How to Do Medical Case Presentations

A medical case presentation is a type of formal exchange between an attending doctor or medical student and his or her colleagues. A case presentation delivers specific pieces of information about a particular patient and is an important component in ensuring consistency and standards in health care. Medical presentations are made for new patients, follow-up cases, and at bedside. According to the Weill Medical College of Cornell University, a case presentation should ideally take five minutes and follow a clear format for conveying patient details.

Instructions

    • 1

      Report the history. Describe the patient's central medical complaint and its duration and identify when the medical problem first developed. Discuss the patient's general medical history, taking note of any past hospitalizations, surgeries or major illnesses. List any medication that the patient is taking, as well as any allergies that he or she has. Briefly outline the patient's social history, such as employment, marital status and childbearing. Also, call attention to any relevant details of family background, such as patterns of disease or genetic risks.

    • 2

      Describe the patient's physical status. Provide information about vital signs and note where functions are irregular, such as an accelerated heart rate. Describe the findings of the physical examination, including cardiovascular and neurological functioning, skin health and the condition of the abdomen, chest and extremities. A case presentation should also always include information on the breast exam for female patients.

    • 3

      Report laboratory data. Provide details about what basic tests have been performed and their findings. Identify whether there are any abnormalities in blood and urine samples.

    • 4

      Summarize the case. In three to five sentences, provide a summary of the patient's condition, background, physical status and lab test results. A case synopsis lays the foundation for making an assessment and planning a course of treatment. It is important to be as clear and succinct as possible and to make sure that all the pertinent details have been addressed.

    • 5

      Make an assessment. Select the most important problems and offer a differential diagnosis. A differential diagnosis is not the same as the chief complaint, but rather identifies the cause of the apparent symptoms based on the patient's history.

    • 6

      Create a plan. Based on the differential diagnosis and the patient's individual needs and history, develop a plan for medical treatment. Explain what further lab work and tests will be required, as well as options for therapy and rehabilitation.

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