
• Social/Habits/other: as relates to/informs the presentation and/or is relevant to that clinic
• Family history: Focus is on heritable illness amongst first degree relatives
• Physical Exam: VS and relevant findings (or their absence)
• Key labs, imaging: For a cardiology clinic patient, this would include echos, catheterizations, coronary interventions, etc.
• Summary, assessment & plan(s) by organ system and/or problems. As many systems/problems as is necessary to cover all of the active issues that are relevant to that clinic.
• Reason for visit: Patient is a 67 year old male presenting for first office visit after admission for STEMI. He was referred by Dr. Goins, his PMD.
• The patient initially presented to the ER 4 weeks ago with acute CP that started 1 hour prior to his coming in. He was found to be in the midst of a STEMI with ST elevations across the precordial leads.
• Taken urgently to cath, where 95% proximal LAD lesion was stented
• EF preserved by Echo; Peak troponin 10
• In-hospital labs were remarkable for normal cbc, chem; LDL 170, hdl 42, nl lfts
• Uncomplicated hospital course, sent home after 3 days.
• Since home, he states that he feels great.
• Denies chest pain, sob, doe, pnd, edema, or other symptoms.
• No symptoms of stroke or TIA.
• No history of leg or calf pain with ambulation.
• Prior to this admission, he had a history of hypertension which was treated with lisinopril
• 40 pk yr smoking history, quit during hospitalization
• No known prior CAD or vascular disease elsewhere. No known diabetes, no family history of vascular disease; He thinks his cholesterol was always “a little high” but doesn’t know the numbers and was never treated with meds.
• History of depression, well treated with prozac
• Discharge meds included: aspirin, metoprolol 50 bid, lisinopril 10, atorvastatin 80, Plavix; in addition he takes Prozac for depression
• Taking all of them as directed.
• Patient lives with his wife; they have 2 grown children who are no longer at home
• Works as a computer programmer
• Smoking as above
• ETOH: 1 glass of wine w/dinner
• No drug use
• No known history of cardiovascular disease among 2 siblings or parents.
• Well appearing; BP 130/80, Pulse 80 regular, 97% sat on Room Air, weight 175lbs, BMI 32
• Lungs: clear to auscultation
• CV: s1 s2 no s3 s4 murmur
• No carotid bruits
• ABD: no masses
• Ext; no edema; distal pulses 2+
• Cath from 4 weeks ago: R dominant; 95% proximal LAD; 40% Cx.
• EF by TTE 1 day post PCI with mild Anterior Hypokinesis, EF 55%, no valvular disease, moderate LVH
• Labs of note from the hospital following cath: hgb 14, plt 240; creat 1, k 4.2, lfts normal, glucose 100, LDL 170, HDL 42.
• EKG today: SR at 78; nl intervals; nl axis; normal r wave progression, no q waves
• Plan: aspirin 81 indefinitely, Plavix x 1y
• Given nitroglycerine sublingual to have at home.
• Reviewed symptoms that would indicate another MI and what to do if occurred
• Plan: continue with current dosages of meds
• Chem 7 today to check k, creatinine
• Plan: Continue atorvastatin 80mg for life
• Smoking cessation: Doing well since discharge without adjuvant treatments, aware of supports.
• Plan: AAA screening ultrasound

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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Oral Case Presentations

The purpose of the oral case presentation is:

• To concisely communicate the findings of your history and exam to other members of your team
• To formulate and address the clinical questions that are important to your patient’s care

On completion of Foundations of Clinical Medicine, students should be able to perform an accurate, complete and well organized comprehensive oral case presentation for a new clinic or hospital patient, and adapt the case presentation to different clinical settings.   A comprehensive OCP includes each of these sections:

The oral case presentation is a mechanism for communicating with your team, which may include residents, attending physicians, nurses, social workers, pharmacists. Your audience may also include the patient and family if it is presented at the hospital bedside.

An oral case presentation includes only a SUBSET of the information that you record in your write-up, the information the team needs to provide care.  The write-up contains ALL the facts while the OCP includes the facts needed to understand and address the current issues.

Purpose and format of each section

Identifying information & chief concern (id/cc).

Purpose: Sets the stage and gives a brief synopsis of the patient’s major problem.

Format: Same as in your writeup!

• Identify the patient by name and age. You can also include gender identity, if confirmed.
• Include no more than four medical problems (sometimes there are zero) that are highly relevant   to the chief concern. List only the diagnoses here, and elaborate on them in the HPI or PMH.
• Report the chief concern and duration of symptoms

Template: “___ is a ___ year-old with a history of ___ who presents with ___ of ___ duration.”

History of present illness (HPI)

Purpose: Provides a complete account of the presenting problem, including any information from the past medical, family and social history related to that problem.

Content: The same as the HPI in the write up! Most new diagnoses are made based on the HPI so this is the most important part.  It should take up 1/3 to 1/2 of your presentation time.

• Background health. If the presenting problem is related to a chronic illness, summarize that illness here.
• Detailed, chronologic description of the presenting problem
• Predisposing conditions and risk factors (a.k.a ‘pertinent positives’)
• Pertinent negatives.  Symptoms from the affected organ system and risk factors that the patient doesn’t have
• Optional: Evaluation or hospital course to date

Past Medical History (PMH)

Purpose: To provide a succinct overview of other important medical and surgical history that will aid in the care of the patient.

Format: Report ONLY active medical problems and other medical history that is pertinent to evaluation or ongoing management. Medical or surgical history that is relevant to the chief concern should be included in the HPI.

If a past diagnosis or surgery is not active or relevant, it is included in the write-up but NOT in the OCP.

Template: Include a brief synopsis of each active major problem – remember POTS

• S ymptoms and control

Medications and Allergies

• List all prescribed medications (by generic name if possible) and doses
• List all non-prescription medications and complementary/alternative therapies
• Report any drug allergies and the type of reaction

Social History

Purpose: To provide your listener with the social context of the illness and its impact on ongoing care

Format: In 2-3 sentences summarize the patient’s living situation and support systems, occupation, identity, and any social issues that could impact care.

Health Related Behaviors

• Summarize substance use not already mentioned in HPI, including tobacco, alcohol, drug use
• Risk factors relevant to the presenting concern should be included in the HPI

Physical Examination

Purpose: Succinctly and accurately describe the patient’s physical examination, emphasizing pertinent findings

Format: Begin with general appearance and vital signs. Name each organ system in order, and report the relevant exam:

• HEENT and Neck
• Musculoskeletal

Report all pertinent physical examination findings, both normal and abnormal:

• Complete exam of the organ system(s) relevant to the chief concern
• Other findings (normal or abnormal) that help your listener answer a clinical question.

Use concise but complete descriptions of positive findings.

• Report all abnormal findings regardless of organ system.
• If the examination of a system NOT relevant to the chief concern was normal, you may say “Normal”.

Summary Statement: The lead in to your assessment

Purpose: To synthesize the important history and exam findings, to frame the clinical problem and to lead your listener into your assessment.  This is NOT simply a restatement of the ID chief concern.

Format: Restate the identifying data and summarize the key features from the patient’s history and physical exam.

Template: “In summary, NAME is a AGE year old patient who presents with a history of PRESENTING CONCERN AND MAJOR ASSOCIATED SYMPTOMS . Their history is notable for KEY ELEMENTS OF HISTORY THAT IMPACT YOUR ASSESSMENT . Physical exam is notable for KEY FINDINGs   THAT IMPACT YOUR ASSESSMENT .

Purpose: Address the clinical problem and demonstrate your clinical reasoning.  The clinical problem may range from a new and undiagnosed problem to routine follow-up of a chronic problem. The format varies for each.

For an undiagnosed problem.

Your assessment would address the top 3-4 items on the differential diagnosis suggested by your patient’s history and exam findings

Example: The most likely reason for Lily’s rash is eczema. Her skin dryness and pruritis, and her family history of atopy are all consistent with eczema, as is the history of worsening in the winter and after frequent swimming. She also has a classic distribution on the hands and elbow creases. A less likely possibility is scabies, which frequently affects the hands. However, Lily’s skin between the wrists and elbows is spared, which would be atypical for scabies.

