Presenting A Clinical Case Study


A Practical Guide to Clinical Medicine

A comprehensive physical examination and clinical education site for medical students and other health care professionals

Web Site Design by Jan Thompson, Program Representative, UCSD School of Medicine.
Content and Photographs by Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, California 92093-0611.
Send Comments to: Charlie Goldberg, M.D.

Overview and General Information about Oral Presentation

The goal of any oral presentation is to pass along the “right amount” of patient information to a specific audience in an efficient fashion. When done well, this enables the listener to quickly understand the patient’s issues and generate an appropriate plan of action. As with any skill, it can be learned, although this takes time and practice. In addition, the world of medicine presents some additional challenges, including:

  • The structure of presentations varies from service to service (e.g. medicine vs. surgery), amongst subspecialties, and between environments (inpatient vs. outpatient). Applying the correct style to the right setting requires that the presenter seek guidance from the listeners at the outset.
  • Time available for presenting is rather short, which makes the experience more stressful.
  • Individual supervisors (residents, faculty) often have their own (sometimes quirky) preferences regarding presentation styles, adding another layer of variability that the presenter has to manage.
  • Students are evaluated/judged on the way in which they present, with faculty using this as one way of gauging a student’s clinical knowledge.
  • Done well, presentations promote efficient, excellent care. Done poorly, they promote tedium, low morale, and inefficiency.

General Tips:

  • Practice, Practice, Practice! Do this on your own, with colleagues, and/or with anyone who will listen (and offer helpful commentary) before you actually present in front of other clinicians. Speaking "on-the-fly" is difficult, as rapidly organizing and delivering information in a clear and concise fashion is not a naturally occurring skill.

  • Immediately following your presentations, seek feedback from your listeners. Ask for specifics about what was done well and what could have been done better – always with an eye towards gaining information that you can apply to improve your performance the next time.

  • Listen to presentations that are done well – ask yourself, “Why was it good?” Then try to incorporate those elements into your own presentations.

  • Listen to presentations that go poorly – identify the specific things that made it ineffective and avoid those pitfalls when you present.

  • Effective presentations require that you have thought through the case beforehand and understand the rationale for your conclusions and plan. This, in turn, requires that you have a good grasp of physiology, pathology, clinical reasoning and decision-making - pushing you to read, pay attention, and in general acquire more knowledge.

  • Think about the clinical situation in which you are presenting so that you can provide a summary that is consistent with the expectations of your audience. Work rounds, for example, are clearly different from conferences and therefore mandate a different style of presentation.

  • Presentations are the way in which we tell medical stories to one another. When you present, ask yourself if you’ve described the story in an accurate way. Will the listener be able to “see” the patient the same way that you do? Can they come to the correct conclusions? If not, re-calibrate.

  • It's O.K. to use notes, though the oral presentation should not simply be reduced to reading the admission note – rather, it requires appropriate editing/shortening.

  • In general, try to give your presentations on a particular service using the same order and style for each patient, every day. Following a specific format makes it easier for the listener to follow, as they know what’s coming and when they can expect to hear particular information. Additionally, following a standardized approach makes it easier for you to stay organized, develop a rhythm, and lessens the chance that you’ll omit elements.

Specific types of presentations

There are a number of common presentation-types, each with its own goals and formats. These include:

  1. Daily presentations during work rounds for patients known to a service.
  2. Newly admitted patients, where you were the clinician that performed the H&P.
  3. Newly admitted patients that were “handed off” to the team in the morning, such that the H&P was performed by others.
  4. Outpatient clinic presentations, covering several common situations.

Key elements of each presentation type are described below. Examples of how these would be applied to most situations are provided in italics. The formats are typical of presentations done for internal medicine services and clinics.

Note that there is an acceptable range of how oral presentations can be delivered. Ultimately, your goal is to tell the correct story, in a reasonable amount of time, so that the right care can be delivered. Nuances in the order of presentation, what to include, what to omit, etc. are relatively small points. Don’t let the pursuit of these elements distract you or create undue anxiety.

