Presenting a Case
Purpose: A case presentation is a verbal report usually presented from one student physician to another, which gives a detailed description of a patient. The same format is used to communicate among physicians for the remainder of one’s career.
Format:
- Orientating statement (age, sex, relevant past medical history)
- Chief complaint in the patient’s own words
- History of present illness (describe the illness chronologically leading up to the present time). Include comments on the general well-being and effects of illness on patient’s life, include any family past medical/surgical or social history that is pertinent to the illness, include allergies and medications. You may include a short resume of the course of the illness during the hospitalization if appropriate.
- Your Physical Exam, including pertinent positives and negatives. If time has elapsed, discuss changes in the physical exam.
Past Medical History: preventive health measures, and all medical illnesses.
Family History: Provides general description of presence or absence of medical illnesses with ages & health of family
Personal and Social History: Outline who the patient is.
Functional Inquiry: Review of systems not covered in the history of the present illnesses.
Physical Examination: General appearance and vital signs-each major system.
Laboratory Data: Again, pertinent positives and negatives.
Summary: Brief recapitulation of signs and symptoms that lead you to form an assessment, plan and hypothesis about the patient
Assessment of the patient’s problem, plan of investigation and management. You will find a number of physicians don’t want to hear all these details and want you to cut to the chase. If this happens or if your mind goes blank, jump to the assessment and plan.
Tags: assessment of patient, family history, History of present illnes, Orientating statement, Physical Exam, preventive health measures
