Clinical Case Presentations

Starr Newman PA-C, CLS

Trine University
Overview and general information about
presenting cases to your preceptor

Goals:
pass along the “right amount” of
information
pass along the appropriate information to
the specific audience
be efficient
Challenges

 Structure varies from service to service (i.e. pediatrics,

IM, surgery)
 Very short period of time – makes the event more
stressful
 Preceptors may have their own preferences (sometimes
quirky)
 You’re being graded – more stress
 Poorly done case presentations over and over can lead
to a disconnect between student and preceptor
General Tips
 Practice, practice, practice
 Be aware of your posture
 Present with a clear, energetic, and interested voice
 Keep your language precise, avoid ummms
 Use positive statements “CXR shows normal heart size rather than
CXR shows no cardiomegaly”
 Just tell the facts – do not rationalize or editorialize “I would
have gathered more information but the baby was crying and the
medical assistant came in to get more nasal swabs out of the
room”, etc.
 You will get interrupted – don’t take it personally, it may mean
you are meandering. Be patient.
General Tips
 Practice, practice, practice
 Ask for feedback on your case presentation
 Listen to presentations that are done well and learn
from them
 Listen to presentations that are done poorly and learn
from them
 Effective presentations require that you have thought
things through
 REQUIRES you to have a good grasp on anatomy, physiology,
pathology, clinical reasoning, and decision making – so make
sure you read, pay attention, and in general acquire more
knowledge
General Tips
 Practice, Practice, Practice
 Presentations are a way we tell medical stories – think to
yourself “will the listener be able to “see” the patient the same
way that I do?” You are the storyteller!
 Its OK to use notes – but oral presentations should not be you
just reading them
 Develop a rhythm
 Stay organized which will lessen your chances that you will omit
something
 Inpatient based case presentations are different than
Outpatient based cases.
Outpatient based case presentations
4 main types of visits
1. Patient is presenting for their first visit to the clinic and is
entirely new to the physician

2. Patient who is returning to the clinic for a scheduled follow-up

visit

3. Patient is presenting with an acute complaint to the clinic

4. Specialty clinic evaluation (new or follow-up)

New Patient to the Clinic
Purpose of the presentation

 Organizes the information for the preceptor (think things through)

 Review of all the patient’s history and any new concerns

 Identify health related problems for evaluation and/or treatment

New Patient to the Clinic
Duration of the presentation

8-10 minutes
Key Features (New Patient to the Clinic)
Identifying Information/Chief
Complaint/Reason for Visit
Content – contains 4 elements
1. Patient’s age and sex
2. Patient’s ongoing medical problems – order of importance
3. Patient’s reason for presentation – establish care, needs treatment
4. Duration of symptoms

***there may not be a chief complaint with a patient establishing new

care
Examples: This will be your opening
statement!
 Mr. Tyler is a 45 year old male with a 5 year history diabetes
mellitus and hyperlipidemia.

 Ms. Griner is a 58 year old woman with prior diagnosis of

breast cancer, rheumatoid arthritis, and hypertension who
presents with 2.5 months of bilateral leg weakness.

 Mr. Smith is a 48 year old man who is being transferred from

Cook County Jail for further evaluation of a right lung mass.
Example: Do NOT make this your
opening statement!
 M.r Luigi is a 46 year old male presenting with 2 weeks of
dyspnea…
 Then reveal 2 minutes later that the patient has asthma,
your preceptor (who started forming differentials in their
head from your initial sentence) will suddenly realize that
you didn’t think things through before talking.
 Mr. Luigi is a 46 year old male patient with a 15 year history
of asthma presenting with 2 weeks of increasing dyspnea
***your first statement may be the only thing they hear – make
it count!
Key Features (New Patient to the Clinic)
Relevant history
 This is your opportunity to highlight the main issues that the
patient may have come in to see you for.

 This can include: chronic disorders (diabetes, CHF, HTN,

anemia); ongoing symptoms (shortness of breath, fatigue),
care (finger sticks, bp readings, etc.)