Daily presentations during work rounds of patients that you’re following:

Purpose:

  • Organize the presenter (forces you to think things through)
  • Inform the listener(s) of 24 hour events and plan moving forward
  • Promote focused discussion amongst your listeners and supervisors
  • Opportunity to reassess plan, adjust as indicated
  • Demonstrate your knowledge and engagement in the care of the patient
Duration:
  • Rapid (5 min) presentation of the key facts
Key features of presentation:
  • Opening one liner: Describe who the patient is, number of days in hospital, and their main clinical issue(s).
  • 24-hour events: Highlighting changes in clinical status, procedures, consults, etc.
  • Subjective sense from the patient about how they’re feeling, vital signs (ranges), and key physical exam findings (highlighting changes)
  • Relevant labs (highlighting changes) and imaging
  • Assessment and Plan: Presented by problem or organ systems(s), using as many or few as are relevant. Early on, it’s helpful to go through the main categories in your head as a way of making sure that you’re not missing any relevant areas. The broad organ system categories include (presented here head-to-toe): Neurological; Psychiatric; Cardiovascular; Pulmonary; Gastrointestinal; Renal/Genitourinary; Hematologic/Oncologic; Endocrine/Metabolic; Infectious; Tubes/lines/drains; Disposition.

Example of a daily presentation for a patient known to a team:

  • Opening one liner:This is Mr. Smith, a 65 year old man, Hospital Day #3, being treated for right leg cellulitis
  • Events of the past 24 hours:
    • MRI of the leg, negative for osteomyelitis
    • Evaluation by Orthopedics, who I&D’d a superficial abscess in the calf, draining a moderate amount of pus
  • PE remarkable for:
    • Patient appears well, states leg is feeling better, less painful
    • T Max 101 yesterday, T Current 98; Pulse range 60-80; BP 140s-160s/70-80s; O2 sat 98% Room Air
    • Ins/Outs: 3L in (2 L NS, 1 L po)/Out 4L urine
    • Right lower extremity redness now limited to calf, well within inked lines – improved compared with yesterday; bandage removed from the I&D site, and base had small amount of purulence; No evidence of fluctuance or undrained infection.
  • Labs and imaging remarkable for:
    • Creatinine .8, down from 1.5 yesterday
    • WBC 8.7, down from 14
    • Blood cultures from admission still negative
    • Gram stain of pus from yesterday’s I&D: + PMNS and GPCs; Culture pending
    • MRI lower extremity as noted above – negative for osteomyelitis
  • Assessment and Plan
    This is a 65 yo male, hospital day 3, being treated for lower extremity cellulitis and abscess. Issues are as follows:
    • Cellulitis complicated by abscess, which has now been adequately drained. Exam improved and feels better. Likely organism is Staph, covering for MRSA until cultures back
      • Continue Vancomycin for today
      • Ortho to reassess I&D site, though looks good
      • Follow-up on cultures: if MRSA, will transition to PO Doxycycline; if MSSA, will use PO Dicloxacillin
    • Hypertension: When admitted, outpatient anti-hypertensive medications held as blood pressure was low due to sepsis. Now BP is climbing back to hypertensive range. No symptoms
      • Given AKI, will continue to hold ace-inhibitor; will likely wait until outpatient follow-up to restart
      • Add back amlodipine 5mg/d today
    • Renal: Now back to baseline kidney function, which is normal. On admission AKI due to sepsis. All improved as expected with control of infection. Appears euvolemic
      • Hep lock IV as no need for more IVF
      • Continue to hold ace-I as above
    • Disposition: Anticipate d/c tomorrow on po antibiotics – pending final culture results as above to determine best oral med.
      • Wound care teaching with RNs today – wife capable and willing to assist. She’ll be in this afternoon.
      • Set up follow-up with PMD to reassess wound and cellulitis within 1 week

The Brand New Patient (admitted by you)

