Now that you've got the history, what do you do with it? One of your more important tasks is to transmit the information you've gathered to other health care professionals. This is frequently accomplished through a combination of written documentation (the medical record) and verbal presentation (face to face or over the telephone). Developing these skills is essential for your medical career. The following outline summarizes the elements of a good case presentation.
Keep in mind that a case presentation is not simply reading your write-up. The medical record and your presentation are complimentary. The former serves as the primary documentation of the patient's clinical situation. The latter is a formalized way of communicating the patient's story to your colleagues. A good case presentation includes all the "important" details in a very terse, easy to assimilate package. Knowing which details are important and which can be left out is an acquired skill that comes with practice. Finally, the length of the presentation (and thus the level of detail) will vary depending on the purpose. In a busy clinic this might be only 1 or 2 minutes. A formal case presentation to a large group might last as long as ten minutes or more.
Begin with an arresting sentence; close with a strong summary; in between speak simply, clearly, and always to the point; and above all be brief. - William J. MayoThe opening statement sets the stage for the presentation, so it is worth looking at in detail. You should include a bit of demographic information ("Jean Smith is a 40 year old woman who...") and a description of the patient's problem or chief complaint ("...came to clinic because of increasing dyspnea.") Note that, unlike the subjective section of the written record, it is okay to use medical terms and state exactly what you think. The entire presentation is your interpretation of what is going on.
The opening statement may also contain additional information about who the person is as an individual (what they do for a living, their general level of health, where they live). Including this information helps the listener paint a more complete mental picture of the patient and prevents the discussion from becoming totally focused on the disease.
Finally, you may want to comment about the source(s) and validity of the information you are reporting. If you don't otherwise state it, your listener will assume that you got the history from the patient and that you consider the information valid. If the patient is mentally incapacitated or otherwise unable to communicate well (e.g. speaks a language you don't understand), say so!
Remember that you are telling a story. As with any story, the events of the patient's illness unfold in a specific sequence. This sequence is referred to as the clinical time course or chronology. Think of it as the scaffold on which all the other details of the history of present illness (HPI) will hang. Elements of the time course should include:
Once you've established the time course, you should fill in the details that are "pertinent" to the case. These include other elements of the HPI such as:
Note that what is not present is often more important as what is. These are called pertinent negatives and should always be included. For example, in a patient with shortness of breath, the absence of chest pain is significant because it makes certain diagnoses less likely.
At this point your listeners will expect you to "put it together" for them. What pathologic processes might explain the symptoms you've presented? As part of your analysis you will be expected to develop and prioritize a list possible causes (differential diagnosis). You should bring in elements of the HPI; family, social, and past medical history; review of systems; and physical exam that support or oppose each diagnosis. At the end of this process you should have narrowed the field to one or two possibilities. These are your working diagnoses - what you think is actually going on. The remainder of your presentation should explain what you intend to treat or better characterize these diagnoses.
Keep in mind that medicine has a bias towards simpler explanations. A single cause is always preferred over a combination of causes. This doesn't mean that a patient can't have more than one thing going on. If you believe there are two distinct symptom complexes present, say so at the beginning of your presentation and develop a differential diagnosis for each.