what is a clinical case presentation

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Writing a Clinical Vignette (Case Report) Abstract

Case reports represent the oldest and most familiar form of medical communication. Far from a "second-class" publication, many original observations are first presented as case reports. Like scientific abstracts, the case report abstract is governed by rules that dictate its format and length. This article will outline the features of a well-written case report abstract and provide an example to emphasize the main features.

Scientific forums have specific rules regarding how the abstract should appear. For the ACP, the rules are available on the electronic abstracts portal. Organizers of scientific meetings set explicit limits on the length of abstracts.

The most difficult decision to make is whether your case report is worth submitting as an abstract. Of course, rarity of a condition almost always meets the criterion of worthiness, but few of us have the opportunity to describe something that is completely new. Another reason to report a case is the lesson that it teaches. With this in mind, consider presenting a case if it increases awareness of a condition, suggests the proper diagnostic strategy, or demonstrates a more cost-effective approach to management. Alternatively, a case can be presented because it represents an unusual presentation of a relatively common condition. Other twists include an unusual complication of a disease and its management. Again, it's important to think about the message or lesson that the case can deliver.

Before you begin writing the abstract, present a quick summary of your case to colleagues or mentors to determine if they agree that the case is worthy of presentation. It is important to contribute something unique, but not if it depends on some trivial variation from previously presented cases. For example, if it is known that a certain cancer widely metastasizes, it is not worthwhile to report each new site. Similarly, drug reactions often merit a case report, but not if it is simply a report of a drug in a class whose other members are known to cause the same reaction.

Once you have decided to submit a case report abstract, describe it in such a way as to make it interesting, yet conform to the accepted format. The following paragraphs provide suggestions on both style and format.

Title and Author Information: The title is a summary of the abstract itself and should convince the reader that the topic is important, relevant, and innovative. However, don't tell everything about the case in the title, otherwise the reader's interest might lag. Make the title short, descriptive, and interesting. Some organizations require a special format for the title, such as all uppercase letters. Be sure to check the instructions. Following the title, include the names of authors followed by their institutional affiliations. Deciding upon the authorship of a case report can be tricky. In the past, it was acceptable to include as authors those contributing to the management of the patient, but this is no longer true. Currently, it is expected that the authors contribute significantly to the intellectual content of the case report. It is assumed that the first author will present the work if the abstract is accepted. The first author may need to meet certain eligibility requirements in order to present the abstract, for example, be a member of the professional society sponsoring the research meeting. This information is always included with the abstract instructions.

Introduction: Most case report abstracts begin with a short introduction. This typically describes the context of the case and explains its relevance and importance. However, it is perfectly acceptable to begin directly with the description of the case.

Case Description: When reporting the case, follow the basic rules of medical communication; describe in sequence the history, physical examination, investigative studies, and the patient's progress and outcome. The trick is to be complete without obscuring the essence of the case with irrelevant details.

Discussion: The main purpose of the discussion is to review why decisions were made and extract the lesson from the case. Not uncommonly, reports from the literature, or their absence, are cited that either directly support or contradict the findings of the case. Be wary of boasting that your case is the "first" to describe a particular phenomenon, since even the most thorough searches often fail to reveal all instances of similar cases. Keep in mind that the best case report abstracts are those that make a small number of teaching points (even just one) in clear and succinct language.

When writing the abstract, avoid the use of medical jargon and excessive reliance on abbreviations. Limit abbreviations to no more than three, and favor commonly used abbreviations. Always spell out the abbreviations the first time they are mentioned unless they are commonly recognized (e.g., CBC).

It typically takes several days to write a good abstract, and the process should not be undertaken alone. Get help from a mentor who is not familiar with the case; such mentors can quickly point out areas that are unclear or demand more detail. Make revisions based upon the feedback. Finally, have others read your draft in order to check for technical errors, such as spelling and grammar mistakes. Reading the abstract out loud is another good way to catch awkward phrasing and word omissions. Finally, a Clinical Vignette Abstract Checklist  and an example of a clinical vignette abstract  are available to help you with the process of writing a successful abstract.

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

Last Updated on June 24, 2022 by Laura Turner

Updated and verified by Dr. Lee Burnett on March 19, 2022.

The ability to deliver oral case presentations is a core skill for any physician. Effective oral case presentations help facilitate information transfer among physicians and are essential to delivering quality patient care. Oral case presentations are also a key component of how medical students and residents are assessed during their training.

At its core, an oral case presentation functions as an argument. It is the presenter’s job to share the pertinent facts of a patient’s case with the other members of the medical care team and establish a clear diagnosis and treatment plan. Thus, the presenter should include details to support the proposed diagnosis, argue against alternative diagnoses, and exclude extraneous information. While this task may seem daunting at first, with practice, it will become easier. That said, if you are unsure if a particular detail is important to your patient’s case, it is probably best to be safe and include it.

Now, let’s go over how to present a case. While I will focus on internal medicine inpatients, the following framework can be applied to patients in any setting with slight modifications.

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 keep in mind:

• Be confident: Speak clearly at the loudest volume appropriate to protect patient privacy, vary your tone to emphasize the most important details, and maintain eye contact with members of your team.
• Don’t fidget : Stand up straight and avoid unnecessary, distracting movements.
• Use your notes : You may glance at your notes from time to time while presenting. However, while there is no need to memorize your presentation, there is no better way to lose your team’s attention than to read your notes to them.
• Be honest: Given the importance of presentations in guiding medical care, never guess or report false information to the team. If you are unsure about a particular detail, say so.

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 presentations, with a median of 7 minutes.

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 differences are often stylistic, and content expectations are generally quite similar. Thus, developing a familiarity with the core elements of a strong oral case presentation is essential.

How to Present a Patient

You should begin every oral presentation with a brief one-liner that contains the patient’s name, age, relevant past medical history, and chief complaint. Remember that the chief complaint is why the patient sought medical care in his or her own words. An example of an effective opening is as follows: “Ms. X is a 78-year-old female with a past medical history of chronic obstructive pulmonary disease who presents to the hospital after she felt short of breath at home.”

Following the opener, elaborate on why the patient sought medical care. Describe the events that preceded the patient’s presentation in chronological order. A useful mnemonic to use when deciding what to report is OPQRST , which includes: • The Onset of the patient’s symptoms • Any Palliative or Provoking factors that make the symptoms better or worse, respectively • The Quality of his or her symptoms (how he or she describes them) • The Region of the body where the patient is experiencing his or her symptoms and (if the symptom is pain) whether the patient’s pain Radiates to another location or is well-localized • The Severity of the symptoms and any other associated Symptoms • The Time course of the symptoms (how they have changed over time and whether the patient has experienced them before) Additionally, include any other details here that may support your final diagnosis or rule out alternative diagnoses. For example, if you are concerned about a pulmonary embolism and your patient recently completed a long-distance flight, that would be worth mentioning.

The review of systems is sometimes included in the history of present illness, but it may also be separated. Given the potential breadth of the review of systems (a comprehensive list of questions that may be asked can be found here ), when presenting, only report information that is relevant to your patient’s condition.