  • Purpose
    • Organize the presenter (forces you to think things through)
    • Provide enough information so that the listeners can understand the presentation and generate an appropriate differential diagnosis.
    • Present a thoughtful assessment
    • Present diagnostic and therapeutic plans
    • Provide opportunities for senior listeners to intervene and offer input
  • Duration
  • Key features of presentation:
    • Chief concern: Reason why patient presented to hospital (symptom/event and key past history in one sentence). It often includes a limited listing of their other medical conditions (e.g. diabetes, hypertension, etc.) if these elements might contribute to the reason for admission.
    • History of present illness (HPI):
      • The history is presented highlighting the relevant events in chronological order.
      • Events are best presented as temporally oriented bullets (from the starting point of the illness to the present moment), making it easy to follow the sequence in which things progressed. These events are often described based on how many days ago they occurred. For example:
        • 7 days ago, the patient began to notice vague shortness of breath.
        • 5 days ago, the breathlessness worsened and they developed a cough productive of green sputum.
        • 3 days ago his short of breath worsened to the point where he was winded after walking up a flight of stairs, accompanied by a vague right sided chest pain that was more pronounced with inspiration.
        • Etc.
      • Enough historical information has to be provided so that the listener can understand the reasons that lead to admission and be able to draw appropriate clinical conclusions.
      • Past history that helps to shed light on the current presentation are included towards the end of the HPI and not presented later as “PMH.” This is because knowing this “past” history is actually critical to understanding the current complaint. For example, past cardiac catheterization findings and/or interventions should be presented during the HPI for a patient presenting with chest pain.
      • Where relevant, the patient's baseline functional status is described, allowing the listener to understand the degree of impairment caused by the acute medical problem(s).
      • It should be explicitly stated if a patient is a poor historian, confused or simply unaware of all the details related to their illness. Historical information obtained from family, friends, etc. should be described as such.
    • Review of Systems (ROS): Pertinent positive and negative findings discovered during a review of systems are generally incorporated at the end of the HPI. The listener needs this information to help them put the story in appropriate perspective. Any positive responses to a more inclusive ROS that covers all of the other various organ systems are then noted. If the ROS is completely negative, it is generally acceptable to simply state, "ROS negative.”
    • Other Past Medical and Surgical History (PMH/PSH): Past history that relates to the issues that lead to admission are typically mentioned in the HPI and do not have to be repeated here. That said, selective redundancy (i.e. if it’s really important) is OK. Other PMH/PSH are presented here if relevant to the current issues and/or likely to affect the patient’s hospitalization in some way. Unrelated PMH and PSH can be omitted (e.g. if the patient had their gall bladder removed 10y ago and this has no bearing on the admission, then it would be appropriate to leave it out). If the listener really wants to know peripheral details, they can read the admission note, ask the patient themselves, or inquire at the end of the presentation.
    • Medications and Allergies: Typically all meds are described, as there’s high potential for adverse reactions or drug-drug interactions.
    • Family History: Emphasis is placed on the identification of illnesses within the family (particularly among first degree relatives) that are known to be genetically based and therefore potentially heritable by the patient. This would include: coronary artery disease, diabetes, certain cancers and autoimmune disorders, etc. If the family history is non-contributory, it’s fine to say so.
    • Social History, Habits, other → as relates to/informs the presentation or hospitalization. Includes education, work, exposures, hobbies, smoking, alcohol or other substance use/abuse.
    • Sexual history if it relates to the active problems.
    • Physical Exam
      • Vital signs and relevant findings (or their absence) are provided. As your team develops trust in your ability to identify and report on key problems, it may become acceptable to say “Vital signs stable.”
      • Note: Some listeners expect students (and other junior clinicians) to describe what they find in every organ system and will not allow the presenter to say “normal.” The only way to know what to include or omit is to ask beforehand.
    • Key labs and imaging: Abnormal findings are highlighted as well as changes from baseline.
    • Summary, assessment & plan(s) Presented by problem or organ systems(s), using as many or few as are relevant. Early on, it’s helpful to go through the main categories in your head as a way of making sure that you’re not missing any relevant areas. The broad organ system categories include (presented here head-to-toe): Neurological; Psychiatric; Cardiovascular; Pulmonary; Gastrointestinal; Renal/Genitourinary; Hematologic/Oncologic; Endocrine/Metabolic; Infectious; Tubes/lines/drains; Disposition.
    • The assessment and plan typically concludes by mentioning appropriate prophylactic considerations (e.g. DVT prevention), code status and disposition.