***sometimes there are no specific things the patient wants to

discuss
Key Features (New Patient to the Clinic)
Review of Systems (ROS)
 Typically comprehensive, covering all organ systems
Health in general: no problems, lack of energy, weight gain or
loss, loss of appetite, difficulty sleeping, chronic pain, fever,
chills, sweats, feeling well or poorly, in general, etc.
Vision: blurriness, double vision, chronic or past disorders,
glasses, contacts, etc.
Head and Neck: chronic or past disorders, pain, sores – in or
around mouth or nose, masses or growths, change in hearing, ear
pain or discharge, nasal discharge, post nasal drip, hoarseness or
change in voice, tooth pain or problems, sense of lump in throat
with swallowing, etc.
Pulmonary: chronic or past disorders, shortness of breath (at
rest or exertion), chest pain, cough, hemoptysis, wheezing,
snoring, stop breathing, etc.
Key Features (New Patient to the Clinic)
Review of Systems (ROS)
 Typically comprehensive, covering all organ systems
Cardiovascular: chronic disorders, chest pain or pressure, shortness
of breath at rest or with exertion, orthopnea, paroxysmal nocturnal
dyspnea, lower extremity edema, syncope, palpitations, calf/leg
pain/cramps with ambulation, wounds/ulcers on the feet,
difficult/slow to heal wounds, etc.
Gastrointestinal: chronic or past GI disorders, heart burn or sternal
burning, abdominal pain, pain with swallowing, nausea, vomiting,
abdominal swelling, distention, jaundice, hematemesis, change in
bowel habits, black/tarry stools, diarrhea, constipation
Genitourinary: chronic or past GU problems, blood in urine, burning
w/urination, urinating at night, incontinence, urgency, frequency,
incomplete emptying, hesitancy, decreased force of stream, etc.
Key Features (New Patient to the Clinic)
Review of Systems (ROS)
 Typically comprehensive, covering all organ systems
Genitourinary For Men: erectile dysfunction, penile discharge or
pain, testicular pain, testicular swelling or mass, penile ulcers or
growths, fertility problems, Hx STIs, # of sexual partners and type of
sexual activity
Hematology/Oncology: Chronic or past Heme/Onc disease, fevers,
chills, sweats, weight loss, abnormal bleeding or bruising,
new/growing lumps, bumps, moles, hypercoagulability, etc.
OB/GYN: chronic or past disease, menstrual hx, sweats/hot flashes,
past pregnancies (including miscarriages), vaginal discharge, # of
sexual partners, type of sexual activity, breast pain, nipple discharge,
STIs, etc.
Key Features (New Patient to the Clinic)
Review of Systems (ROS)

 Typically comprehensive, covering all organ systems

Neurological: Known disease, sudden loss of neurological function,
abrupt loss/change in level of consciousness, witnessed seizure
activity, numbness, weakness, headaches, tremors, dizziness, balance
problems, etc.
Endocrine: known endocrine disorder (thyroid, diabetes, etc.),
polyuria, polydipsia, polyphagia, fatigue, weight loss/gain, etc.
Infectious disease: known disease, fever, chills, sweats, etc.
Key Features (New Patient to the Clinic)
Review of Systems (ROS)
 Typically comprehensive, covering all organ systems
Musculoskeletal: Known disease, joint pain, joint swelling, muscle
aches or fatigue, low back pain, knee pain/swelling, hand symptoms,
elbow symptoms, hip area symptoms, shoulder pain, etc.
Mental Health: known mental health disorder, sad or depressed, lack
of interest in things you use to enjoy, overwhelmed easily, irritable,
angry, alcohol or substance abuse, anxiety, panic attacks, memory
problems, concentration problems, confusion, etc.
Skin, Nails & Hair: known disease, hair loss/thinning, skin eruptions
or rashes, brittle nails, nail changes, growths, sores that do not heal,
lesions changing size, shape, color, itching, etc.
Key Features (New Patient to the Clinic)
Review of Systems (ROS)
 Do not report over every ROS component if they are not relevant.
 Example of what not to say:
 Mr. Tobin’s ROS general health – fatigued, vision – negative, head and
neck – dry mouth, cardiovascular – CHF, pulmonary – occasional sob,
gastrointestinal – negative...

 Example of what to say:

 Mr. Tobin’s general health he reports fatigue, head and neck dry
mouth, cardiovascular and pulmonary history of CHF with sob on
exertion that occurs daily…..
Key Features (New Patient to the Clinic)
Past Medical History (PMH)
 All known medical conditions (in particular those requiring ongoing
treatment)
 Note the time of onset and duration
 Start by asking if they have any medical problems. This could get hairy or you
will hear crickets chirping. Some people are more forthcoming than others.
 You will encounter a patient who reports very little during their ROS and then
once you start asking these questions, you will be amazed what they have
forgotten…they simply need to be prompted in the right direction.
 “have you ever received medical care?” if yes, for what?
 “have you ever had an x-ray, MRI, CT scan, or special testing?” if yes, for what?
 “have you ever been hospitalized?” if so, what for?
 “have you ever been to the ER?” if yes, what for?
Key Features (New Patient to the Clinic)
Past Medical History (PMH)
 Examples of what to include in oral presentation
 Patient with diabetes mellitus – include most recent A1C
 Patient with COPD – mention most recent FEV1
 Patient with CAD – mention results of most recent stress test,
cath or echo
 Patient with asthma – mention if ever hospitalized for asthma
or intubated
 Patientwith ETOH abuse – mentioned if ever hospitalized or
had withdrawal seizures
Key Features (New Patient to the Clinic)
Past Medical History (PMH)
 Examples of what to include in oral presentation