The past medical history comes next. This should include the following information: • The patient’s medical conditions, including any that were not highlighted in the opener • Any past surgeries the patient has had and when they were performed • The timing of and reasons for past hospitalizations • Any current medications, including dosages and frequency of administration

The next section should detail the patient’s relevant family history. This should include: • Any relevant conditions that run in the patient’s family, with an emphasis on first-degree relatives

After the family history comes the social history. This section should include information about the patient’s: • Living situation • Occupation • Alcohol and tobacco use • Other substance use You may also include relevant details about the patient’s education level, recent travel history, history of animal and occupational exposures, and religious beliefs. For example, it would be worth mentioning that your anemic patient is a Jehovah’s Witness to guide medical decisions regarding blood transfusions.

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, which includes the patient’s: • Temperature • Heart rate • Blood pressure • Respiratory rate • Oxygen saturation (if the patient is using supplemental oxygen, this should also be reported) Next, you should discuss the findings of your physical exam. At the minimum, this should include: • 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 Additional relevant physical examination findings may be included, as well. Quick note: resist the urge to report an exam as being “normal.” Instead, report your findings. For example, for a normal abdominal exam, you could report that “the patient’s abdomen is soft, non-tender, and non-distended, with normoactive bowel sounds.”

This section includes the results of any relevant laboratory testing, imaging, or other diagnostics that were obtained. You do not have to report the results of every test that was ordered. Before presenting, consider which results will further support your proposed diagnosis and exclude alternatives.

The emergency department (ED) course is classically reported towards the end of the presentation. However, different attendings may prefer to hear the ED course earlier, usually following the history of present illness. When unsure, report the ED course after the results of diagnostic testing. Be sure to include initial ED vital signs and any administered treatments.

You should conclude your presentation with the assessment and plan. This is the most important part of your presentation and allows you to show your team how much you really know. 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. An example could be: “Ms. X is a 78-year-old female with a past medical history of chronic obstructive pulmonary disease who presents with shortness of breath in the setting of an upper respiratory tract infection who is now stable on two liters of supplemental oxygen delivered via nasal cannula. Her symptoms are thought to be secondary to an acute exacerbation of chronic obstructive pulmonary disease.” • A differential diagnosis . For students, this should consist of 3-5 potential diagnoses. You should explain why you think each diagnosis is or is not the final diagnosis. Be sure to rule out potentially life-threatening conditions (unless you think your patient has one). For our fictional patient, Ms. X, for example, you could explain why you think she does not have a pulmonary embolism or acute coronary syndrome. For more advanced trainees, the differential can be more limited in scope. • Your plan . On regular inpatient floors, this should include a list of the patient’s medical problems, ordered by acuity, followed by your proposed plan for each. After going through each active medical problem, be sure to mention your choice for the patient’s diet and deep vein thrombosis prophylaxis, the patient’s stated code status, and the patient’s disposition (whether you think they need to remain in the hospital). In intensive care units, you can organize the patient’s medical problems by organ system to ensure that no stone is left unturned (if there are no active issues for an organ system, you may say so).

Presenting Patients Who Have Been in the Hospital for Multiple Days

After the initial presentation, subsequent presentations can be delivered via SOAP note format as follows:

• The  Subjective  section includes details about any significant overnight events and any new complaints the patient has.
• In the  Objective  section, report your physical exam (focus on any changes since you last examined the patient) and any significant new laboratory, imaging, or other diagnostic results.
• The  Assessment  and  Plan  are typically delivered as above. For the initial patient complaint, you do not have to restate your differential diagnosis if the diagnosis is known. For new complaints, however, you should create another differential and argue for or against each diagnosis. Be sure to update your plan every day.

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.

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. You may replace the history of present illness with any relevant interval history since his or her last visit.

And that’s it! Delivering oral case presentations is challenging at first, so remember to practice. In time, you will become proficient in this essential medical skill. Good luck!

Kunal Sindhu, MD, is an assistant professor in the Department of Radiation Oncology at the Icahn School of Medicine at Mount Sinai and New York Proton Center. Dr. Sindhu specializes in treating cancers of the head, neck, and central nervous system.

2 thoughts on “How To Present a Patient: A Step-To-Step Guide”

To clarify, it should take 5-10 minutes to present (just one) new internal medicine inpatient? Or if the student had 4 patients to work up, it should take 10 minutes to present all 4 patients to the preceptor?

Good question. That’s per case, but with time you’ll become faster.

Comments are closed.

Mastering the Art of Case Presentations: A guide for allied health students

Understanding the Purpose of Case Presentations

As allied health students progress through training and begin clinical experience, case presentations become important to communicate with clinical supervisors effectively . Mastering the art of case presentations allows students to succinctly convey patient information, including relevant history, symptoms, and examination results. Additionally, case presentations allow students to demonstrate their clinical reasoning skills, including their ability to formulate differential diagnoses and develop evidence-based treatment plans. 

The Patient Information Pyramid

At its core, a case presentation is a patient history summary, with all of the clinically irrelevant information omitted. Similarly, a clinical impression is a distilled case presentation. This is represented graphically below:

BSIP SA / Alamy Stock Photo

A case presentation is a detailed narrative describing a specific problem experienced by one or more patients. Pharmacists usually focus on the medicines aspect , for example, where there is potential harm to a patient or proven benefit to the patient from medication, or where a medication error has occurred. Case presentations can be used as a pedagogical tool, as a method of appraising the presenter’s knowledge and as an opportunity for presenters to reflect on their clinical practice [1] .

The aim of an oral presentation is to disseminate information about a patient for the purpose of education, to update other members of the healthcare team on a patient’s progress, and to ensure the best, evidence-based care is being considered for their management.

Within a hospital, pharmacists are likely to present patients on a teaching or daily ward round or to a senior pharmacist or colleague for the purpose of asking advice on, for example, treatment options or complex drug-drug interactions, or for referral.

Content of a case presentation

As a general structure, an oral case presentation may be divided into three phases [2] :

• Reporting important patient information and clinical data;
• Analysing and synthesising identified issues (this is likely to include producing a list of these issues, generally termed a problem list);
• Managing the case by developing a therapeutic plan.

Specifically, the following information should be included [3] :

Patient and complaint details

Patient details: name, sex, age, ethnicity.

Presenting complaint: the reason the patient presented to the hospital (symptom/event).

History of presenting complaint: highlighting relevant events in chronological order, often presented as how many days ago they occurred. This should include prior admission to hospital for the same complaint.

Review of organ systems: listing positive or negative findings found from the doctor’s assessment that are relevant to the presenting complaint.

Past medical and surgical history

Social history: including occupation, exposures, smoking and alcohol history, and any recreational drug use.

Medication history, including any drug allergies: this should include any prescribed medicines, medicines purchased over-the-counter, any topical preparations used (including eye drops, nose drops, inhalers and nasal sprays) and any herbal or traditional remedies taken.

Sexual history: if this is relevant to the presenting complaint.

Details from a physical examination: this includes any relevant findings to the presenting complaint and should include relevant observations.

Laboratory investigation and imaging results: abnormal findings are presented.

Assessment: including differential diagnosis.

Plan: including any pharmaceutical care issues raised and how these should be resolved, ongoing management and discharge planning.

Any discrepancies between the current management of the patient’s conditions and evidence-based recommendations should be highlighted and reasons given for not adhering to evidence-based medicine ( see ‘Locating the evidence’ ).