For an exacerbation of a chronic problem.

Your assessment would address the most likely reasons for the exacerbation, as suggested by your patient’s history and exam findings.

Example: The most likely reason for Mr. C’s CHF exacerbation is medication nonadherence due to both costs and confusion. He reports filling his medications less often than monthly because even the co-pay is expensive, which is confirmed by his pharmacy. Although he manages his own medications, he is unable to accurately describe what each is for, or his dosing schedule. A second possibility is new ischemia; however, he’s had no chest pain or tightness, and initial ECG and enzymes were negative. Finally, a URI could have precipitated this exacerbation, as he had low grade fever, cough, and rhinorrhea last week. However, those symptoms have resolved as his edema and shortness of breath have progressed, making this possibility less likely.

Routine follow-up of a chronic problem.

Your assessment would address current control of the problem, evidence of complications, and adequacy of current education and treatment.

Example:   Ms. B’s type 2 diabetes is well controlled, with most recent HgbA1c of 6.8. She reports excellent adherence to diet and exercise, as well as metformin. She has no evidence of retinopathy or neuropathy on exam and urine for microalbumin was negative.

Purpose: To outline your next steps in addressing your patient’s clinical problem(s).

Format: The plan is usually presented as a bulleted list, and may include interventions in these categories:

Delivery Tips for Oral Case Presentations:

• At the bedside, introduce your patient and any family members to all members of your team.
• Establish eye contact with your team and your patient, glancing at your notes only as necessary.
• Present with a clear, energetic, and interested voice.
• When presenting at the bedside, recognize the impact of your choice of words on your patient. Avoid medical language that might frighten your patient, unless he has used it. Examples: “ End-stage liver disease ” and “ Another possibility is lung cancer… ”
• Avoid language your patient might find insulting. Examples: “O bese” and “Pleasantly confused elderly woman. ”
• Follow the standard format of the OCP precisely.
• Orient your listeners to the next section of the OCP with a brief pause followed by the title of that section.
• Use precise language.
• Do not rationalize, editorialize, or justify as you present. Just present the “facts”.
• Be aware of your patient’s confidentiality, especially if the patient is in a shared room.

Example OCP

References & resources.

The FCM OCP Benchmark is adapted from Dr. Steve McGee’s Guidelines for OCPs on the Third Year Internal Medicine Clerkship.  These guidelines are too advanced for what you know at the beginning of medical school but by the time you reach the Patient Care Phase, you should be able to follow them. Current version is available here. Oral Case Presentation (uw.edu)

This work ( Oral Case Presentations by Karen McDonough) is free of known copyright restrictions.

How to make an oral case presentation to healthcare colleagues

The content and delivery of a patient case for education and evidence-based care discussions in clinical practice.

BSIP SA / Alamy Stock Photo

A case presentation is a detailed narrative describing a specific problem experienced by one or more patients. Pharmacists usually focus on the medicines aspect , for example, where there is potential harm to a patient or proven benefit to the patient from medication, or where a medication error has occurred. Case presentations can be used as a pedagogical tool, as a method of appraising the presenter’s knowledge and as an opportunity for presenters to reflect on their clinical practice [1] .

The aim of an oral presentation is to disseminate information about a patient for the purpose of education, to update other members of the healthcare team on a patient’s progress, and to ensure the best, evidence-based care is being considered for their management.

Within a hospital, pharmacists are likely to present patients on a teaching or daily ward round or to a senior pharmacist or colleague for the purpose of asking advice on, for example, treatment options or complex drug-drug interactions, or for referral.

Content of a case presentation

As a general structure, an oral case presentation may be divided into three phases [2] :

• Reporting important patient information and clinical data;
• Analysing and synthesising identified issues (this is likely to include producing a list of these issues, generally termed a problem list);
• Managing the case by developing a therapeutic plan.

Specifically, the following information should be included [3] :

Patient and complaint details

Patient details: name, sex, age, ethnicity.

Presenting complaint: the reason the patient presented to the hospital (symptom/event).

History of presenting complaint: highlighting relevant events in chronological order, often presented as how many days ago they occurred. This should include prior admission to hospital for the same complaint.

Review of organ systems: listing positive or negative findings found from the doctor’s assessment that are relevant to the presenting complaint.

Past medical and surgical history

Social history: including occupation, exposures, smoking and alcohol history, and any recreational drug use.

Medication history, including any drug allergies: this should include any prescribed medicines, medicines purchased over-the-counter, any topical preparations used (including eye drops, nose drops, inhalers and nasal sprays) and any herbal or traditional remedies taken.

Sexual history: if this is relevant to the presenting complaint.

Details from a physical examination: this includes any relevant findings to the presenting complaint and should include relevant observations.

Laboratory investigation and imaging results: abnormal findings are presented.

Assessment: including differential diagnosis.

Plan: including any pharmaceutical care issues raised and how these should be resolved, ongoing management and discharge planning.

Any discrepancies between the current management of the patient’s conditions and evidence-based recommendations should be highlighted and reasons given for not adhering to evidence-based medicine ( see ‘Locating the evidence’ ).

Locating the evidence

The evidence base for the therapeutic options available should always be considered. There may be local guidance available within the hospital trust directing the management of the patient’s presenting condition. Pharmacists often contribute to the development of such guidelines, especially if medication is involved. If no local guidelines are available, the next step is to refer to national guidance. This is developed by a steering group of experts, for example, the British HIV Association or the National Institute for Health and Care Excellence . If the presenting condition is unusual or rare, for example, acute porphyria, and there are no local or national guidelines available, a literature search may help locate articles or case studies similar to the case.

Giving a case presentation

Currently, there are no available acknowledged guidelines or systematic descriptions of the structure, language and function of the oral case presentation [4] and therefore there is no standard on how the skills required to prepare or present a case are taught. Most individuals are introduced to this concept at undergraduate level and then build on their skills through practice-based learning.

A case presentation is a narrative of a patient’s care, so it is vital the presenter has familiarity with the patient, the case and its progression. The preparation for the presentation will depend on what information is to be included.

Generally, oral case presentations are brief and should be limited to 5–10 minutes. This may be extended if the case is being presented as part of an assessment compared with routine everyday working ( see ‘Case-based discussion’ ). The audience should be interested in what is being said so the presenter should maintain this engagement through eye contact, clear speech and enthusiasm for the case.

It is important to stick to the facts by presenting the case as a factual timeline and not describing how things should have happened instead. Importantly, the case should always be concluded and should include an outcome of the patient’s care [5] .

An example of an oral case presentation, given by a pharmacist to a doctor,  is available here .

A successful oral case presentation allows the audience to garner the right amount of patient information in the most efficient way, enabling a clinically appropriate plan to be developed. The challenge lies with the fact that the content and delivery of this will vary depending on the service, and clinical and audience setting [3] . A practitioner with less experience may find understanding the balance between sufficient information and efficiency of communication difficult, but regular use of the oral case presentation tool will improve this skill.

Tailoring case presentations to your audience

Most case presentations are not tailored to a specific audience because the same type of information will usually need to be conveyed in each case.

However, case presentations can be adapted to meet the identified learning needs of the target audience, if required for training purposes. This method involves varying the content of the presentation or choosing specific cases to present that will help achieve a set of objectives [6] . For example, if a requirement to learn about the management of acute myocardial infarction has been identified by the target audience, then the presenter may identify a case from the cardiology ward to present to the group, as opposed to presenting a patient reviewed by that person during their normal working practice.

Alternatively, a presenter could focus on a particular condition within a case, which will dictate what information is included. For example, if a case on asthma is being presented, the focus may be on recent use of bronchodilator therapy, respiratory function tests (including peak expiratory flow rate), symptoms related to exacerbation of airways disease, anxiety levels, ability to talk in full sentences, triggers to worsening of symptoms, and recent exposure to allergens. These may not be considered relevant if presenting the case on an unrelated condition that the same patient has, for example, if this patient was admitted with a hip fracture and their asthma was well controlled.