    • Example of a New Admission Presentation:
    • Chief Concern: Mr. H is a 50 year old male with AIDS, on HAART, with preserved CD4 count and undetectable viral load, who presents for the evaluation of fever, chills and a cough over the past 7 days.
    • HPI: Mr. H has been known to be HIV + since 2000
      • Until 1 week ago, he had been quite active, walking up to 2 miles a day without feeling short of breath.
      • Approximately 1 week ago, he began to feel dyspneic with moderate activity.
      • 3 days ago, he began to develop subjective fevers and chills along with a cough productive of red-green sputum.
      • 1 day ago, he was breathless after walking up a single flight of stairs and spent most of the last 24 hours in bed.
      • Past HIV history is remarkable for:
        • Diagnosed with HIV in 2000, done as a screening test when found to have gonococcal urethritis
        • Was not treated with HAART at that time due to concomitant alcohol abuse and non-adherence.
        • Diagnosed and treated for PJP pneumonia 2006
        • Diagnosed and treated for CMV retinitis 2007
        • Became sober in 2008, at which time interested in HAART. Started on Atripla, a combination pill containing: Efavirenz, Tonofovir, and Emtricitabine. He’s taken it ever since, with no adverse effects or issues with adherence. Receives care thru Dr. Smiley at the University HIV clinic.
        • CD4 count 3 months ago was 400 and viral load was undetectable.
        • He is homosexual though he is currently not sexually active. He has never used intravenous drugs.
      • He has no history of asthma, COPD or chronic cardiac or pulmonary condition. No known liver disease. Hepatitis B and C negative. His current problem seems different to him then his past episode of PJP.
    • Review of systems: negative for headache, photophobia, stiff neck, focal weakness, chest pain, abdominal pain, diarrhea, nausea, vomiting, urinary symptoms, leg swelling, or other complaints.
    • Other PMH/PSH:
      • Hypertension x 5 years, no other known vascular disease
      • GERD
      • Gonorrhea as above
      • Alcohol abuse above and now sober – no known liver disease
      • No relevant surgeries
    • MEDS and Allergies:
      • Atripla, 1 po qd
      • Omeprazole 20 mg, 1 PO, qd
      • Lisinopril 20mg, qd
      • Naprosyn 250 mg, 1-2, PO, BID PRN
      • No allergies
    • Family History
      • Both of the patient's parents are alive and well (his mother is 78 and father 80). He has 2 brothers, one 45 and the other 55, who are also healthy. There is no family history of heart disease or cancer.
    • Social history, habits
      • Patient works as an accountant for a large firm in San Diego. He lives alone in an apartment in the city.
      • Smokes 1 pack of cigarettes per day and has done so for 20 years.
      • No current alcohol use. Denies any drug use.
    • Sexual History as noted above; has sex exclusively with men, last partner 6 months ago.
    • Physical Exam notable for:
      • Seated on a gurney in the ER, breathing through a face-mask oxygen delivery system. Breathing was labored and accessory muscles were in use. Able to speak in brief sentences, limited by shortness of breath
      • Vital signs: Temp 102 F, Pulse 90, BP 150/90, Respiratory Rate 26, O2 Sat (on 40% Face Mask) 95%
      • HEENT: No thrush, No adenopathy
      • Lungs: Crackles and Bronchial breath sounds noted at right base. E to A changes present. No wheezing or other abnormal sounds noted over any other area of the lung. Dullness to percussion was also appreciated at the right base.
      • Cardiac: JVP less than 5 cm; Rhythm was regular. Normal S1 and S2. No murmurs or extra heart sounds noted.
      • Abdomen and Genital exams: normal
      • Extremities: No clubbing, cyanosis or edema; distal pulses 2+ and equal bilaterally.
      • Skin: no eruptions noted.
      • Neurological exam: normal
    • Labs and Imaging notable for:
      • WBC 18 thousand with 10% bands;
      • Normal Chem 7 and LFTs.
      • Room air blood gas: pH of 7.47/ PO2 of 55/PCO2 of 30.
      • Sputum gram stain remarkable for an abundance of polys along with gram positive diplococci.
      • CXR remarkable for dense right lower lobe infiltrate without effusion.
    • Assessment and Plan:
      • Acute community acquired pneumonia: Mr. H is an HIV + male with preserved CD 4 count and undetectable viral load while on HAART, who presents with an acute pulmonary process. The rapid progression, focality of findings on lung exam and chest x-ray, along with the sputum gram stain suggest a bacterial infection, in particular Streptococcal Pneumoniae. Other pathogens to consider include influenza, H Flu and Legionella. His presentation, compliance with PJP prophylaxis, reasonably intact immune system and statement that his current illness seems different then past PJP infection would argue against this as the etiologic agent. Mycobacterial infection also seems unlikely. Viral infections and neoplastic processes like CMV or Kaposi's Sarcoma of the lung do not typically give this clinical presentation nor should they occur given his level of immune function. In addition, he received a flu vaccine 2 months ago. The data does not support the existence of either a primary cardiac or noninfectious pulmonary process. The current plan for his pneumonia is as follows:
        • Continue Ceftriaxone and Azithromycin started in the ED for acute CAP
        • Follow up on cultures of sputum and blood; will try to narrow coverage based on final cultures.
        • Obtain rapid flu test
        • Continue Atripla
        • Continue O2, with goal to keep sats greater then 92%
        • IV fluid replacement with Normal Saline at 125cc/H for next 24 hours to correct mild hypovolemia, with plan to reassess volume status at that time
        • If patient does not show improvement (or worsens) and cultures are unrevealing, consider bronchoscopy as a means of making more definitive diagnosis.
        • Monitored care unit, with vigilance for clinical deterioration.
      • Hypertension: given significant pneumonia and unclear clinical direction, will hold lisinopril. If BP > 180 and or if clear not developing sepsis, will consider restarting.
      • DVT Prophylaxis: immobile and ill, which makes him high risk
        • Low molecular weight heparin
      • Code Status: Wishes to be full code full care, including intubation and ICU stay if necessary. Has good quality of life and hopes to return to that functional level. Wishes to reconsider if situation ever becomes hopeless. Older brother Tom is surrogate decision maker if the patient can’t speak for himself. Tom lives in San Diego and we have his contact info. He is aware that patient is in the hospital and plans on visiting later today or tomorrow.
      • Expected duration of hospitalization unclear – will know more based on response to treatment over next 24 hours.