Locating the evidence

The evidence base for the therapeutic options available should always be considered. There may be local guidance available within the hospital trust directing the management of the patient’s presenting condition. Pharmacists often contribute to the development of such guidelines, especially if medication is involved. If no local guidelines are available, the next step is to refer to national guidance. This is developed by a steering group of experts, for example, the British HIV Association or the National Institute for Health and Care Excellence . If the presenting condition is unusual or rare, for example, acute porphyria, and there are no local or national guidelines available, a literature search may help locate articles or case studies similar to the case.

Giving a case presentation

Currently, there are no available acknowledged guidelines or systematic descriptions of the structure, language and function of the oral case presentation [4] and therefore there is no standard on how the skills required to prepare or present a case are taught. Most individuals are introduced to this concept at undergraduate level and then build on their skills through practice-based learning.

A case presentation is a narrative of a patient’s care, so it is vital the presenter has familiarity with the patient, the case and its progression. The preparation for the presentation will depend on what information is to be included.

Generally, oral case presentations are brief and should be limited to 5–10 minutes. This may be extended if the case is being presented as part of an assessment compared with routine everyday working ( see ‘Case-based discussion’ ). The audience should be interested in what is being said so the presenter should maintain this engagement through eye contact, clear speech and enthusiasm for the case.

It is important to stick to the facts by presenting the case as a factual timeline and not describing how things should have happened instead. Importantly, the case should always be concluded and should include an outcome of the patient’s care [5] .

An example of an oral case presentation, given by a pharmacist to a doctor,  is available here .

A successful oral case presentation allows the audience to garner the right amount of patient information in the most efficient way, enabling a clinically appropriate plan to be developed. The challenge lies with the fact that the content and delivery of this will vary depending on the service, and clinical and audience setting [3] . A practitioner with less experience may find understanding the balance between sufficient information and efficiency of communication difficult, but regular use of the oral case presentation tool will improve this skill.

Tailoring case presentations to your audience

Most case presentations are not tailored to a specific audience because the same type of information will usually need to be conveyed in each case.

However, case presentations can be adapted to meet the identified learning needs of the target audience, if required for training purposes. This method involves varying the content of the presentation or choosing specific cases to present that will help achieve a set of objectives [6] . For example, if a requirement to learn about the management of acute myocardial infarction has been identified by the target audience, then the presenter may identify a case from the cardiology ward to present to the group, as opposed to presenting a patient reviewed by that person during their normal working practice.

Alternatively, a presenter could focus on a particular condition within a case, which will dictate what information is included. For example, if a case on asthma is being presented, the focus may be on recent use of bronchodilator therapy, respiratory function tests (including peak expiratory flow rate), symptoms related to exacerbation of airways disease, anxiety levels, ability to talk in full sentences, triggers to worsening of symptoms, and recent exposure to allergens. These may not be considered relevant if presenting the case on an unrelated condition that the same patient has, for example, if this patient was admitted with a hip fracture and their asthma was well controlled.

Case-based discussion

The oral case presentation may also act as the basis of workplace-based assessment in the form of a case-based discussion. In the UK, this forms part of many healthcare professional bodies’ assessment of clinical practice, for example, medical professional colleges.

For pharmacists, a case-based discussion forms part of the Royal Pharmaceutical Society (RPS) Foundation and Advanced Practice assessments . Mastery of the oral case presentation skill could provide useful preparation for this assessment process.

A case-based discussion would include a pharmaceutical needs assessment, which involves identifying and prioritising pharmaceutical problems for a particular patient. Evidence-based guidelines relevant to the specific medical condition should be used to make treatment recommendations, and a plan to monitor the patient once therapy has started should be developed. Professionalism is an important aspect of case-based discussion — issues must be prioritised appropriately and ethical and legal frameworks must be referred to [7] . A case-based discussion would include broadly similar content to the oral case presentation, but would involve further questioning of the presenter by the assessor to determine the extent of the presenter’s knowledge of the specific case, condition and therapeutic strategies. The criteria used for assessment would depend on the level of practice of the presenter but, for pharmacists, this may include assessment against the RPS  Foundation or Pharmacy Frameworks .

Acknowledgement

With thanks to Aamer Safdar for providing the script for the audio case presentation.

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[1] Onishi H. The role of case presentation for teaching and learning activities. Kaohsiung J Med Sci 2008;24:356–360. doi: 10.1016/s1607-551x(08)70132–3

[2] Edwards JC, Brannan JR, Burgess L et al . Case presentation format and clinical reasoning: a strategy for teaching medical students. Medical Teacher 1987;9:285–292. doi: 10.3109/01421598709034790

[3] Goldberg C. A practical guide to clinical medicine: overview and general information about oral presentation. 2009. University of California, San Diego. Available from: https://meded.ecsd.edu/clinicalmed.oral.htm (accessed 5 December 2015)

[4] Chan MY. The oral case presentation: toward a performance-based rhetorical model for teaching and learning. Medical Education Online 2015;20. doi: 10.3402/meo.v20.28565

[5] McGee S. Medicine student programs: oral presentation guidelines. Learning & Scholarly Technologies, University of Washington. Available from: https://catalyst.uw.edu/workspace/medsp/30311/202905 (accessed 7 December 2015)

[6] Hays R. Teaching and Learning in Clinical Settings. 2006;425. Oxford: Radcliffe Publishing Ltd.

[7] Royal Pharmaceutical Society. Tips for assessors for completing case-based discussions. 2015. Available from: http://www.rpharms.com/help/case_based_discussion.htm (accessed 30 December 2015)

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How to Write a Case Conceptualization: 10 Examples (+ PDF)

Such understanding can be developed by reading relevant records, meeting with clients face to face, and using assessments such as a mental status examination.

As you proceed, you are forming a guiding concept of who this client is, how they became who they are, and where their personal journey might be heading.

Such a guiding concept, which will shape any needed interventions, is called a case conceptualization, and we will examine various examples in this article.

Before you continue, we thought you might like to download our three Positive CBT Exercises for free . These science-based exercises will provide you with detailed insight into positive Cognitive-Behavioral Therapy (CBT) and give you the tools to apply it in your therapy or coaching.

This Article Contains:

What is a case conceptualization or formulation, 4 things to include in your case formulation, a helpful example & model, 3 samples of case formulations, 6 templates and worksheets for counselors, relevant resources from positivepsychology.com, a take-home message.

In psychology and related fields, a case conceptualization summarizes the key facts and findings from an evaluation to provide guidance for recommendations.

This is typically the evaluation of an individual, although you can extend the concept of case conceptualization to summarizing findings about a group or organization.

Based on the case conceptualization, recommendations can be made to improve a client’s self-care , mental status, job performance, etc (Sperry & Sperry, 2020).

• Summary of the client’s identifying information, referral questions, and timeline of important events or factors in their life . A timeline can be especially helpful in understanding how the client’s strengths and limitations have evolved.
• Statement of the client’s core strengths . Identifying core strengths in the client’s life should help guide any recommendations, including how strengths might be used to offset limitations.
• Statement concerning a client’s limitations or weaknesses . This will also help guide any recommendations. If a weakness is worth mentioning in a case conceptualization, it is worth writing a recommendation about it.