Case-based discussion

The oral case presentation may also act as the basis of workplace-based assessment in the form of a case-based discussion. In the UK, this forms part of many healthcare professional bodies’ assessment of clinical practice, for example, medical professional colleges.

For pharmacists, a case-based discussion forms part of the Royal Pharmaceutical Society (RPS) Foundation and Advanced Practice assessments . Mastery of the oral case presentation skill could provide useful preparation for this assessment process.

A case-based discussion would include a pharmaceutical needs assessment, which involves identifying and prioritising pharmaceutical problems for a particular patient. Evidence-based guidelines relevant to the specific medical condition should be used to make treatment recommendations, and a plan to monitor the patient once therapy has started should be developed. Professionalism is an important aspect of case-based discussion — issues must be prioritised appropriately and ethical and legal frameworks must be referred to [7] . A case-based discussion would include broadly similar content to the oral case presentation, but would involve further questioning of the presenter by the assessor to determine the extent of the presenter’s knowledge of the specific case, condition and therapeutic strategies. The criteria used for assessment would depend on the level of practice of the presenter but, for pharmacists, this may include assessment against the RPS  Foundation or Pharmacy Frameworks .

Acknowledgement

With thanks to Aamer Safdar for providing the script for the audio case presentation.

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[1] Onishi H. The role of case presentation for teaching and learning activities. Kaohsiung J Med Sci 2008;24:356–360. doi: 10.1016/s1607-551x(08)70132–3

[2] Edwards JC, Brannan JR, Burgess L et al . Case presentation format and clinical reasoning: a strategy for teaching medical students. Medical Teacher 1987;9:285–292. doi: 10.3109/01421598709034790

[3] Goldberg C. A practical guide to clinical medicine: overview and general information about oral presentation. 2009. University of California, San Diego. Available from: https://meded.ecsd.edu/clinicalmed.oral.htm (accessed 5 December 2015)

[4] Chan MY. The oral case presentation: toward a performance-based rhetorical model for teaching and learning. Medical Education Online 2015;20. doi: 10.3402/meo.v20.28565

[5] McGee S. Medicine student programs: oral presentation guidelines. Learning & Scholarly Technologies, University of Washington. Available from: https://catalyst.uw.edu/workspace/medsp/30311/202905 (accessed 7 December 2015)

[6] Hays R. Teaching and Learning in Clinical Settings. 2006;425. Oxford: Radcliffe Publishing Ltd.

[7] Royal Pharmaceutical Society. Tips for assessors for completing case-based discussions. 2015. Available from: http://www.rpharms.com/help/case_based_discussion.htm (accessed 30 December 2015)

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ORAL CASE PRESENTATION

Oct 15, 2017 | Clinical Teaching

• Oral case presentations are the fundamental way in which we communicate in medicine. To do this effectively, the content should be organized, clear, succinct, and with sufficient repetition to ensure understanding.
• Experts build OCPs by first considering the diagnoses they have in mind, then distilling the narrative in a way that implicitly highlights information relevant to the diagnoses under consideration.
• OCPs follow the same organization as a written H&P, and effective transition sentences ensure that listeners remain oriented to each relevant section.
• The OCP assessment is an opportunity to highlight important findings, using repetition to ensure understanding among listeners.

Additional Resources

• Oral Case Presentation (PDF)

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The Oral Case Presentation : A Key Tool for Assessment and Teaching in Competency-Based Medical Education

• 1 Wilson Centre, University of Toronto, Toronto, Ontario, Canada
• 2 Department of Medicine, University of Toronto, Toronto, Ontario, Canada
• 3 HoPingKong Centre, University Health Network, Toronto, Ontario, Canada

Oral case presentations by trainees to supervisors are core activities in academic hospitals across all disciplines and form a key milestone in US and Canadian educational frameworks. Yet despite their widespread use, there has been limited attention devoted to developing case presentations as tools for structured teaching and assessment. In this Viewpoint, we discuss the challenges in using oral case presentations in medical education, including lack of standardization, high cognitive demands, and the role of trust between supervisor and trainee. We also articulate how, by addressing these tensions, case presentations can play an important role in competency-based education, both for assessment of clinical competence and for teaching clinical reasoning.

Read More About

Melvin L , Cavalcanti RB. The Oral Case Presentation : A Key Tool for Assessment and Teaching in Competency-Based Medical Education . JAMA. 2016;316(21):2187–2188. doi:10.1001/jama.2016.16415

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The Oral Case Presentation: Time for a “Refresh”

• Perspective
• Published: 25 June 2021
• Volume 36 , pages 3852–3856, ( 2021 )

Cite this article

• Rebecca Rodin MD, MSc 1 ,
• Sagar Rohailla MD, MSc 2 &
• Allan S. Detsky MD, PhD, CM   ORCID: orcid.org/0000-0003-2772-3121 3 , 4  

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Despite enormous changes in medicine over the last 50 years, the oral presentation of newly admitted patients remains a core activity in academic teaching hospitals. With increased pace and complexity of care, it is time to refresh this tradition, as its efficiency and utility in contemporary practice are open to question. In this paper, we suggest a revised structure to help presenters organize their thoughts before the oral presentation and provide an online tool for doing so. We then offer tips on how to present the facts and inferences to the team in a compelling and memorable fashion; how to tell a story. Organizing information and oral presentation are advanced skills that require repeated practice to learn.

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General internal medicine inpatient units in North American academic medical centers feature routines that reflect the team hierarchy and workflow of patient care. Resident physicians and medical students gather data about patients they admit to the hospital, and present that information, their inferences, and plans to the other members of the team including the attending physician, who also uses that opportunity to evaluate the learners’ clinical skills. The purpose of this oral case presentation is to transmit a mental image of a patient’s story (including diagnostic possibilities and treatment plans) from the speaker to the listeners using a story-telling technique. 1 The story features several main components: identifying demographics (the protagonist); chief complaint and history of presenting illness (the plot); past medical, social, and family history (the context); physical examination and test results (rising or falling action); and summary assessment and diagnostic and treatment plan (resolution).

Medical students are taught at a rudimentary stage to be thorough when gathering the data about their patient—to leave no stone unturned. This tradition dates back more than a century, 2 and while some aspects of the process have evolved over time, learners are still encouraged to explore an exhaustive and detailed list of positive and negative findings. 3 , 4 , 5 Learners are then encouraged to display their thoroughness by reciting all of these details during their oral presentations, in part to transmit the data, and in part to show they gathered it. While such traditions have nostalgic appeal, their efficiency and utility in contemporary practice are open to question.

In the modern era, patient volumes and acuity are high, and many more and different physicians participate in the care of individual patients 6 —the pace of medicine is faster. Time constraints require effective and efficient communication to ensure that the mental image of each patient is successfully transmitted with information that is sufficient but not overwhelming. There is therefore an urgent need to modify the structure of the traditional oral case presentation for new patients to better suit this evolving landscape of chaos and cacophony. 6 , 7 In this paper, we first suggest a revised structure to help presenters organize their thoughts before the oral presentation and provide an online tool for doing so. We then offer tips on how to present the facts and inferences to the team in a compelling and memorable fashion. The process we describe here takes place between the time the consultation or admission note is written and the patient is presented to the rest of the team. This preparation technique can be used for either bedside or classroom presentations.

TEMPLATE FOR ORGANIZING INFORMATION BEFORE THE PRESENTATION

Learners should be instructed to complete this form ( accessed here ; Fig. 1 ) for each patient they admit to hospital. We suggest providing paper or electronic copies delivered from and to Health Insurance Portability and Accountability Act (HIPPA)–complying email addresses to each team member at the time of the oral presentation as a visual and cognitive aid. Although some might argue that visual aids may take away from the story tellers’ ability to captivate their audiences, we find that listeners often get distracted, so the visual aid helps to bring them back. This fillable template comprises a series of nudges that cue the presenter to share information that listeners need to know about each patient (Table 1 ). It differs from the way the story is told orally, with some of the information left unspoken (hence the need for providing copies).