The holdover admission (presenting data that was generated by other physicians)

  • Purpose
    • Handoff admissions are very common and present unique challenges
    • The accepting team has several goals:
      • Understand the reasons why the patient was admitted
      • Review key history, exam, imaging and labs to assure that they support the working diagnostic and therapeutic plans
    • The presentation provides an opportunity for the accepting team to determine if the impression and plan told to them makes sense. This requires them to carefully consider the following:
      • Does the data support the working diagnosis?
      • Do the planned tests and consults make sense?
      • What else should be considered (both diagnostically and therapeutically)?
    • This process requires that the accepting team thoughtfully review their colleagues efforts with a critical eye – which is not disrespectful but rather constitutes one of the main jobs of the accepting team and is a cornerstone of good care
      *Note: At some point during the day (likely not during rounds), the team will need to verify all of the data directly with the patient.
  • Duration
  • Key features of the presentation
    • Chief concern: Reason for admission (symptom and/or event)
    • History of Present Illness:
      • Temporally presented bullets of events leading up to the admission
    • Review of systems
    • Relevant PMH/PSH – historical information that might affect the patient during their hospitalization.
    • Meds and Allergies
    • Family and Social History – focusing on information that helps to inform the current presentation.
    • Habits and exposures
    • Physical exam, imaging and labs that were obtained in the Emergency Department
    • Assessment and plan that were generated in the Emergency Department.
    • Overnight events (i.e. what happened in the Emergency Dept. and after the patient went to their hospital room)? Responses to treatments, changes in symptoms?
    • How does the patient feel this morning? Key exam findings this morning (if seen)? Morning labs (if available)?
    • Assessment and Plan, with attention as to whether there needs to be any changes in the working differential or treatment plan. The broad organ system categories include (presented here head-to-toe): Neurological; Psychiatric; Cardiovascular; Pulmonary; Gastrointestinal; Renal/Genitourinary; Hematologic/Oncologic; Endocrine/Metabolic; Infectious; Tubes/lines/drains; Disposition.