Note: As with mental status examinations , observations in this context concerning weaknesses are not value judgments, about whether the client is a good person, etc. The observations are clinical judgments meant to guide recommendations.

• A summary of how the strengths, limitations, and other key information about a client inform diagnosis and prognosis .

You should briefly clarify how you arrived at a given diagnosis. For example, why do you believe a personality disorder is primary, rather than a major depressive disorder?

Many clinicians provide diagnoses in formal psychiatric terms, per the International Classification of Diseases (ICD-10) or Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Some clinicians will state a diagnosis in less formal terms that do not coincide exactly with ICD-10 or DSM-5 codes. What is arguably more important is that a diagnostic impression, formal or not, gives a clear sense of who the person is and the support they need to reach their goals.

Prognosis is a forecast about whether the client’s condition can be expected to improve, worsen, or remain stable. Prognosis can be difficult, as it often depends on unforeseeable factors. However, this should not keep you from offering a conservative opinion on a client’s expected course, provided treatment recommendations are followed.

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Based on the pointers for writing a case conceptualization above, an example for summarizing an adolescent case (in this instance, a counseling case for relieving depression and improving social skills) might read as follows.

Background and referral information

This is a 15-year-old Haitian–American youth, referred by his mother for concerns about self-isolation, depression, and poor social skills. He reportedly moved with his mother to the United States three years ago.

He reportedly misses his life and friends in Haiti. The mother states he has had difficulty adjusting socially in the United States, especially with peers. He has become increasingly self-isolating, appears sad and irritable, and has started to refuse to go to school.

His mother is very supportive and aware of his emotional–behavioral needs. The youth has been enrolled in a social skills group at school and has attended three sessions, with some reported benefit. He is agreeable to start individual counseling. He reportedly does well in school academically when he applies himself.

Limitations

Behavioral form completed by his mother shows elevated depression scale (T score = 80). There is a milder elevation on the inattention scale (T score = 60), which suggests depression is more acute than inattention and might drive it.

He is also elevated on a scale measuring social skills and involvement (T score = 65). Here too, it is reasonable to assume that depression is driving social isolation and difficulty relating to peers, especially since while living in Haiti, he was reportedly quite social with peers.

Diagnostic impressions, treatment guidance, prognosis

This youth’s history, presentation on interview, and results of emotional–behavioral forms suggest some difficulty with depression, likely contributing to social isolation. As he has no prior reported history of depression, this is most likely a reaction to missing his former home and difficulty adjusting to his new school and peers.

Treatments should include individual counseling with an evidence-based approach such as Cognitive-Behavioral Therapy (CBT). His counselor should consider emotional processing and social skills building as well.

Prognosis is favorable, with anticipated benefit apparent within 12 sessions of CBT.

How to write a case conceptualization: An outline

The following outline is necessarily general. It can be modified as needed, with points excluded or added, depending on the case.

• Client’s gender, age, level of education, vocational status, marital status
• Referred by whom, why, and for what type of service (e.g., testing, counseling, coaching)
• In the spirit of strengths-based assessment, consider listing the client’s strengths first, before any limitations.
• Consider the full range of positive factors supporting the client.
• Physical health
• Family support
• Financial resources
• Capacity to work
• Resilience or other positive personality traits
• Emotional stability
• Cognitive strengths, per history and testing
• The client’s limitations or relative weaknesses should be described in a way that highlights those most needing attention or treatment.
• Medical conditions affecting daily functioning
• Lack of family or other social support
• Limited financial resources
• Inability to find or hold suitable employment
• Substance abuse or dependence
• Proneness to interpersonal conflict
• Emotional–behavioral problems, including anxious or depressive symptoms
• Cognitive deficits, per history and testing
• Diagnoses that are warranted can be given in either DSM-5 or ICD-10 terms.
• There can be more than one diagnosis given. If that’s the case, consider describing these in terms of primary diagnosis, secondary diagnosis, etc.
• The primary diagnosis should best encompass the client’s key symptoms or traits, best explain their behavior, or most need treatment.
• Take care to avoid over-assigning multiple and potentially overlapping diagnoses.

When writing a case conceptualization, always keep in mind the timeline of significant events or factors in the examinee’s life.

• Decide which events or factors are significant enough to include in a case conceptualization.
• When these points are placed in a timeline, they help you understand how the person has evolved to become who they are now.
• A good timeline can also help you understand which factors in a person’s life might be causative for others. For example, if a person has suffered a frontal head injury in the past year, this might help explain their changeable moods, presence of depressive disorder, etc.

Sample #1: Conceptualization for CBT case

This is a 35-year-old Caucasian man referred by his physician for treatment of generalized anxiety.

Strengths/supports in his case include willingness to engage in treatment, high average intelligence per recent cognitive testing, supportive family, and regular physical exercise (running).

Limiting factors include relatively low stress coping skills, frequent migraines (likely stress related), and relative social isolation (partly due to some anxiety about social skills).

The client’s presentation on interview and review of medical/psychiatric records show a history of chronic worry, including frequent worries about his wife’s health and his finances. He meets criteria for DSM-5 generalized anxiety disorder. He has also described occasional panic-type episodes, which do not currently meet full criteria for panic disorder but could develop into such without preventive therapy.

Treatments should include CBT for generalized anxiety, including keeping a worry journal; regular assessment of anxiety levels with Penn State Worry Questionnaire and/or Beck Anxiety Inventory; cognitive restructuring around negative beliefs that reinforce anxiety; and practice of relaxation techniques, such as progressive muscle relaxation and diaphragmatic breathing .

Prognosis is good, given the evidence for efficacy of CBT for anxiety disorders generally (Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012).

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Sample #2: Conceptualization for DBT case

This 51-year-old Haitian–American woman is self-referred for depressive symptoms, including reported moods of “rage,” “sadness,” and “emptiness.” She says that many of her difficulties involve family, friends, and coworkers who regularly “disrespect” her and “plot against her behind her back.”

Her current psychiatrist has diagnosed her with personality disorder with borderline features, but she doubts the accuracy of this diagnosis.

Strengths/supports include a willingness to engage in treatment, highly developed and marketable computer programming skills, and engagement in leisure activities such as playing backgammon with friends.

Limiting factors include low stress coping skills, mild difficulties with attention and recent memory (likely due in part to depressive affect), and a tendency to self-medicate with alcohol when feeling depressed.

The client’s presentation on interview, review of medical/psychiatric records, and results of MMPI-2 personality inventory corroborate her psychiatrist’s diagnosis of borderline personality disorder.

The diagnosis is supported by a longstanding history of unstable identity, volatile personal relationships with fear of being abandoned, feelings of emptiness, reactive depressive disorder with suicidal gestures, and lack of insight into interpersonal difficulties that have resulted in her often stressed and depressive state.

Treatments should emphasize a DBT group that her psychiatrist has encouraged her to attend but to which she has not yet gone. There should also be regular individual counseling emphasizing DBT skills including mindfulness or present moment focus, building interpersonal skills, emotional regulation, and distress tolerance. There should be a counseling element for limiting alcohol use. Cognitive exercises are also recommended.

Of note, DBT is the only evidence-based treatment for borderline personality disorder (May, Richardi, & Barth, 2016). Prognosis is guardedly optimistic, provided she engages in both group and individual DBT treatments on a weekly basis, and these treatments continue without interruption for at least three months, with refresher sessions as needed.

