Whenever you admit a new patient, you will ordinarily present the case the next morning. This case presentation should be complete and concise.


Format of the case presentation

1. Report the history, succinctly, in standard format:

• Chief complaint
• History of the present illness
• Past medical history
• Medications
• Medication allergies
• Social history
• Family history
• Review of systems (specify only pertinent positive and negative findings)

2. Describe the physical examination, succinctly, in standard format:

• Vital signs (specify)
• HEENT (acceptable to say "normal" or "unremarkable", if this is so)
• Neck
• Nodes
• Breasts (always include a breast exam for women on the medicine service)
• Chest
• Cardiovascular
• Abdomen
• Genitourinary
• Rectal
• Extremities
• Skin
• Neurologic

3. Report the basic laboratory data

4. Summarize the case: this is important! The summary should include a few well-crafted sentences, perhaps 3-5 in all. A concise, accurate summary shows that you have grasped the essentials of the case and can distill the clinical data into its essence.

5. Assessment. In the assessment, you choose the most important one or two problems and discuss the differential diagnosis. Remember that the differential diagnosis should address the possible causes in the case at hand, not for the problem in general. For example, in a patient with acute fever, cough, rhonchi and pulmonary infiltrate, discuss pneumonia, not cough.

6. Plan. Outline your recommendations for diagnostic tests and therapy.

Tips for good case presentation

• Aim for a duration of five minutes. This is readily achievable if you are organized and concise.
• Practice. You may wish to go over your presentation with the resident, before presenting it.
• It is better not to read the case. You may refer to brief notes.
• Further details are described in Essential Skills in Clinical Medicine.