    • Typically, the discussion also includes appropriate prophylactic considerations (e.g. DVT prevention), code status and disposition.
  • Example of a Hold Over Admission Presentation
    • Chief concern: 70 yo male who presented with 10 days of progressive shoulder pain, followed by confusion. He was brought in by his daughter, who felt that her father was no longer able to safely take care for himself.
    • HPI:
      • 10 days ago, Mr. X developed left shoulder pain, first noted a few days after lifting heavy boxes. He denies falls or direct injury to the shoulder.
      • 1 week ago, presented to outside hospital ER for evaluation of left shoulder pain. Records from there were notable for his being afebrile with stable vitals. Exam notable for focal pain anteriorly on palpation, but no obvious deformity. Right shoulder had normal range of motion. Left shoulder reported as diminished range of motion but not otherwise quantified. X-ray negative. Labs remarkable for wbc 8, creat 2.2 (stable). Impression was that the pain was of musculoskeletal origin. Patient was provided with Percocet and told to see PMD in f/u
      • Brought to our ER last night by his daughter. Pain in shoulder worse. Also noted to be confused and unable to care for self. Lives alone in the country, home in disarray, no food.
      At baseline, patient is fully functional and able to care for himself. He has no cognitive issues.
      The history is largely provided by the daughter, as patient is confused about his symptoms and the order in which they developed.
    • ROS: negative for falls, prior joint or musculoskeletal problems, fevers, chills, cough, sob, chest pain, head ache, abdominal pain, urinary or bowel symptoms, substance abuse
    • Relevant PMH/PSH:
      • Hypertension
      • Coronary artery disease, s/p LAD stent for angina 3 y ago, no symptoms since. Normal EF by echo 2 y ago
      • Chronic kidney disease stage 3 with creatinine 1.8; felt to be secondary to atherosclerosis and hypertension
      • Depression
    • MEDS and Allergies:
      • aspirin 81mg qd, atorvastatin 80mg po qd, amlodipine 10 po qd, Prozac 20
      • Allergies: none
    • Family and Social: lives alone in a rural area of the county, in contact with children every month or so. Retired several years ago from work as truck driver. Otherwise non-contributory.
    • Habits: denies alcohol or other drug use.
    • Physical Exam in Emergency Department
      • Temp 98 Pulse 110 BP 100/70
      • Drowsy though arousable; oriented to year but not day or date; knows he’s at a hospital for evaluation of shoulder pain, but doesn’t know the name of the hospital or city
      • CV: regular rate and rhythm; normal s1 and s2; no murmurs or extra heart sounds.
      • Lungs: CTA
      • Left shoulder with generalized swelling, warmth and darker coloration compared with Right; generalized pain on palpation, very limited passive or active range of motion in all directions due to pain. Right shoulder appearance and exam normal.
    • Labs and imaging in Emergency Department
      • CXR: normal
      • EKG: sr 100; nl intervals, no acute changes
      • WBC 13; hemoglobin 14
      • Na 134, k 4.6; creat 2.8 (1.8 baseline 4 m ago); bicarb 24
      • LFTs and UA normal
    • Assessment and plan in the Emergency Department and by overnight team.
      • Acute shoulder pain and systemic symptoms concerning for septic shoulder
        • Vancomycin and Zosyn for now
        • Orthopedics to see asap to aspirate shoulder for definitive diagnosis
        • If aspiration is consistent with infection, will need to go to Operating Room for wash out.
      • AKI: From poor oral intake and sepsis. Given 3L NS in ER, with positive response in terms of heart rate and BP. Also, urine output now ~50 cc/h.
        • IVF with NS at 125cc/h
        • Urine electrolytes
        • Follow-up on creatinine and obtain renal ultrasound if not improved
        • Renal dosing of meds
        • Strict Ins and Outs.
      • Confusion: Delirium from infection. Baseline cognitive function is reportedly normal.
        • will approach infection as above
        • follow exam
        • obtain additional input from family to assure baseline is, in fact, normal
    • Over night events/response to treatments.
      • Since admission (6 hours) no change in shoulder pain
      • This morning, pleasant, easily distracted; knows he’s in the hospital, but not date or year
    • Key morning exam findings
      • T Current 101F Pulse 100 BP 140/80
      • Ins and Outs: IVF Normal Saline 3L/Urine output 1.5 liters
      • L shoulder with obvious swelling and warmth compared with right; no skin breaks; pain limits any active or passive range of motion to less than 10 degrees in all directions
    • Key morning labs
      • Labs this morning remarkable for WBC 10 (from 13), creatinine 2 (down from 2.8)
    • Assessment and Plan:
      • Agree with assessment of over night admitting team, which is sepsis with source of infection based in the left shoulder.
        • Plan:
          • Continue with Vancomycin and Zosyn for now
          • I already paged Orthopedics this morning, who are en route for aspiration of shoulder, fluid for gram stain, cell count, culture
          • If aspirate consistent with infection, then likely to the OR
      • Renal: AKI due to hypovolemia and sepsis. Now appears volume replete
        • Continue IVF at 125/h, follow I/O
        • Repeat creatinine later today
        • Not on any nephrotoxins, meds renaly dosed
      • Delirium: related to infection as above
        • Continue antibiotics, evaluation for primary source as above
        • Discuss with family this morning to establish baseline; possible may have underlying dementia as well
      • Prophylaxis:
        • SC Heparin for DVT prophylaxis
      • Code status: full code/full care.