Sample #3: Conceptualization in a family therapy case

This 45-year-old African-American woman was initially referred for individual therapy for “rapid mood swings” and a tendency to become embroiled in family conflicts. Several sessions of family therapy also appear indicated, and her psychiatrist concurs.

The client’s husband (50 years old) and son (25 years old, living with parents) were interviewed separately and together. When interviewed separately, her husband and son each indicated the client’s alcohol intake was “out of control,” and that she was consuming about six alcoholic beverages throughout the day, sometimes more.

Her husband and son each said the client was often too tired for household duties by the evening and often had rapid shifts in mood from happy to angry to “crying in her room.”

On individual interview, the client stated that her husband and son were each drinking about as much as she, that neither ever offered to help her with household duties, and that her son appeared unable to keep a job, which left him home most of the day, making demands on her for meals, etc.

On interview with the three family members, each acknowledged that the instances above were occurring at home, although father and son tended to blame most of the problems, including son’s difficulty maintaining employment, on the client and her drinking.

Strengths/supports in the family include a willingness of each member to engage in family sessions, awareness of supportive resources such as assistance for son’s job search, and a willingness by all to examine and reduce alcohol use by all family members as needed.

Limiting factors in this case include apparent tendency of all household members to drink to some excess, lack of insight by one or more family members as to how alcohol consumption is contributing to communication and other problems in the household, and a tendency by husband and son to make this client the family scapegoat.

The family dynamic can be conceptualized in this case through a DBT lens.

From this perspective, problems develop within the family when the environment is experienced by one or more members as invalidating and unsupportive. DBT skills with a nonjudgmental focus, active listening to others, reflecting each other’s feelings, and tolerance of distress in the moment should help to develop an environment that supports all family members and facilitates effective communication.

It appears that all family members in this case would benefit from engaging in the above DBT skills, to support and communicate with one another.

Prognosis is guardedly optimistic if family will engage in therapy with DBT elements for at least six sessions (with refresher sessions as needed).

Introduction to case conceptualization – Thomas Field

The following worksheets can be used for case conceptualization and planning.

• Case Conceptualization Worksheet: Individual Counseling helps counselors develop a case conceptualization for individual clients.
• Case Conceptualization Worksheet: Couples Counseling helps counselors develop a case conceptualization for couples.
• Case Conceptualization Worksheet: Family Counseling helps counselors develop a case conceptualization for families.
• Case Conceptualization and Action Plan: Individual Counseling helps clients facilitate conceptualization of their own case, at approximately six weeks into counseling and thereafter at appropriate intervals.
• Case Conceptualization and Action Plan: Couples Counseling helps couples facilitate conceptualization of their own case, at approximately six weeks into counseling and thereafter at appropriate intervals.
• Case Conceptualization and Action Plan: Family Counseling helps families facilitate conceptualization of their own case, at approximately six weeks into counseling and thereafter at appropriate intervals.

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The following resources can be found in the Positive Psychology Toolkit© , and their full versions can be accessed by a subscription.

Analyzing Strengths Use in Different Life Domains can help clients understand their notable strengths and which strengths can be used to more advantage in new contexts.

Family Strength Spotting is another relevant resource. Each family member fills out a worksheet detailing notable strengths of other family members. In reviewing all worksheets, each family member can gain a greater appreciation for other members’ strengths, note common or unique strengths, and determine how best to use these combined strengths to achieve family goals.

Four Front Assessment is another resource designed to help counselors conceptualize a case based on a client’s personal and environmental strengths and weaknesses. The idea behind this tool is that environmental factors in the broad sense, such as a supportive/unsupportive family, are too often overlooked in conceptualizing a case.

If you’re looking for more science-based ways to help others through CBT, check out this collection of 17 validated positive CBT tools for practitioners. Use them to help others overcome unhelpful thoughts and feelings and develop more positive behaviors.

In helping professions, success in working with clients depends first and foremost on how well you understand them.

This understanding is crystallized in a case conceptualization.

Case conceptualization helps answer key questions. Who is this client? How did they become who they are? What supports do they need to reach their goals?

The conceptualization itself depends on gathering all pertinent data on a given case, through record review, interview, behavioral observation, questionnaires completed by the client, etc.

Once the data is assembled, the counselor, coach, or other involved professional can focus on enumerating the client’s strengths, weaknesses, and limitations.

It is also often helpful to put the client’s strengths and limitations in a timeline so you can see how they have evolved and which factors might have contributed to the emergence of others.

Based on this in-depth understanding of the client, you can then tailor specific recommendations for enhancing their strengths, overcoming their weaknesses, and reaching their particular goals.

We hope you have enjoyed this discussion of how to conceptualize cases in the helping professions and that you will find some tools for doing so useful.

We hope you enjoyed reading this article. For more information, don’t forget to download our three Positive CBT Exercises for free .

• Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy and Research , 36 (5), 427–440.
• May, J. M., Richardi, T. M., & Barth, K. S. (2016). Dialectical behavior therapy as treatment for borderline personality disorder. The Mental Health Clinician , 6 (2), 62–67.
• Sperry, L., & Sperry, J. (2020).  Case conceptualization: Mastering this competency with ease and confidence . Routledge.

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During medical school, students often come across patients with a unique presentation, an unfamiliar response to treatment, or even an obscure disease. Writing a case report is an excellent way of documenting these findings for the wider medical community—sharing new knowledge that will lead to better and safer patient care.

For many medical students and junior doctors, a case report may be their first attempt at medical writing. A published case report will look impressive on your curriculum vitae, particularly if it is on a topic of your chosen specialty. Publication will be an advantage when applying for foundation year posts and specialty training, and many job applications have points allocated exclusively for publications in peer reviewed journals, including case reports.

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If you are considering writing a case report, try to find a senior doctor who can be a supervising coauthor and help you decide whether you have a message worth writing about, that you have chosen the correct journal to submit to (considering the format that the journal requires), that the process is transparent and ethical at all times, and that your patient is not compromised in your writing. Indeed, try to include your patient in the process from the …

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Role of case presentation for teaching and learning activities

Affiliation.

• 1 International Research Center for Medical Education, The University of Tokyo, Tokyo, Japan. [email protected]
• PMID: 18805750
• DOI: 10.1016/s1607-551x(08)70132-3

In most clinical teaching settings, case presentation is the most frequently used teaching and learning activity. 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. The presenter sometimes does not recall what to ask or to examine with relation to pertinent differential diagnoses while seeing a patient, and afterward he/she might note that more information should have been collected. He/she is able to note the processes by reflection-on-action and improve the processes the next time. Such a reflective process is the most important role of case conference for a presenter. When a clinician has a consultation with a patient, early problem representation determines the quality of differential diagnoses. Clinicians make a "big picture" while listening to the patient (sometimes only a glance is enough to diagnose a patient) as problem representation to narrow down clinical areas to ask questions. If the early problem representation is far from the optimal direction, the possibility of misdiagnosis will be higher. To correct the cognitive processes that lead to misdiagnosis, disclosure of uncertainty will be the key. If the teaching environment among residents or young clinicians is too competitive, some might feel reluctant to disclose incorrect reasoning processes to their peers. Or, if a clinician educator is too authoritative, students may hide key information from the educator. The educator should construct the best environment for students to be able to disclose such uncertainty. The main role of clinician educators is to facilitate and evaluate case presentations and to suggest points for improvement. Neher et al's "five microskills" are a typical example of these processes, after a short presentation of an outpatient case. Yet, for an inpatient or for formal discussion, a longer version presentation is used. To improve the clinical reasoning processes of the presenter, the short presentation has several advantages: (1) shortening the presentation requires abstraction of information, possibly leading to better problem representation; (2) it is time-efficient; and (3) it stimulates more informal interactions with the facilitator and the audience. In clinical settings, a presenter uses his/her time for the preparation of case presentations to reflect on the information he/she has collected. The facilitator should know how to improve case presentations to diagnose and improve the presenter. The advantages of the short presentation should be emphasized.