New patient template.

The top of the form designates two content areas that are commonly overlooked by trainees: (1) patient identification, contact, and insurance information; (2) names of prior treating physicians: primary care physician, specialists relevant to the current issue, and referring physician. Gathering these names enables other members of the team to communicate with any of these physicians to learn more about the patient, discuss their treatments, provide updates in real time, and secure follow-up upon discharge. Verbal confirmation of contact information from the patient or family member is essential to ensure that follow-up care occurs—we have all experienced the frustration of trying to arrange care when the documented phone number turns out to be incorrect.

The form’s medication section uses the following subheadings: new medications, changed medications (i.e., dose or frequency changes to existing medications), stable cardiac medications, stable respiratory medications, and other medications (e.g., diabetes drugs, analgesics). This format differs from the typical presentation of patient medications, which is often loosely organized by system or disease (e.g., cardiac drugs first, respiratory drugs second, diabetes drugs third, analgesics fourth). While systematic, that approach may make new or changed medications easy to miss. Our structure helps to identify drug-related complications and toxicity, which account for approximately 15% of all hospital admissions, a proportion that grows with increasing age, comorbidity, and polypharmacy. 8 Drawing attention to the “new” and “changed” categories on the admission template helps to ensure that the presenter and the receiving team consider these as possible causes of a patient’s presentation to hospital.

The next section of the admission template comprises the main narrative, organized into 10 “focal findings” that best summarize the patient’s story. This task requires the presenter to reflect and synthesize information, particularly in complex cases, from the history, physical exam, and investigations. The first focal finding of every case should always be the identifying demographics: age, sex, gender, and whence the patient came (e.g., home, another hospital, long-term care, shelter).

The second focal finding should be the chief concern—the patient’s reason for coming to hospital in their own stated words. In reporting this finding during the oral presentation, the presenter should be explicit in describing the reason for the patient’s transition from where they were (e.g., home) to where they are now (i.e., the hospital). Identifying both the primary symptom of the patient and the trigger for coming to hospital focusses the listener on why the patient is under their care. For example, a patient with abdominal pain for a few weeks may have decided to come to hospital only when becoming unable to tolerate oral intake—raising important diagnostic considerations, such as bowel obstruction or acute kidney injury.

Following the identifying demographics and chief concern, the presenter has 8 focal findings left to describe the rest of the story. These may be anything from the patient’s history (including social context), physical examination, test results, or previous opinions from other clinicians that are relevant to the current presentation. Clustering related information together into a single focal finding can assist with efficiency in conceptualizing the patient’s story and disease processes. For example, “hepatitis B ➔ cirrhosis ➔ hepatic encephalopathy” could be listed as one focal finding and “alcohol use disorder ➔ prior withdrawal seizure ➔ last drink 48 hours ago” as another. Each focal finding should contain unique and relevant information for the listener to shape their mental image of the patient and to flag important issues. For example, penicillin allergy could be a clinically relevant focal finding for a patient presenting with fever, cough, and consolidation on chest x-ray, when antibiotic therapy may be considered. Such focal findings are communicated on the form not merely for the sake of documentation, but to stimulate a process of thinking about all the facts and findings of the case. Identifying which among them are important to understanding the cause and goals of this hospital visit helps to organize information in a way that tells a concise and coherent story about the patient.

The most important thing to note is that filling out the form is not about the writing, it is about the thinking: do not just write down all the facts again, write just a few words to evoke the key facts. It is worth noting that these steps, both the clustering of data into one finding and selection of the 10 most important findings, are advanced skills; they will take time and repeated practice to learn.

THE ORAL PRESENTATION: HOW TO TELL A COMPELLING STORY

The oral presentation of the story from the ten focal findings can still follow the traditional outline. But we offer the following advice to make it compelling. After stating the identifying information and chief concern, some learners have been taught to give the past medical history in detail. Doing so frustrates the listeners; they want to know why the patient is here now! So while you can list the bullet points of the past history that are relevant to the story first, get to the “history of present illness” (HPI) as soon as possible. One way of signaling the sections of the story is to begin the HPI by saying, “The patient was last well (or in their usual state of health) X days ago, when she noticed the onset of….” This phrase gives the listener the temporal context (like “once upon a time”) which is always an important feature of their story.

Beginning the physical exam section should start with the general inspection. 9 The following phrase is useful here: “When I walked into the room, I saw an X-year-old person who looked….” 9 This cue allows the listener to generate a visual image and often forecasts the end of the story—the diagnosis, treatment, or disposition plan. The remaining physical examination and laboratory findings should be communicated as concisely as possible. Stating, for example, that there were “no peripheral stigmata of infective endocarditis,” can be more effective than listing, “there were no Osler nodes, no Janeway lesions, no splinter hemorrhages, no petechiae” in a patient with fever and new heart murmur. By recording the medications on the form, the presenter does not have to state them if they are not a key part of the story—let the team read them without speaking them. Similarly, there is no need to restate all the blood tests and imaging interpretations; just list the important ones in the template and let the audience ask for others if they need to. Again, doing so is an acquired skill; novices will need to learn it.

SUMMARY, INFERENCES, AND PLANS

The final portion of the oral presentation is the summary, inferred diagnoses, and plans for further tests and treatment, which are reflected in the second half of the admission template form. It is essential, but often challenging, for presenting trainees to commit themselves to their leading diagnostic hypotheses and to explain their reasoning. The admission template facilitates this process by providing a previously published matrix with organ systems on side (e.g., cardiovascular, respiratory, integumentary, hematologic) and etiologies across the top (e.g., infectious, neoplastic, vascular, autoimmune, toxic/metabolic/endocrine). 10 Balanced and critical thinking are required to avoid being led astray in the grand search for unlikely or rare diagnoses, on the one hand, or coming to premature diagnostic closure, on the other. While this matrix has many cells, the purpose is to make the learner commit to the top 2 or 3 diagnoses which can be presented in order of descending probability. And the plan can be limited to the key steps of the patient’s management; the detailed order list can be reviewed after discussion with the team. Of course, the team may well broaden the inferences and plans beyond those listed on the template during and after the oral presentation; but that is the point of learning from patients. An example of a patient story with a completed template is available in the Supplementary Materials as a reference guide.

Organizing thoughts with this template before presenting the story orally may be of particular value to trainees who are learning to perform this skill early in their career. They may also benefit from rehearsing before presenting to the entire team, recording their presentations, and listening back to them to better hone their skills.

The oral case presentation is an art and a skill that has endured through the technological transformation of medicine and takes practice to master. Its most important function is for listeners to absorb key information to determine if the inferences and plans need modification. It is also a stressful experience for early learners because the stakes are high if the information is wrong and because it is one of the key times that they can showcase their critical thinking. While there are many other methods of evaluating learners, we contend that oral presentations dominate the impression they make on their teachers.

We have provided a series of cognitive nudges, in the form of an online tool, and advice about how to tell the story that supports developing presentation skills by cuing both presenters and listeners to think about the salient points in the patient’s story. This process does involve an extra step, and therefore more work. But we believe that especially for early learners (medical students and first year residents), this additional work on the part of the presenter reduces the work and mental energy expended by the listeners in a way that improves overall efficiency. Modifying the ritual of the oral case presentation to meet the demands of modern medicine can help to ensure that information is successfully transmitted. Future work might include ways to incorporate this framework into the electronic medical record or billing processes. For now, we will settle for improving the way we tell each other our patients’ stories.

Glatch S. The 5 elements of dramatic structure; Understanding Freytag’s Pyramid. Writers Com. May 12.2020. https:writers.com/freytags-pyramid.

Harvard Medical School. Guide to patient interview and examination. Harvard Medical School 1974

Hunter KM. Doctors stories: The narrative structure of medical knowledge. Princeton University Press, 1991. Princeton, New Jersey.