Outpatient-based presentations

There are 4 main types of visits that commonly occur in an outpatient continuity clinic environment, each of which has its own presentation style and purpose. These include the following, each described in detail below.

  1. The patient who is presenting for their first visit to a primary care clinic and is entirely new to the physician.
  2. The patient who is returning to primary care for a scheduled follow-up visit.
  3. The patient who is presenting with an acute problem to a primary care clinic
  4. The specialty clinic evaluation (new or follow-up)
It’s worth noting that Primary care clinics (Internal Medicine, Family Medicine and Pediatrics) typically take responsibility for covering all of the patient’s issues, though the amount of energy focused on any one topic will depend on the time available, acuity, symptoms, and whether that issue is also followed by a specialty clinic.

The Brand New Primary Care Patient

Purpose of the presentation

  • Organize the presenter (forces you to think things through)
  • Accurately review all of the patient’s history as well as any new concerns that they might have.
  • Identify health related problems that need additional evaluation and/or treatment
  • Provide an opportunity for senior listeners to intervene and offer input
Duration Key features of the presentation
  • Reason for the visit:
    • If this is truly their first visit, then one of the main reasons is typically to "establish care" with a new doctor.
    • It might well include continuation of therapies and/or evaluations started elsewhere.
    • If the patient has other specific goals (medications, referrals, etc.), then this should be stated as well.
      Note: There may well not be a "chief complaint."
  • Relevant acute/sub-acute history
    • For a new patient, this is an opportunity to highlight the main issues that might be troubling/bothering them.
    • This can include chronic disorders (e.g. diabetes, congestive heart failure, etc.) which cause ongoing symptoms (shortness of breath) and/or generate daily data (finger stick glucoses) that should be discussed.
    • Sometimes, there are no specific areas that the patient wishes to discuss up-front.
  • Review of systems (ROS): This is typically comprehensive, covering all organ systems. If the patient is known to have certain illnesses (e.g. diabetes), then the ROS should include the search for disorders with high prevalence (e.g. vascular disease). There should also be some consideration for including questions that are epidemiologically appropriate (e.g. based on age and sex).
  • Past Medical History (PMH): All known medical conditions (in particular those requiring ongoing treatment) are listed, noting their duration and time of onset. If a condition is followed by a specialist or co-managed with other clinicians, this should be noted as well. If a problem was described in detail during the “acute” history, it doesn’t have to be re-stated here.
  • Past Surgical History (PSH): All surgeries, along with the year when they were performed
  • Medications and allergies: All meds, including dosage, frequency and over-the-counter preparations. Allergies (and the type of reaction) should be described.
  • Social: Work, hobbies, exposures.
  • Sexual activity – may include type of activity, number and sex of partner(s), partner’s health.
  • Smoking, Alcohol, other drug use: including quantification of consumption, duration of use.
  • Family history: Focus on heritable illness amongst first degree relatives. May also include whether patient married, in a relationship, children (and their ages).
  • Physical Exam: Vital signs and relevant findings (or their absence).
  • Key labs and imaging if they’re available. Also when and where they were obtained.
  • Summary, assessment & plan(s) presented by organ system and/or problems. As many systems/problems as is necessary to cover all of the active issues that are relevant to that clinic. This typically concludes with a “health care maintenance” section, which covers age, sex and risk factor appropriate vaccinations and screening tests.