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The Ultimate Patient Case Presentation Template for Med Students

• April 6, 2024
• Reviewed by: Amy Rontal, MD

Knowing how to deliver a patient presentation is one of the most important skills to learn on your journey to becoming a physician. After all, when you’re on a medical team, you’ll need to convey all the critical information about a patient in an organized manner without any gaps in knowledge transfer.

One big caveat: opinions about the correct way to present a patient are highly personal and everyone is slightly different. Additionally, there’s a lot of variation in presentations across specialties, and even for ICU vs floor patients.

My goal with this blog is to give you the most complete version of a patient presentation, so you can tailor your presentations to the preferences of your attending and team. So, think of what follows as a model for presenting any general patient.

Here’s a breakdown of what goes into the typical patient presentation.

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7 Ingredients for a Patient Case Presentation Template

1. the one-liner.

The one-liner is a succinct sentence that primes your listeners to the patient.

A typical format is: “[Patient name] is a [age] year-old [gender] with past medical history of [X] presenting with [Y].

2. The Chief Complaint

This is a very brief statement of the patient’s complaint in their own words. A common pitfall is when medical students say that the patient had a chief complaint of some medical condition (like cholecystitis) and the attending asks if the patient really used that word!

An example might be, “Patient has chief complaint of difficulty breathing while walking.”

3. History of Present Illness (HPI)

The goal of the HPI is to illustrate the story of the patient’s complaint. I remember when I first began medical school, I had a lot of trouble determining what was relevant and ended up giving a lot of extra details. Don’t worry if you have the same issue. With time, you’ll learn which details are important. 

The OPQRST Framework

In the beginning of your clinical experience, a helpful framework to use is OPQRST:

Describe when the issue started, and if it occurs during certain environmental or personal exposures.

P rovocative

Report if there are any factors that make the pain better or worse. These can be broad, like noting their shortness of breath worsened when lying flat, or their symptoms resolved during rest. 

Relay how the patient describes their pain or associated symptoms. For example, does the patient have a burning versus a pressure sensation? Are they feeling weakness, stiffness, or pain?

R egion/Location

Indicate where the pain is located and if it radiates anywhere.

Talk about how bad the pain is for the patient. Typically, a 0-10 pain scale is useful to provide some objective measure.

Discuss how long the pain lasts and how often it occurs.

A Case Study

While the OPQRST framework is great when starting out, it can be limiting. Let’s take an example where the patient is not experiencing pain and comes in with altered mental status along with diffuse jaundice of the skin and a history of chronic liver disease. You will find that certain sections of OPQRST do not apply. In this event, the HPI is still a story, but with a different framework. Try to go in chronological order. Include relevant details like if there have been any changes in medications, diet, or bowel movements.

Pertinent Positive and Negative Symptoms

Regardless of the framework you use, the name of the game is pertinent positive and negative symptoms the patient is experiencing. I’d like to highlight the word “pertinent.” It’s less likely the patient’s chronic osteoarthritis and its management is related to their new onset shortness of breath, but it’s still important for knowing the patient’s complete medical picture. A better place to mention these details would be in the “Past Medical History” section, and reserve the HPI portion for more pertinent history. As you become exposed to more illness scripts, experience will teach you which parts of the history are most helpful to state. Also, as you spend more time on the wards, you will pick up on which questions are relevant and important to ask during the patient interview.   By painting a clear picture with pertinent positives and negatives during your presentation, the history will guide what may be higher or lower on the differential diagnosis. Some other important components to add are the patient’s additional past medical/surgical history, family history, social history, medications, allergies, and immunizations.

The HEADSSS Method

Particularly, the social history is an important time to describe the patient as a complete person and understand how their life story may affect their present condition. One way of organizing the social history is the HEADSSS method: – H ome living situation and relationships – E ducation and employment – A ctivities and hobbies – D rug use (alcohol, tobacco, cocaine, etc.) Note frequency of use, and if applicable, be sure to add which types of alcohol consumption (like beer versus hard liquor) and forms of drug use. – S exual history (partners, STI history, pregnancy plans) – S uicidality and depression – S piritual and religious history   Again, there’s a lot of variation in presenting social history, so just follow the lead of your team. For example, it’s not always necessary/relevant to obtain a sexual history, so use your judgment of the situation.

4. Review of Symptoms

Oftentimes, most elements of this section are embedded within the HPI. If there are any additional symptoms not mentioned in the HPI, it’s appropriate to state them here.

5. Objective

Vital signs.

Some attendings love to hear all five vital signs: temperature, blood pressure (mean arterial pressure if applicable), heart rate, respiratory rate, and oxygen saturation. Others are happy with “afebrile and vital signs stable.” Just find out their preference and stick to that. 

Physical Exam  

This is one of the most important parts of the patient presentation for any specialty. It paints a picture of how the patient looks and can guide acute management like in the case of a rigid abdomen. As discussed in the HPI section, typically you should report pertinent positives and negatives. When you’re starting out, your attending and team may prefer for you to report all findings as part of your learning. For example, pulmonary exam findings can be reported as: “Regular chest appearance. No abnormalities on palpation. Lungs resonant to percussion. Clear to auscultation bilaterally without crackles, rhonchi, or wheezing.” Typically, you want to report the physical exams in a head to toe format: General Appearance, Mental Status, Neurologic, Eyes/Ears/Nose/Mouth/Neck, Cardiovascular, Pulmonary, Breast, Abdominal, Genitourinary, Musculoskeletal, and Skin. Depending on the situation, additional exams can be incorporated as applicable.

Now comes reporting pertinent positive and negative labs. Several labs are often drawn upon admission. It’s easy to fall into the trap of reading off all the labs and losing everyone’s attention. Here are some pieces of advice: 

You normally can’t go wrong sticking to abnormal lab values. 

One qualification is that for a patient with concern for acute coronary syndrome, reporting a normal troponin is essential. Also, stating the normalization of previously abnormal lab values like liver enzymes is important.

Demonstrate trends in lab values.

A lab value is just a single point in time and does not paint the full picture. For example, a hemoglobin of 10g/dL in a patient at 15g/dL the previous day is a lot more concerning than a patient who has been stable at 10g/dL for a week.

Try to avoid editorializing in this section.

Save your analysis of the labs for the assessment section. Again, this can be a point of personal preference. In my experience, the team typically wants the raw objective data in this section. This is also a good place to state the ins and outs of your patient (if applicable). In some patients, these metrics are strictly recorded and are typically reported as total fluid in and out over the past day followed by the net fluid balance. For example, “1L in, 2L out, net -1L over the past 24 hours.”

