patient presenting with case report

by Hayley Halvorson 4 min read

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

4 hours ago  · A well delivered presentation has the potential to facilitate patient care and improve efficiency on ward rounds, as well as a means of teaching and assessing clinical … >> Go To The Portal


The purpose of a case presentation is to communicate your diagnostic reasoning to the listener, so that he or she has a clear picture of the patient’s condition and further management can be planned accordingly. 2 To give a high quality presentation you need to take a thorough history.

Full Answer

What do you need to know about patient case reports?

Patient case reports are valuable resources of new and unusual information that may lead to vital research. Patient case reports are valuable resources of new and unusual information that may lead to vital research. How to write a patient case report Am J Health Syst Pharm.

What is the importance of presenting patient cases?

This article contains... Presenting patient cases is a key part of everyday clinical practice. A well delivered presentation has the potential to facilitate patient care and improve efficiency on ward rounds, as well as a means of teaching and assessing clinical competence. 1

How do you write an abstract for a patient case report?

Summary: The abstract of a patient case report should succinctly include the four sections of the main text of the report. The introduction section should provide the subject, purpose, and merit of the case report.

What is a case report?

Case reports usually describe an unusual or novel occurrence and as such, remain one of the cornerstones of medical progress and provide many new ideas in medicine. Some reports contain an extensive review of the relevant literature on the topic.

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How do you present a case report presentation?

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

How do you present a patient case study?

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.

Do you need patient consent to write a case report?

Although not technically required, especially if the case report does not include any identifying information, some journals require informed consent for all case reports before publishing. The CARE guidelines recommend obtaining informed consent AND the patient's perspective on the treatment/outcome (if possible).

What are the components of patient case presentation?

Highlighted in this chapter are the essential components of the presentation: the chief complaint, the history of present illness (HPI), the past medical history, the family and social history, the review of systems, and finally, the physical examination findings.

How do you present a case study in nursing?

How to Write a Case Study Paper for NursingThe status of the patient. Demographic data. Medical History. ... The nursing assessment of the patient. Vital signs and test results. ... Current Care Plan and Recommendations. Details of the nursing care plan (including nursing goals and interventions)

What is the purpose of a case presentation?

From an educational viewpoint, the two important roles of case presentations are the presenter's reflective opportunity and the clinician educator's clues to diagnose the presenter. When a presenter prepares for a case presentation, he/she has to organize all the information collected from a patient.

Do case reports require ethical approval?

Case reports and studies intended for quality improvement are often considered not research and do not need IRB approval. Nevertheless, there should be some processes of clearing those studies with respect to ethical handling of patients and related data.

How do you take consent from a patient to a case report?

Consent to use a patient's story should be obtained prior to publishing the report wherever possible. This consent should be obtained directly and preferably in writing from the individual affected. A suitable consent form is provided here. To not obtain consent for a case report requires justification.

What does patient presentation mean?

In medicine, a presentation is the appearance in a patient of illness or disease—or signs or symptoms thereof—before a medical professional. In practice, one usually speaks of a patient as presenting with this or that.

How do you structure a case report?

Case reports should encompass the following five sections: an abstract, an introduction with a literature review, a description of the case report, a discussion that includes a detailed explanation of the literature review, and a brief summary of the case and a conclusion.

How do you begin a presentation?

How to start a presentationTell your audience who you are. Start your presentation by introducing yourself. ... Share what you are presenting. ... Let them know why it is relevant. ... Tell a story. ... Make an interesting statement. ... Ask for audience participation.

History of Present Illness

Alice is a 66-year-old Caucasian female, who presents to the neurology department after being referred by her primary care provider for complaints of mood swings and memory problems. Patient states, “I’ve been forgetting things. Yesterday, I couldn’t remember my dog’s name.

Neurological exam

Neurological exam: Neurophyschological exam revealed impairments on multiple cognitive tests.

What is the purpose of case presentation?