 Mr. Jones has a 7 year history of type 2 diabetes mellitus, most

recent A1C was 6.5 – 6 months ago. He denies retinopathy,
neuropathy, or nephropathy. His current medications include hs
NPH insulin, glyburide, isordil, aspirin, metoprolol, Lisinopril and
simvastatin.
Key Features (New Patient to the Clinic)
Past Medical History (PMH)
 If a condition is followed by a specialist or co-managed with
other clinicians, this should be stated as well.
 Since we are talking about a new patient here, if there was a
problem with his diabetes in an acute form, it would have been
stated in the beginning sentence.
 Example - Mr. Tyler is a 45 year old male with a 5 year history
diabetes mellitus and hyperlipidemia. He presents today with
shortness of breath, bilateral leg edema, and blurring vision.
Key Features (New Patient to the Clinic)
Past Medical History (PMH)

 List the diagnosis in decreasing order of importance and

relevance
 Do not just list past medical history from an old EHR. These may
be incomplete, old, or not correct.
 GET THE INFO FROM THE PATIENT!
Key Features (New Patient to the Clinic)
Past Surgical History (PSH)
 Ask if they were ever operated on, even as a child.
 What year or how old were they when the surgeries occurred.
 Were there any complications?
 If they do not know the name of the operation, try to atleast
find out where it was performed on their body.
 Encourage them to be as specific as possible.
 Example: Mrs. Cowden had her gallbladder removed in 1995 and
a total hysterectomy in 1999. There was an extended stay for
antibiotic therapy with the hysterectomy. She had a total left
knee replacement in 2002.
Key Features (New Patient to the Clinic)
Medications and Allergies
 All medications should be stated here
 Including dosage and frequency
 Ask them if they know why they are taking their medicine
 Medical non-compliance/confusion is a major problem
 Its important to know if they are actually taking the medications as
prescribed.
 Include all over the counter preparations and supplements
 Ask them if they are physician prescribed or self-prescribed
Key Features (New Patient to the Clinic)
Medications/Allergies/Reactions
 Allergies and their types of reactions
 “Have you experienced any adverse reactions to medications?”
 “What were the adverse reactions?”
 “Did you have to go to the ER for a medication reaction?”

 Anaphylaxis is life-threatening and an absolute contraindication

to ever taking that particular drug again.
 A rash from a medication/supplement raises a level of concern,
and may alert you not to use that particular med but may need
too.
Key Features (New Patient to the Clinic)
Smoking history
 How much and duration of use
 Determine what they are smoking or chewing
 Determine how many packs per day, packs per year and duration
 Make note if they have quit
 Example:
 Mrs. Hayden has a 60 pack year hx and now 1 pack per day
 “packsyears” is the number of packs per day multiplied by the
number of years they have smoked
 Mr. Cardon chews tobacco daily and has for 22 years
Key Features (New Patient to the Clinic)
Alcohol Intake
 Specify quantity, type and duration
 Ask “do you drink alcohol? If so, how much per day and what
type of alcohol do you drink?”
 Encourage them to be as specific as possible
 If they don’t drink daily, how much do they drink weekly or
monthly
 Try to avoid using “social drinking” what does that really mean?
 Do they binge drink on the weekends, do they have a glass of
wine with dinner every night, do they only drink on special
occasions…ask the questions to get the answers
Key Features (New Patient to the Clinic)
Other drug use
 Any drug use, past or present should be noted
 Specify type, quantity and duration
 Remind the patient, when asking these questions, that they are
not meant to judge them but rather to assist you in identifying
risk factors for particular illnesses (i.e. hepatitis)
 In some cases, the patient will state that they do not want to
discuss this issue
 Respect their wishes and move on
 Maybe they will tell you at another visit
Key Features (New Patient to the Clinic)
Sexual history/marital status/# of children
 Include type of activity – past and present
 Do they participate in intercourse? With persons of the same or opposite sex?
 Include number of sexual partners
 Are they in a stable relationship? Do they practice safe sex?
 ALWAYS ask about their partner(s) health, past STDs both of pt and partner(s)
 Number of children, are they healthy
 Example: Married 27 years, sexually active with wife, 3 healthy children
 Example: Single, multiple sexual partners, no use of any type of contraception
by patient or partners, sexual partners health status unknown
 Example: Divorced 3 years, married for 27, currently sexually active with
multiple partners and ex-wife, ex-wife healthy, sexual partners health unknown,
6 children
Key Features (New Patient to the Clinic)
Family History
 Focus on heritable illnesses amongst first and second degree relatives
 In particular, cancer, coronary artery disease, hypertension, thyroid
diseases, diabetes mellitus, etc.
 Find out the age of onset of illness
 Example: A father who had an MI at 75 is not a marker, but one who
had an MI at 39 certainly would be.
 Also ask about any unusual illnesses
 You can also include their marital status here and with their number
of kids and their ages
 Example: Sister and mother with ovarian cancer, father with type II
diabetes mellitus, hypertension, and hyperlipidemia
Key Features (New Patient to the Clinic)
Work/Hobbies/Other
 What sort of work does the patient do?
 Have they always done this sort of work?
 Are they retired?
 What do they do to stay busy? Hobbies?
 Do they participate in any sports or other physical activity?
 This information may reveal exposures, sports that cause certain
injuries, or its just a way to talk to the patient about something
other than their health
 It also gives you something to ask them about when they come
back to see you – build the relationship!
Key Features (New Patient to the Clinic)
Military Service