6. Diagnostics/Imaging

Next, you’ll want to review any important diagnostic tests and imaging. For example, describe how the EKG and echo look in a patient presenting with chest pain or the abdominal CT scan in a patient with right lower quadrant abdominal pain. Try to provide your own interpretation to develop your skills and then include the final impression. Also, report if a diagnostic test is still pending.

7. Assessment/Plan

This is the fun part where you get to use your critical thinking (aka doctor) skills! For the scope of this blog, we’ll review a problem-based plan. It’s helpful to begin with a summary statement that incorporates the one-liner, presenting issue(s)/diagnosis(es), and patient stability. Then, go through all the problems relevant to the admission. You can impress your audience by casting a wide differential diagnosis and going through the elements of your patient presentation that support one diagnosis over another.  Following your assessment, try to suggest a management plan. In a patient with congestive heart failure exacerbation, initiating a diuresis regimen and measuring strict ins/outs are good starting points. You may even suggest a follow-up on their latest ejection fraction with an echo and check if they’re on guideline-directed medical therapy. Again, with more time on the clinical wards you’ll start to pick up on what management plan to suggest. One pointer is to talk about all relevant problems, not just the presenting issue. For example, a patient with diabetes may need to be put on a sliding scale insulin regimen or another patient may require physical/occupational therapy. Just try to stay organized and be comprehensive.

A Note About Patient Presentation Skills

When you’re doing your first patient presentations, it’s common to feel nervous. There may be a lot of “uhs” and “ums.”

Here’s the good news: you don’t have to be perfect! You just need to make a good faith attempt and keep on going with the presentation.

With time, your confidence will build. Practice your fluency in the mirror when you have a chance. No one was born knowing medicine and everyone has gone through the same stages of learning you are!

Practice your presentation a couple times before you present to the team if you have time. Pull a resident aside if they have the bandwidth to make sure you have all the information you need. 

One big piece of advice: NEVER LIE. If you don’t know a specific detail, it’s okay to say, “I’m not sure, but I can look that up.” Someone on your team can usually retrieve the information while you continue on with your presentation.

Example Patient Case Presentation Template

Here’s a blank patient case presentation template that may come in handy. You can adapt it to best fit your needs.   One-Liner:   Chief Complaint:   History of Present Illness:   Past Medical History: Past Surgical History: Family History: Social History: Medications: Allergies: Immunizations:   ROS:   Objective:   Vital Signs : Temp ___ BP ___ /___ HR ___ RR ___ O2 sat ___   Physical Exam:

General Appearance:

Mental Status:

Neurological:

Eyes, Ears, Nose, Mouth, and Neck:

Cardiovascular:

Genitourinary:

Musculoskeletal:

Most Recent Labs:

Previous Labs:

Diagnostics/Imaging:

Impression/Interpretation:

Assessment/Plan:

One-line summary:

#Problem 1:

Assessment:

#Problem 2:

Final Thoughts on Patient Presentations

I hope this post demystified the patient presentation for you. Be sure to stay organized in your delivery and be flexible with the specifications your team may provide.   Something I’d like to highlight is that you may need to tailor the presentation to the specialty you’re on. For example, on OB/GYN, it’s important to include a pregnancy history. Nonetheless, the aforementioned template should set you up for success from a broad overview perspective.   Stay tuned for my next post on how to give an ICU patient presentation. And if you’d like me to address any other topics in a blog, write to me at [email protected] ! Looking for more (free!) content to help you through clinical rotations? Check out these other posts from Blueprint tutors on the Med School blog:

• How I Balanced My Clinical Rotations with Shelf Exam Studying
• How (and Why) to Use a Qbank to Prepare for USMLE Step 2
• How to Study For Shelf Exams: A Tutor’s Guide

About the Author

Hailing from Phoenix, AZ, Neelesh is an enthusiastic, cheerful, and patient tutor. He is a fourth year medical student at the Keck School of Medicine of the University of Southern California and serves as president for the Class of 2024. He is applying to surgery programs for residency. He also graduated as valedictorian of his high school and the USC Viterbi School of Engineering, obtaining a B.S. in Biomedical Engineering in 2020. He discovered his penchant for teaching when he began tutoring his friends for the SAT and ACT in the summer of 2015 out of his living room. Outside of the academic sphere, Neelesh enjoys surfing at San Onofre Beach and hiking in the Santa Monica Mountains. Twitter: @NeeleshBagrodia LinkedIn: http://www.linkedin.com/in/neelesh-bagrodia

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Clinical Case Study Presentation Template

Number of slides: 10

A clinical case study is a report where medical practitioners share a patient’s case. Generally, clinical case studies are valuable tools for medical research as they provide detailed information on the development of a disease or illness in particular individuals. Use this PowerPoint template to document extraordinary patient cases and share your findings with the healthcare community. You can also use these slides to report the progress of your patient’s disease and work on the proper treatment alongside your team.

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Free Template for presenting a Clinical Case Study in PowerPoint

Patient’s clinical profile.

Before starting, share the patient’s clinical profile. This slide is great to describe your patient’s clinical history, underlying conditions, and other relevant health information. You can include demographic data and specific facts related to your patient but remember to keep their anonymity.

Clinical Treatment Slide

This is one of the most important sections of your patient’s case study. You’ll find a creative slide to explain the medical treatment stage by stage. You can go deep into the medicines or drugs the patient used and their reaction in different stages of the treatment. This means you’ll be able to cover the evolution of your patient from the beginning and provide detailed insights. 

Medical Team Slide

As in any research, you should acknowledge the professionals that worked with you. So, here’s a slide to showcase the whole medical team involved in the case study. You can add photos and short descriptions of each team member. Make sure to ask for professional images and double-check the spelling of role titles and names.   

Roadmaps for Clinical Case Study Presentations

If you’re wondering how to present a patient case study in PowerPoint, the best way to do so is by taking full advantage of its visual elements. Here you’ll find creative roadmaps, diagrams, and icons

Medical PowerPoint Slides

The Clinical Case Study PowerPoint template has a clean and minimalistic style that makes your work stand out in high-level professional slides.

Medical icons in PowerPoint

You’ll find medical icons on every PowerPoint slide. Use them to organize your information and direct your audience’s attention exactly where you want it to be.

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TEACHING TIPS: TWELVE TIPS FOR MAKING CASE PRESENTATIONS MORE INTERESTING *

1. set the stage.

Prepare the audience for what is to come. If the audience is composed of people of mixed expertise, spend a few minutes forming them into small mixed groups of novices and experts. Explain that this is an opportunity for the more junior to learn from the more senior people. Tell them that the case to be presented is extremely interesting, why it is so and what they may learn from it. The primary objective is to analyze the clinical reasoning that was used rather than the knowledge required, although the acquisition of such knowledge is an added benefit of the session. A “well organized case presentation or clinicopathological conference incorporates the logic of the workup implicitly and thus makes the diagnostic process seem almost preordained”.

A psychiatry resident began by introducing the case as an exciting one, explaining the process and dividing the audience into teams mixing people with varied expertise. He urged everyone to think in ‘real time’ rather than jump ahead and to refrain from considering information that is not normally available at the time: for example, a laboratory report that takes 24 hours to obtain be assessed in the initial workup.