The purpose of a case presentation is to communicate your diagnostic reasoning to the listener, so that he or she has a clear picture of the patient’s condition and further management can be planned accordingly . 2 To give a high quality presentation you need to take a thorough history.

Why is it important to present patient cases?

A well delivered presentation has the potential to facilitate patient care and improve efficiency on ward rounds, as well as a means of teaching and assessing clinical competence. 1

What should you anticipate in a presentation?

Everyone has their own presenting style, and the context of the presentation will determine how much detail you need to put in. You should anticipate what information your senior colleagues will need to know about the patient’s history and the care he or she has received since admission, to enable them to make further management decisions. In this article, I use a fictitious case to …

Where do medical students present?

As a medical student, you are likely to be asked to present in numerous settings. A formal case presentation may take place at a teaching session or even at a conference or scientific meeting. These presentations are usually thorough and have an accompanying PowerPoint presentation or poster. More often, case presentations take place on the wards or over the phone and tend to be brief, using only memory or short, handwritten notes as an aid.

What is the best phrase to use when you suspect a more serious cause is in the differential diagnosis?

Differential diagnoses. Mentioning one or two of the most likely diagnoses is sufficient. A useful phrase you can use is, “I would like to rule out,” especially when you suspect a more serious cause is in the differential diagnosis.

Do not trail off at the end of a diagnosis?

Do not trail off at the end, and state the diagnosis if you are confident you know what it is. If you are not sure what the diagnosis is then communicate this uncertainty and do not pretend to be more confident than you are.

Do you need to present all findings on an examination?

Findings on examination. Initially, it can be useful to practise presenting the full examination to make sure you don ’t leave anything out, but it is rare that you would need to present all the normal findings. Instead, focus on the most important main findings and any abnormalities.

What is patient case report?

Patient case reports are valuable resources of new and unusual information that may lead to vital research.

What should be included in the abstract of a patient case report?

The abstract of a patient case report should succinctly include the four sections of the main text of the report. The introduction section should provide the subject, purpose, and merit of the case report.

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Style

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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 ke…
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Length

  • 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 pres…
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Structure

  • 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 difference…
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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.
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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. Yo…
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History of Present Illness

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Alice is a 66-year-old Caucasian female, who presents to the neurology department after being referred by her primary care provider for complaints of mood swings and memory problems. Patient states, “I’ve been forgetting things. Yesterday, I couldn’t remember my dog’s name. I was trying to call her to come in and I just st…
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Relevant Medical History

  1. Tonsillectomy, Age 10 years
  2. Appendectomy Age 17 years
  3. Post Menopausal, Age 50 years
  4. Hyperlipidemia diagnosed 5 years ago
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Family History

  1. Mother, 85, Type II DM, HTN, both controlled with oral medications
  2. Father died from liver failure, dementia, at age 76. History of ETOH abuse for many years
  3. Patient does not have any siblings
  4. Maternal grandmother diagnosed with dementia in her final years of life. Died at age 82, following a fall at home.
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Psychosocial History

  1. Retired high school biology teacher, retired 18 months ago
  2. Lives with husband of 35 years
  3. Hobbies include gardening, traveling, reading history books
  4. Active in school activities.  She heads a science club for 7th and 8th graders that meets bi-weekly after school
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Current Medication

  1. Zocor 10 mg daily
  2. Lisinopril 20 mg daily
  3. Glyburide 2.5 mg daily
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Physical Exam

  1. Height 5’6″, Weight 185 lbs.
  2. Temperature: 98.7 degrees farenheit, temporal
  3. HR: 85, regular
  4. BP: 142/76
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Neurological Exam

  • Neurological exam: Neurophyschological exam revealed impairments on multiple cognitive tests. Many of these performances were associated with a high level of emotional distress and the patient frequently complains that she simply “couldn’t think straight.” Her behavior during the evaluation was initially well composed, she was conversant and affectively stable during the inte…
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