Google Scholar  

Mahmud NFF, Ali AM, Yuit CM. Review of studies on oral case presentations in clinical settings. Malaysian Journal of Languages and Linguistics . 2014;3:108-128.

Article   Google Scholar  

Degowin R, et al. Degowin’s Diagnostic Examination. 7th edition. McGraw Hill 2000.

Detsky AS, Berwick DM. Teaching physicians to care amid chaos. JAMA. 2013;309(10):987-988.

Article   CAS   Google Scholar  

Dhaliwal G, Hauer KE. The oral patient presentation in the era of night float admissions: Credit and Critique. JAMA. 2013;310(21):2247-2248.

Ayalew MB, Tegegn HG, Abdela O. Drug related hospital admissions: a systematic review of recent literatures. Bull Emerg Trauma . 2019;7(4):339-346.

Gupta S, Saint S, Detsky AS. Hiding in plain sight: resurrecting the power of inspecting the patient. JAMA. 2017;177(6):757-758.

Sacher AG, Detsky AS. Taking the stress out of morning report: an analytic approach to the differential diagnosis. J Gen Intern Med . 2009;24(6):747-751.

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Acknowledgements

We thank Gurpreet Dhaliwal (University of California San Francisco) and Patrick D. Clarke (University of Vermont Medical School) for providing valuable comments on an earlier draft. He was not compensated for doing so.

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Department of Medicine, University of Toronto, Toronto, Ontario, Canada

Rebecca Rodin MD, MSc

Department of Medicine, North York General Hospital, Toronto, Ontario, Canada

Sagar Rohailla MD, MSc

Institute of Health Policy, Management and Evaluation and Department of Medicine, University of Toronto, Toronto, Ontario, Canada

Allan S. Detsky MD, PhD, CM

Department of Medicine, Sinai Health System, Toronto, Ontario, Canada

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Correspondence to Allan S. Detsky MD, PhD, CM .

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Rodin, R., Rohailla, S. & Detsky, A.S. The Oral Case Presentation: Time for a “Refresh”. J GEN INTERN MED 36 , 3852–3856 (2021). https://doi.org/10.1007/s11606-021-06964-6

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Received : 24 February 2021

Accepted : 04 June 2021

Published : 25 June 2021

Issue Date : December 2021

DOI : https://doi.org/10.1007/s11606-021-06964-6

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Tools for the Patient Presentation

The formal patient presentation.

• Posing the Clinical Question
• Searching the Medical Literature for EBM

Sources & Further Reading

First Aid for the Wards

Lingard L, Haber RJ.  Teaching and learning communications in medicine: a rhetorical approach .  Academic Medicine. 74(5):507-510 1999 May.

Lingard L, Haber RJ.  What do we mean by "relevance"? A clinical and rhetorical definition with implications for teaching and learning the case-presentation format . Academic Medicine. 74(10):S124-S127.

The Oral Presentation (A Practical Guide to Clinical Medicine, UCSD School of Medicine)  http://meded.ucsd.edu/clinicalmed/oral.htm

"Classically, the formal oral presentation is given in 7 minutes or less. Although it follows the same format as a written report, it is not simply regurgitation. A great presentation requires style as much as substance; your delivery must be succinct and smooth. No time should be wasted on superfluous information; one can read about such matters later in your admit note. Ideally, your presentation should be formulated so that your audience can anticipate your assessment and plan; that is, each piece of information should clue the listener into your thinking process and your most likely diagnosis."  [ Le, et al, p. 15 ]

Types of Patient Presentations

New Patient

New patients get the traditional H&P with assessment and plan.  Give the chief complaint and a brief and pertinent HPI.  Next give important PMH, PSH, etc.  The ROS is often left out, as anything important was in the HPI.  The PE is reviewed.  Only give pertinent positives and negatives.  The assessment and plan should include what you think is wrong and, briefly, why.  Then, state what you plan to do for the patient, including labs.  Be sure to know why things are being done: you will be asked.

The follow-up presentation differs from the presentation of a new patient.  It is an abridged presentation, perhaps referencing major patient issues that have been previously presented, but focusing on new information about these issues and/or what has changed. Give the patient’s name, age, date of admission, briefly review the present illness, physical examination and admitting diagnosis.  Then report any new finding, laboratory tests, diagnostic procedures and changes in medications.

The attending physician will ask the patient’s permission to have the medical student present their case.  After making the proper introductions the attending will let the patient know they may offer input or ask questions at any point.  When presenting at bedside the student should try to involve the patient.

Preparing for the Presentation

There are four things you must consider before you do your oral presentation

• Occasion (setting and circumstances)

Ask yourself what do you want the presentation to do

• Present a new patient to your preceptor : the amount of detail will be determined by your preceptor.  It is also likely to reflect your development and experience, with less detail being required as you progress.
• Present your patient at working or teaching rounds : the amount of detail will be determined by the customs of the group. The focus of the presentation will be influenced by the learning objectives of working responsibilities of the group.
• Request a consultant’s advice on a clinical problem : the presentation will be focused on the clinical question being posed to the consultant.
• Persuade others about a diagnosis and plan : a shorter presentation which highlights the pertinent positives and negatives that are germane to the diagnosis and/or plan being suggested.
• Enlist cooperation required for patient care : a short presentation focusing on the impact your audience can have in addressing the patient’s issues.

Preparation

• Patient evaluation : history, physical examination, review of tests, studies, procedures, and consultants’ recommendations.
• Selected reading : reference texts; to build a foundational understanding.
• Literature search : for further elucidation of any key references from selected reading, and to bring your understanding up to date, since reference text information is typically three to seven years old.
• Write-up : for oral presentation, just succinct notes to serve as a reminder or reference, since you’re not going to be reading your presentation.

Knowledge (Be prepared to answer questions about the following)

• Pathophysiology
• Complications
• Differential diagnosis
• Course of conditions
• Diagnostic tests
• Medications
• Essential Evidence Plus

Template for Oral Presentations

Chief Complaint (CC)

The opening statement should give an overview of the patient, age, sex, reason for visit and the duration of the complaint. Give marital status, race, or occupation if relevant.  If your patient has a history of a major medical problem that bears strongly on the understanding of the present illness, include it.  For ongoing care, give a one sentence recap of the history.

History of Present Illness (HPI)

This will be very similar to your written HPI. Present the most important problem first. If there is more than one problem, treat each separately. Present the information chronologically.  Cover one system before going onto the next. Characterize the chief complaint – quality, severity, location, duration, progression, and include pertinent negatives. Items from the ROS that are unrelated to the present problem may be mentioned in passing unless you are doing a very formal presentation. When you do your first patient presentation you may be expected to go into detail.  For ongoing care, present any new complaints.

Review of Systems (ROS)

Most of the ROS is incorporated at the end of the HPI. Items that are unrelated to the present problem may be briefly mentioned.  For ongoing care, present only if new complaints.  

Past Medical History (PMH)

Discuss other past medical history that bears directly on the current medical problem.  For ongoing care, have the information available to respond to questions.

Past Surgical History

Provide names of procedures, approximate dates, indications, any relevant findings or complications, and pathology reports, if applicable.  For ongoing care, have the information available to respond to questions.

Allergies/Medications

Present all current medications along with dosage, route and frequency. For the follow-up presentation just give any changes in medication.  For ongoing care, note any changes.

Smoking and Alcohol (and any other substance abuse)

Note frequency and duration. For ongoing care, have the information available to respond to questions.

Social/Work History

Home, environment, work status and sexual history.  For ongoing care, have the information available to respond to questions.

Family History Note particular family history of genetically based diseases.  For ongoing care, have the information available to respond to questions.

Physical Exam/Labs/Other Tests

Include all significant abnormal findings and any normal findings that contribute to the diagnosis. Give a brief, general description of the patient including physical appearance. Then describe vital signs touching on each major system. Try to find out in advance how thorough you need to be for your presentation. There are times when you will be expected to give more detail on each physical finding, labs and other test results.  For ongoing care, mention only further positive findings and relevant negative findings.