 Inquire about time and service in the armed forces

 Inquire about any physical trauma, mental health issues
(suicidal thoughts, PTSD, depression, substance abuse), and
unusual exposures (toxins and infections)
 Inquire about all the countries they have been too and how
recently
Key Features (New Patient to the Clinic)
Physical Exam
 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:
 • Temperature
 • Heart rate
 • Blood pressure
 • Respiratory rate
 • Oxygen saturation (if the patient is using supplemental oxygen,
this should also be reported)
***know what the normal vital signs are for all age groups
 Key Features (New Patient to the Clinic)
Physical Exam (ask your preceptor how much
information they want)
 Next, you should discuss the findings of your physical exam. Include all
abnormal findings and a brief discussion of the following:
 • 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
 Key Features (New Patient to the Clinic)
Physical Exam (ask your preceptor how much
information they want)
 A quick note: resist the urge to report an exam as being “normal”
or “abnormal”
 Example “On physical exam, he appeared in no acute distress.
His blood pressure was 152/88, pulse 78 and regular, respirations
18, temperature 98.4 and oxygen saturation is 98%. Vision is
20/20 bilaterally. Pupils normal and reactive to light, bilaterally;
nares patent; throat clear; no palpable lymphadenopathy. Lungs
are clear to auscultation bilaterally; on cardiac exam normal
S1S2 without any notable murmurs on auscultation no S3.
Abdomen is soft, nontender, and nondistended, with normoactive
bowel sounds. No edema noted -bilaterally. No clubbing or
cyanosis. Reflexes are 2+ bilaterally.

 Key Features (New Patient to the Clinic)
Key Labs or Imaging
 Sometimes new patients will have all of their medical
information transferred
 Other times you will have to request it
 Ask the patient if they have had any testing done and where
 Sometimes you will find that they had certain tests and that will
lead you to a diagnosis that they forgot to tell you about
 Which in turn leads them to tell you about some other
medications they forgot to tell you about
 At first, you will be amazed at what people forget to tell you
about…
 Key Features (New Patient to the Clinic)
Key Labs or Imaging
 In your report, include all relevant labs explicitly
Give the actual numbers – not “normal” or “abnormal”
So, you need to know what is normal and abnormal

 Include comparison labs if there has been a change

 Attribute studies if you did not do the interpretation yourself

“Per the radiology report the ultrasound show…”
 Key Features (New Patient to the Clinic)
Summary
 The summary statement is usually your time to state the
diagnosis (or diagnoses) are and if there is anything new you can
create a differential list. This is also the time to prime your
preceptor with the reasons why.
 Keep the summary short – one to two statements that include
only the most relevant information (hx, exam, labs, and studies)
 Example: Ms. Hayes is a 64 year old woman with a history of type
2 diabetes mellitus well controlled, hyperlipidemia, and
controlled hypertension. She is seeking a new IM physician to
manage her diseases.
 Key Features (New Patient to the Clinic)
Summary

 Presented by organ system and/or problems

 As many systems/problems as necessary to cover all of the active
issues that are relevant to that clinic
 Typically concludes with a “health care maintenance” section
 Covers age, sex, and risk factor appropriate vaccinations and
screening test
 Key Features (New Patient to the Clinic)
Assessment & Plan
 Usually begins with a statement about the patient’s problem
 Symptom
 Sign
 Abnormal lab test
 Diagnosis
 Ask yourself “What is the principal unresolved issue”
 If it is a diagnosis, your assessment focuses on differential diagnosis:
 List 3-5 most likely diagnosis
 State which diagnosis is most likely and why
 Statewhy other diagnostic possibilities are less likely (get evidence
from H&P)
 Key Features (New Patient to the Clinic)
Assessment & Plan
 If the principal unresolved issue is therapy, your assessment:
 States the diagnosis or problem
 States which therapy you plan to discontinue or give and why
 States complications you might anticipate
Key Features (New Patient to the Clinic)
Let’s try one!