2. PROVIDE ONLY INITIAL CUES AT FIRST

Give them the first two to live cues that were picked up in the first minute or two of the patient encounter either verbally, or written on a transparency. For example, age, sex race and reason for seeking medical help. Ask each group to discuss their first diagnostic hypotheses. Experts and novices will learn a great deal from each other at this stage and the discussions will be animated. The initial cues may number only one or two and hypothesis generation occurs very quickly even in the novices. Indeed, the only difference between the hypotheses of novices and those of experts is in the degree of refinement, not in number.

It is Saturday afternoon and you are the psychiatric emergency physician. A 25-year-old male arrives by ambulance and states that he is feeling suicidal. Groups talked for 4 minutes before the resident called for order to commence step three.

3. ASK FOR HYPOTHESES AND WRITE THEM UP ON THE BLACKBOARD

Call for order and ask people to offer their suggested diagnoses and write these up on a board or transparency.

The following hypotheses were suggested by the groups and the resident wrote them on a flip chart: depression, substance abuse, recent social stressors-crisis, adjustment disorder, organic problem, dysthymia, schizophrenia, bipolar affective disorder. The initial three or four bits of information generated eight hypotheses.

4. ALLOW THE AUDIENCE TO ASK FOR INFORMATION

After all hypotheses have been listed instruct the audience to ask for the information they need to confirm or refute these hypotheses. Do not allow them to ‘jump the gun’ by asking for a test result, for example, that would not have been received within the time frame that is being re-lived. There will be a temptation to move too fast and the exercise is wasted if information is given too soon. Recall that the purpose is to help them go through a thinking process which requires time.

Teachers participating in this exercise will receive much diagnostic information about students’ thinking at this stage. Indeed, an interesting teaching session can be conducted by simply asking students to generate hypotheses without proceeding further. There is evidence to suggest that when a diagnosis is not considered initially it is unlikely to be reached over time, Hence it is worth spending time with students to discuss the hypotheses they generate before they proceed with an enquiry.

Directions to the group were to determine what questions they would like to ask, based on gender, age and probabilities, to support or exclude the listed diagnostic possibilities. A sample of question follow:

• Does he work? No, he's unemployed.
• Does he drink? one to three beers a week.
• Why now? He's been feeling worse and worse for the last 3 weeks.
• Social support? He gives alone. Has no girlfriend.
• Appearance? Looks his age. Not shaved today. No shower in 3 days.
• Cultural background? Refugee from Iraq. Muslim.
• How did he get here? He spent 4 years in a refugee camp after spending 4 months walking to Pakistan from Iraq. He left Iraq to avoid military service.
• Suicide thoughts? Increasing the last 3 weeks. He was admitted in December and has been taking chloral hydrate.

This step took 13 minutes.

5. HAVE THE AUDIENCE RE-FORMULATE THEIR LIST OF HYPOTHESES

After enough information has been gained to proceed, ask them to resume their discussion about the problem and reformulate their diagnostic hypotheses in light of the new information. Instruct them to discuss which pieces of information changed the working diagnosis and why. Call for order again and ask people what they now think.

After allowing the group to talk for a few minutes, the resident asked them if there was enough information to strike off any hypotheses or if new hypotheses should be added to the list. One more possibility was added, post-traumatic stress disorder (PTSD). One group's list of priorities was major affective disorder with psychosis, schizophrenia, personality disorder. Another group also placed affective disorder first followed by organic mood disorder.

This step took 25 minutes.

6. FACILITATE A DISCUSSION ABOUT REASONING

Alter the original lists of hypotheses on the board in light of the discussion, or allow one member from each group to alter their own lists. By the use of open-ended questions encourage a general discussion about the reasons a group has for preferring one diagnosis over another.

A general discussion ensued about reasons for these priorities. Then the list was altered so that it read: schizophrenia, personality disorder, PTSD, major affective disorder with psychosis, organic mood disorder.

7. ALLOW ANOTHER ROUND OF INFORMATION SEEKING

Continue with another round of information and small-group discussion or else allow the whole group to interact. By giving information only when asked for and only in correct sequence, each person is challenged to think through the problem.

More information was sought, such as: form of speech? eye contact? affect? substance use? After 5 minutes the resident asked if there were only lab tests they would like. The group asked for thyroid stimulating hormone, T4, electrolytes and were given the results. They also asked for the results of the physical examination and were told that the pulse was 110 and the thyroid was enlarged. At this point some hypotheses were removed from the list.

8. ASK GROUPS TO REACH A FINAL DIAGNOSIS

When there is a lull in the search for information, ask the groups to reach consensus on their final diagnosis, given the information they have. Allow discussion within the groups.

9. CALL FOR EACH GROUP'S FINAL DIAGNOSIS

On each group's list of hypothesis, star or underline the final diagnosis.

The group decided that the most likely diagnosis was affective disorder with psychosis, the actual working diagnosis of the patient.

10. ASK FOR MANAGEMENT OPTIONS

If there is enough time, ask them to form small groups again to discuss treatment options, or conduct the discussion as a large group. Again ask for the reasons why one approach is preferred over another. Particularly ask the experts in the room for their reasoning so that the novices can learn from them.

11. SUMMARIZE

By the time the end is in sight the audience will be so involved that they will not wish to leave. However, 5 minutes before time, call for order and summarize the session. Highlight the key points that have been raised and refer to the objective of the session.

We are now at the end of our time. You have all had the opportunity to use your clinical reasoning skills to generate several hypotheses which are shown on the board. Initially you thought it possible that this man could have any one of a number of diagnoses including depression, substance abuse, adjustment disorder with depressed mood, organic mood disorder or post-traumatic stress disorder. With further information the possible diagnosis shifted to include schizophrenia and personality disorder as well as depression with psychotic features. Finally the diagnosis of depression or mood disorder with psychosis was most strongly supported because of the history of consistently depressed mood over several months, along with disturbed sleep, poor appetite, weight loss, decreased energy and diminished interest in most activities. The initially abnormal thyroid test proved to be a red herring so organic mood disorder related to hyper- or hypo-thyroidism was excluded. Additionally absence of vivid dreams involving a traumatic event made a diagnosis of post-traumatic stress disorder unlikely. Although a diagnosis of schizophrenia could not be totally excluded, this seemed less likely given the findings.

12. CLOSE THE SESSION WITH POSITIVE FEEDBACK

In some respects, but only some, teaching is like acting and one should strive to leave them not laughing as you go, but feeling that they have learned something.

The more novice members of the group have learned from the more experienced and all your suggestions have been valid. It has been interesting for me to follow your reasoning and compare it with mine when I actually saw this man. You have given me a different perspective as you thought of things I had not, and I thank you for your participation.

Although case presentation should be a major learning experience for both novice and experienced physicians they are often conducted in a stultifying way that defies thought. We have presented a series of steps which, if followed, guarantee active participation from the audience and ensure that if experts are in the room their expertise is used. Physicians have been moulded to believe that teaching means telling and, as a consequence, adopt a remote listening stance during case presentations. Indeed the back row often use the time to catch up on much needed sleep! Changing the format requires courage. We urge you to try out these steps so that both you and your audience will learn from and enjoy the process.