Assessment and Plan

Give a summary of the important aspects of the history, physical exam and formulate the differential diagnosis. Make sure to read up on the patient’s case by doing a search of the literature. 

• Include only the most essential facts; but be ready to answer ANY questions about all aspects of your patient.
• Keep your presentation lively.
• Do not read the presentation!
• Expect your listeners to ask questions.
• Follow the order of the written case report.
• Keep in mind the limitation of your listeners.
• Beware of jumping back and forth between descriptions of separate problems.
• Use the presentation to build your case.
• Your reasoning process should help the listener consider a differential diagnosis.
• Present the patient as well as the illness .
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The oral case presentation: what internal medicine clinician-teachers expect from clinical clerks

Affiliation.

• 1 Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA. [email protected]
• PMID: 21240785
• DOI: 10.1080/10401334.2011.536894

Background: The oral case presentation (OCP) is a fundamental communication skill that frequently is taught as part of internal medicine clerkships. However, little is known about the optimal content for an OCP.

Purpose: We hypothesized that internal medicine clinician-teachers have common expectations regarding OCPs by 3rd-year medical students.

Methods: We administered a 42-item survey to 136 internal medicine faculty members at 5 U.S. medical schools who spent at least 8 weeks as "ward attending" in the 2005-6 academic year, or spent at least 4 weeks as a "ward attending" and had an administrative role in medical education. We asked about the relative importance of 14 potential attributes in a 3rd-year medical student OCP using a 6-point Likert scale. We also asked about their expectations for the length of a new patient presentation. Mean responses from the 5 schools were compared using chi-squared, analysis of variance (ANOVA), and t testing, as appropriate.

Results: We received 106 responses (78% response rate). Of our respondents, 45% were hospitalists and 80% self-identified as "clinician-educators." Some aspects of the OCP were rated as more important than others (p<.001) Six items, including aspects of the history of present illness, organization, and structuring the presentation to "make a case" were rated as important or very important by more than 70% of respondents. Fewer than 10% of respondents believed that inclusion of a complete review of systems or detailed family history were important. Few differences were seen between institutions. Faculty expected that OCPs should take 9.9±5.4 min, with faculty at one institution having significantly different expectations than all others (15.9±6.4 min vs. 7.8±2.8, p<.001).

Conclusions: Internal medicine clinician teachers from 5 U.S. medical schools share common expectations for OCPs.

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Overshadowed by Assessment: Understanding Trainee and Supervisor Perspectives on the Oral Case Presentation in Internal Medicine Workplace-Based Assessment

Melvin, Lindsay MD, MHPE; Rassos, James MD; Panisko, Daniel MD, MPH; Driessen, Erik PhD; Kulasegaram, Kulamakan M. PhD; Kuper, Ayelet MD, DPhil

L. Melvin is assistant professor, Department of Medicine, University of Toronto, and staff physician, Division of General Internal Medicine, University Health Network, Toronto, Ontario, Canada.

J. Rassos is a fifth-year resident, general internal medicine subspecialty training program, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.

D. Panisko is professor, Department of Medicine, University of Toronto, and staff physician, Division of General Internal Medicine, University Health Network, Toronto, Ontario, Canada.

E. Driessen is professor of medical education and chair, Department of Educational Development and Research, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands.

K.M. Kulasegaram is scientist and assistant professor, Department of Family and Community Medicine, Wilson Centre, University Health Network and Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.

A. Kuper is associate professor, Department of Medicine, scientist and associate director, Wilson Centre for Research in Education, University Health Network, University of Toronto, and staff physician, Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.

Funding/Support: None reported.

Other disclosures: None reported.

Ethical approval: Ethical approval was obtained from the Research Ethics Board at the University of Toronto, March 9, 2015; protocol no. 31387.

Previous presentations: Earlier versions of this work have been presented at the International Conference on Residency Education, October 20, 2017, in Quebec City, Quebec, Canada.

Supplemental digital content for this article is available at https://links.lww.com/ACADMED/A599 .

Correspondence should be addressed to Lindsay Melvin, Toronto Western Hospital, 399 Bathurst Street, 8E-425, Toronto, Ontario, Canada M5T 2S8; e-mail: [email protected] .

Purpose 

The oral case presentation (OCP) is an essential part of daily clinical practice in internal medicine (IM) and a key competency in medical education. It is not known how supervisors and trainees perceive OCPs in workplace-based learning and assessment.

Method 

Using a constructivist grounded theory approach, 26 semistructured interviews were held with trainees and supervisors (18 clinical clerks and first- through third-year postgraduate trainees, and 8 supervisors) on the IM clinical teaching unit at the University of Toronto, 2015–2016. Interviews focused on how the OCP was viewed by both trainees and supervisors in clinical practice as a tool for patient care, learning, and assessment. Iterative, constant comparative techniques were used to analyze the interviews and develop a framework to understand trainee and supervisor perspectives.

Results 

Supervisors and trainees viewed the OCP as an important part of informal trainee assessment in IM. Supervisors used OCPs to understand the patient through trainee-demonstrated skills including the use of narratives, information synthesis, and management of uncertainty. However, because of awareness of assessment, trainees sought to control the OCP, viewing it as a performance demonstrating their competence, mediated by senior residents and tailored to supervisor preferences.

Conclusions 

Preoccupied with assessment around OCPs, trainees often lost sight of the valuable learning taking place. Use of OCPs in assessment necessitates optimization of the educational activity for trainees. Providing explicit direction to both trainees and supervisors, defining expectations, and clarifying the assessment activity of the OCP can optimize the encounter for best educational practice.

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Case Presentation Skills

Communicating patient care information to colleagues and other health professionals is an essential skill regardless of specialty. Internists have traditionally given special attention to case presentation skills because of the comprehensive nature of patient evaluations and the various settings in which internal medicine is practiced. Students should develop facility with different types of case presentation: written and oral, new patient and follow-up, inpatient and outpatient.

Prerequisite

Basic written and oral case presentation skills, obtained in physical diagnosis courses.

Specific Learning Objectives

• components of comprehensive and abbreviated case presentations (oral and written) and the settings appropriate for each.
• present illness organized chronologically, without repetition, omission, or extraneous information.
• a comprehensive physical examination with detail pertinent to the patient’s problem.
• a succinct and, where appropriate, unified list of all problems identified in the history and physical examination.
• a differential diagnosis for each problem (appropriate to level of training).
• a diagnosis/treatment plan for each problem (appropriate to level of training).
• orally present a new patient’s case in a logical manner, chronologically developing the present illness, summarizing the pertinent positive and negative findings as well as the differential diagnosis and plans for further testing and treatment.
• orally present a follow-up patient’s case, in a focused, problem-based manner that includes pertinent new findings and diagnostic and treatment plans.
• select the appropriate mode of presentation that is pertinent to the clinical situation.
• demonstrate a commitment to improving case presentation skills by regularly seeking feedback on presentations. accurately and objectively record and present data.

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Comparing oral case presentation formats on internal medicine inpatient rounds: a survey study

Brendan appold.

1 University of Michigan Medical School, Ann Arbor, MI USA

Sanjay Saint

2 VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105 USA

Ashwin Gupta

Associated data.

The data that support the findings of this study are available from the corresponding author, AG, upon reasonable request.

Oral case presentations – structured verbal reports of clinical cases – are fundamental to patient care and learner education. Despite their continued importance in a modernized medical landscape, their structure has remained largely unchanged since the 1960s, based on the traditional Subjective, Objective, Assessment, Plan (SOAP) format developed for medical records. We developed a problem-based alternative known as Events, Assessment, Plan (EAP) to understand the perceived efficacy of EAP compared to SOAP among learners.

We surveyed (Qualtrics, via email) all third- and fourth-year medical students and internal medicine residents at a large, academic, tertiary care hospital and associated Veterans Affairs medical center. The primary outcome was trainee preference in oral case presentation format. The secondary outcome was comparing EAP and SOAP on 10 functionality domains assessed via a 5-point Likert scale. We used descriptive statistics (proportion and mean) to describe the results.

The response rate was 21% (118/563). Of the 59 respondents with exposure to both the EAP and SOAP formats, 69% ( n  = 41) preferred the EAP format as compared to 19% ( n  = 11) who preferred SOAP ( p  < 0.001). EAP outperformed SOAP in 8 out of 10 of the domains assessed, including advancing patient care, learning from patients, and time efficiency.

Conclusions

Our findings suggest that trainees prefer the EAP format over SOAP and that EAP may facilitate clearer and more efficient communication on rounds, which in turn may enhance patient care and learner education. A broader, multi-center study of the EAP oral case presentation will help to better understand preferences, outcomes, and barriers to implementation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-023-04292-3.

Excellent inter-physician communication is fundamental to both providing high-quality patient care and promoting learner education [ 1 ], and has been recognized as an important educational goal by the Clerkship Directors in Internal Medicine, the Association of American Medical Colleges, and the Accreditation Council for Graduate Medical Education [ 2 ]. Oral case presentations, structured verbal reports of clinical cases [ 3 ], have been referred to as the “currency with which clinicians communicate” [ 4 ]. Oral case presentations are a key element of experiential learning in clinical medicine, requiring learners to synthesize, assess, and convey pertinent patient information and to formulate care plans. Furthermore, oral case presentations allow supervising clinicians to identify gaps in knowledge or clinical reasoning and enable team members to learn from one another. Despite modernization in much of medicine, oral case presentation formats have remained largely unchanged, based on the traditional Subjective, Objective, Assessment, Plan (SOAP) format developed by Dr. Lawrence Weed in his Problem Oriented Medical Record in 1968 [ 5 ].

Given that the goals of a medical record are different than those of oral case presentations, it should not be assumed that they should share the same format. While Dr. Weed sought to make the medical record as “complete as possible,” [ 6 ] internal medicine education leaders have expressed desire for oral case presentations that are succinct, with an emphasis on select relevant details [ 2 ]. Using a common SOAP format between the medical record and oral case presentations risks conflating the distinct goals for each of these communication methods. Indeed, in studying how learners gain oral case presentation skills, Haber and Lingard [ 7 ] found differences in understanding of the fundamental purpose of oral case presentations between medical students and experienced physicians. While students believed the purpose of oral case presentations was to organize the large amount of data they collected about their patients, experienced physicians saw oral case presentations as a method of telling a story to make an argument for a particular conclusion [ 7 ].

In accordance with Dr. Weed’s “problem-oriented approach to data organization,” [ 6 ] but with an eye toward optimizing for oral case presentations, we developed an alternative to SOAP known as the Events, Assessment, Plan (EAP) format. The EAP format is used for patients who are already known to the inpatient team, and may also be utilized for newly admitted patients for whom the attending physician already has context (e.g., via handoff or review of an admission note). As the EAP approach is utilized by a subset of attending physicians at our academic hospital, we sought to understand the perceived effectiveness of the EAP format in comparison to the traditional SOAP format among learners (i.e., medical students and resident physicians).

EAP is a problem-based format used at the discretion of the attending physician. In line with suggested best practices [ 8 ], the EAP structure aims to facilitate transmission of data integrated within the context of clinical problem solving. In this format, significant interval events are discussed first (e.g., a fall, new-onset abdominal pain), followed by a prioritized assessment and plan for each relevant active problem. Subjective and objective findings are integrated into the assessment and plan as relevant to a particular problem. This integration of subjective and objective findings by problem is distinct from SOAP, where subjective and objective findings are presented separately as their own sections, with each section often containing information that is relevant to several problems (Fig.  1 , Additional file 1 : Appendix A).

Overview: comparing EAP to SOAP

Settings and participants

We surveyed third- and fourth-year medical students, and first- through fourth-year internal medicine and internal medicine-pediatrics residents, caring for patients at a large, academic, tertiary care hospital and an affiliated Veterans Affairs medical center. Internal medicine is a 12-week core clerkship for all medical students in their second year, with 8 weeks spent on the inpatient wards. All student participants had completed their internal medicine clerkship rotation at the time of the survey. We did not conduct a sample size calculation at the outset of this study.

Data collection methods and processes

An anonymous, electronic survey (Qualtrics, Provo, UT) was created to assess student and resident experience with and preference between EAP and SOAP oral case presentation formats during inpatient internal medicine rounds (Additional file 2 : Appendix B). Ten domains were assessed via 5-point Likert scale (1 [strongly disagree] to 5 [strongly agree]), including the ability of the format to incorporate the patient’s subjective experience, the extent to which the format encouraged distillation and integration of information, the extent to which the format focused on the assessment and plan, the format’s ability to help trainees learn from their own patients and those of their peers, time efficiency, and ease of use. Duration of exposure to each format was also assessed, as were basic demographic data for the purposes of understanding outcome differences among respondents (e.g., students versus residents). For those who had experienced both formats, preference between formats was recorded as a binary choice. Participants additionally had the opportunity to provide explanation via free text. For participants with experience in both formats, the order of evaluation of EAP and SOAP formats were randomized by participant. For questions comparing EAP and SOAP formats directly, choice order was randomized.

The survey was distributed via official medical school email in October 2021 and was available to be completed for 20 days. Email reminders were distributed approximately one week after distribution and again 48 h prior to survey conclusion.

The primary outcome was trainee preference in oral case presentation format. Secondary outcomes included comparison between EAP and SOAP on content inclusion/focus, data integration, learning, time efficiency, and ease of use.

Statistical analyses

Descriptive statistics were used to describe the results (proportion and mean). For comparative analysis between EAP and SOAP, responses from respondents who had experience with both formats were compared using the Wilcoxon Signed Rank Test to evaluate differences. All statistical analyses were done using SAS V9.4 (SAS Institute, Cary, NC). We considered p  < 0.05 to be statistically significant.

The overall response rate was 21% (118/563). The response rate was 14% ( n  = 62/441) among medical students and 46% ( n  = 56/122) among residents. Respondents were 61% ( n  = 72) female. A total of 98% ( n  = 116) and 52% ( n  = 61) of respondents reported experience with SOAP and EAP formats, respectively. Among medical students, 60% ( n  = 37) reported experience with SOAP only while 39% ( n  = 24) had experience with both formats. Among residents, 36% ( n  = 20) and 63% ( n  = 35) had experience with SOAP only and both formats, respectively (Table ​ (Table1). 1 ). Most students (93%) and residents (96%) reported > 8 weeks of exposure to the SOAP format. Duration of exposure to the EAP format varied (0 to 2 weeks [32% of students, 17% of residents], 2 to 4 weeks [36% of students, 47% of residents], 4 to 8 weeks [16% of students, 25% of residents], and > 8 weeks [16% of students, 11% of residents]).

Quantifying trainees who only experienced SOAP versus those who experienced both formats

Of the 59 respondents with exposure to both the SOAP and EAP formats, 69% ( n  = 41) preferred the EAP format as compared to 19% ( n  = 11) preferring SOAP ( p  < 0.001). The remainder ( n  = 7, 12%) indicated either no preference between formats or indicated another preference. Among residents, 66% ( n  = 23) favored EAP, whereas 20% ( n  = 7) and 14% ( n  = 5) preferred SOAP or had no preference, respectively ( p  < 0.001). Among students, 75% ( n  = 18) favored EAP, whereas 17% ( n  = 4) and 8% ( n  = 2) favored SOAP or had no preference, respectively ( p  < 0.001).

Likert scale ratings for domains assessed by trainees who had experience in either format are shown in Table ​ Table2. 2 . In general, scores for each domain were higher for EAP than SOAP, with the exception of perceived ease of use among students. Among those with experience using both formats, EAP outperformed SOAP most prominently in time efficiency (mean 4.39 vs 2.59, p  < 0.001) and encouragement to: focus on assessment and plan (4.64 vs 3.05, p  < 0.001), distill pertinent information (4.63 vs 3.17, p  < 0.001), and integrate data (4.58 vs 3.31, p  < 0.001) (Table ​ (Table3). 3 ). Respondents also ranked EAP higher in its effectiveness at advancing patient care (4.31 vs 3.71, p  < 0.001), its capacity to convey one’s thinking (4.53 vs 3.95, p  < 0.001), and its ability to facilitate learning from peers (4.10 vs 3.58, p  < 0.001) and one’s own patients (4.24 vs 3.78, p  = 0.003). There were no significant differences in the amount of time allotted for discussing the patient’s subjective experience or in ease of use.

Domain ratings for the EAP and SOAP formats for all respondents with exposure to either format a

a Mean scores to the prompt: “The ‘___’ presentation format…”

(1 = strongly disagree, 2 = disagree, 3 = neither disagree nor agree, 4 = agree, 5 = strongly agree)

EAP vs SOAP head-to-head for all respondents who experienced both formats a

Evaluation of trainee free text responses regarding oral case presentation preference revealed several general themes (Table ​ (Table4). 4 ). First, respondents generally felt that EAP was more time efficient and less repetitive, allowing for additional time to be spent discussing pertinent patient care decisions. Second, several respondents indicated that EAP aligns well with how trainees consider problems naturally (as a single problem in completion). Finally, respondents generally believed that EAP allowed learners to effectively communicate their thinking and demonstrate their knowledge. Those preferring SOAP most often cited format familiarity and the difficulty in switching between formats in describing their preference, though some also believed SOAP was more effective in describing a patient’s current status.

Themes related to format preference

Our single site survey comparing 2 oral case presentation formats revealed a preference among respondents for EAP over SOAP for those medical students and internal medicine residents who had experience with both formats. Furthermore, EAP outperformed SOAP in 8 out of 10 of the functionality domains assessed, including areas such as advancing patient care, learning from patients, and, particularly, time efficiency. Such a constellation of findings implies that EAP may not only be a more effective means to accomplish the key goals of oral case presentations, but it may also provide an opportunity to save time in the process. In line with SOAP’s current de facto status as an oral case presentation format, almost all respondents reported exposure to the SOAP format. Still, indicative of EAP’s growing presence at our academic system, more than one third of medical students and more than one half of residents also reported having experience with the EAP format.

While limited data exist that compare alternative oral case presentations to SOAP on inpatient medicine rounds, such alternatives have been previously trialed in other clinical venues. One such format, the multiple mini-SOAP, developed for complex outpatient visits, encourages each problem to be addressed “in its entirety” before presenting subsequent problems, and emphasizes prioritization by problem pertinency [ 9 ]. The creators suggest that this approach encourages more active trainee participation in formulating the assessment and plan for each problem, by helping the trainee to avoid getting lost in an “undifferentiated jumble of problems and possibilities” [ 9 ] that accumulate when multiple problems are presented all at once. On the receiving end, the multiple mini-SOAP enables faculty to assess student understanding of specific clinical problems one at a time and facilitates focused teaching accordingly.

Another approach has been assessed in the emergency department. Specifically, Maddow and colleagues explored assessment-oriented oral case presentations to increase efficiency in communication between residents and faculty at the University of Chicago [ 10 ]. In the assessment-oriented format, instead of being presented in a stylized order, pertinent information was integrated into the analysis. The authors found that assessment-oriented oral case presentations were about 40% faster than traditional presentations without significant differences in case presentation effectiveness.

Prior to our study, the nature of the format for inpatient medicine oral case presentations had thus far escaped scrutiny. This is despite the fact that oral case presentations are time (and therefore resource) intensive, and that they play an integral role in patient care and learner education. Our study demonstrates that learners favor the EAP format, which has the potential to increase both the effectiveness and efficiency of rounding.

Still, it should be noted that a transition to EAP does present challenges. Implementing this problem-based presentation format requires a conscious effort to ensure a continued holistic approach to patient care: active problems should be defined and addressed in accordance with patient preferences, and the patient’s subjective experience should be meaningfully incorporated into the assessment and plan for each problem. During initial implementation, attending physicians and learners must internalize this new format, often through trial and error.

From there, on an ongoing basis, EAP may require more upfront preparation by attending physicians as compared to SOAP. While chart review by attendings in advance of rounding is useful regardless of the format utilized, this practice is especially important for the EAP format, where trainees are empowered to interpret and distill – rather than simply report a complete set of – information. Therefore, the attending physician must be aware of pertinent data prior to rounds to ensure that key information is not neglected. Specifically, attendings should pre-orient themselves with laboratory values, imaging, and other studies completed, and new suggestions from consultants. More extensive pre-work may be required if teams wish to employ the EAP format for newly admitted patients, as attending physicians must also familiarize themselves with a patient’s medical history and their current presentation prior to initial team rounds.

Our findings should be interpreted within the context of specific limitations. First, low response rates may have led to selection bias within our surveyed population. For instance, learners who desired change in the oral case presentation format may have been more motivated to engage with our survey. Second, there could be unmeasured confounding variables that could have skewed our results in favor of the EAP format. For example, attendings who utilized the EAP format may have been more likely to innovate in other ways to create a more positive experience for learners, which may have influenced the scoring of the oral case presentation format. Third, our findings were largely based on subjective experience. Objective measurement (e.g., duration of rounds, patient care outcomes) may lend additional credibility to our findings. Lastly, our study included only a single site, limiting our ability to generalize our findings.

Our study also had several strengths. Our learner participant pool was broad and included all third- and fourth-year medical students and all internal medicine residents at a major academic hospital. Participation was encouraged regardless of the nature of a participant’s prior exposure to different oral case presentation formats. Our survey was anonymous with randomization to mitigate order bias, and we focused our comparison analysis on those who had exposure to both the EAP and SOAP formats. We collected data to compare EAP with SOAP in 2 distinct ways: head-to-head preference and numeric ratings amongst key domains. Both of these methods demonstrated a significant preference for EAP among learners in aggregate, as well as for students and residents analyzed independently.

Our findings suggest a preference for the EAP format over SOAP, and that EAP may facilitate clearer and more efficient communication on rounds. These improvements may in turn enhance patient care and learner education. While our preliminary data are compelling, a broader, multi-center study of the EAP oral case presentation is necessary to better understand preferences, outcomes, and barriers to implementation. Further studies should seek to improve response rates, for the data to represent a larger proportion of trainees. One potential strategy to improve response rates among medical students and residents is to survey them directly at the end of each internal medicine clerkship period or rotation, respectively. Ultimately, EAP may prove to be a much-needed update to the “currency with which clinicians communicate.”

Acknowledgements

The authors would like to thank Jason M. Engle, MPH, who helped edit, prepare, format, and submit this manuscript and supporting files.

Authors’ contributions

Conceptualization: BA SS AG. Data curation: BA DR AG. Formal Analysis: BA SS DR AG. Funding acquisition: SS AG. Investigation: BA SS AG. Methodology: BA SS AG. Project administration: BA SS AG. Resources: SS AG. Software: DR. Supervision: SS AG. Validation: BA SS DR AG. Visualization: BA SS DR AG. Writing – original draft: BA AG. Writing – review & editing: BA SS DR AG. The author(s) read and approved the final manuscript.

Availability of data and materials

Declarations.

All methods were carried out in accordance with relevant guidelines and regulations. The need for ethical approval was waived by the ethics committee/Institutional Review Board of the University of Michigan Medical School. The need for informed consent was waived by the ethics committee/Institutional Review Board of the University of Michigan Medical School.

Not applicable.

Dr. Saint, Mr. Ratz, and Dr. Gupta are employed by the US Department of Veterans Affairs. Dr. Saint reports receiving grants from the Department of Veterans Affairs and personal fees from ISMIE Mutual Insurance Company, Jvion, and Doximity. Dr. Appold, Mr. Ratz, and Dr. Gupta report no conflict of interest.

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