The Follow-up Visit to a Primary Care Clinic

Purpose of the presentation

  • Organize the presenter (forces you to think things through).
  • Accurately review any relevant interval health care events that might have occurred since the last visit.
  • Identification of new symptoms or health related issues that might need additional evaluation and/or treatment
  • If the patient has no concerns, then verification that health status is stable
  • Review of medications
  • Provide an opportunity for listeners to intervene and offer input
Duration Key features of the presentation
  • Reason for the visit: Follow-up for whatever the patient’s main issues are, as well as stating when the last visit occurred
    *Note: There may well not be a “chief complaint,” as patients followed in continuity at any clinic may simply be returning for a visit as directed by their doctor.
  • Events since the last visit: This might include emergency room visits, input from other clinicians/specialists, changes in medications, new symptoms, etc.
  • Review of Systems (ROS): Depth depends on patient’s risk factors and known illnesses. If the patient has diabetes, then a vascular ROS would be done. On the other hand, if the patient is young and healthy, the ROS could be rather cursory.
  • PMH, PSH, Social, Family, Habits are all OMITTED. This is because these facts are already known to the listener and actionable aspects have presumably been added to the problem list (presented at the end). That said, these elements can be restated if the patient has a new symptom or issue related to a historical problem has emerged.
  • MEDS: A good idea to review these at every visit.
  • Physical exam: Vital signs and pertinent findings (or absence there of) are mentioned.
  • Lab and Imaging: The reason why these were done should be mentioned and any key findings mentioned, highlighting changes from baseline.
  • Assessment and Plan: This is most clearly done by individually stating all of the conditions/problems that are being addressed (e.g. hypertension, hypothyroidism, depression, etc.) followed by their specific plan(s). If a new or acute issue was identified during the visit, the diagnostic and therapeutic plan for that concern should be described.

The Focused Visit to a Primary Care Clinic

Purpose of the presentation

  • Accurately review the historical events that lead the patient to make the appointment.
  • Identification of risk factors and/or other underlying medical conditions that might affect the diagnostic or therapeutic approach to the new symptom or concern.
  • Generate an appropriate assessment and plan
  • Allow the listener to comment
Duration Key features of the presentation:
  • Reason for the visit
  • History of Present illness: Description of the sequence of symptoms and/or events that lead to the patient’s current condition.
  • Review of Systems: To an appropriate depth that will allow the listener to grasp the full range of diagnostic possibilities that relate to the presenting problem.
  • PMH and PSH: Stating only those elements that might relate to the presenting symptoms/issues.
  • MEDS
  • PE: Vital signs and key findings (or lack thereof)
  • Labs and imaging (if done)
  • Assessment and Plan: This is usually very focused and relates directly to the main presenting symptom(s) or issues.

The Specialty Clinic Visit

Specialty clinic visits focus on the health care domains covered by those physicians. For example, Cardiology clinics are interested in cardiovascular disease related symptoms, events, labs, imaging and procedures. Orthopedics clinics will focus on musculoskeletal symptoms, events, imaging and procedures. Information that is unrelated to these disciples will typically be omitted. It’s always a good idea to ask the supervising physician for guidance as to what’s expected to be covered in a particular clinic environment.

Purpose of the presentation

  • Organize the presenter (forces you to think things through)
  • Highlight the reason(s) for the visit
  • Review key data
  • Generate an appropriate assessment and plan
  • Provide an opportunity for the listener(s) to comment
Duration Key features of the presentation:
  • Reason for the visit
    • If it’s a consult, state the main reason(s) that the patient was referred as well as who referred them.
    • If it’s a return visit, state the reasons why the patient is being followed in the clinic and when the last visit took place
    • If it’s for an acute issue, state up front what the issue is
      Note: There may well not be a “chief complaint,” as patients followed in continuity in any clinic may simply be returning for a return visit as directed
  • Relevant acute/sub-acute history
    • For a new patient, this highlights the main things that might be troubling/bothering the patient.
    • For a specialty clinic, the history presented typically relates to the symptoms and/or events that are pertinent to that area of care.
  • Review of systems, focusing on those elements relevant to that clinic. For a cardiology patient, this will highlight a vascular ROS.
  • PMH/PSH that helps to inform the current presentation (e.g. past cardiac catheterization findings/interventions for a patient with chest pain) and/or is otherwise felt to be relevant to that clinic environment.
  • Meds and allergies: Typically all meds are described, as there is always the potential for adverse drug interactions.
  • Social/Habits/other: as relates to/informs the presentation and/or is relevant to that clinic
  • Family history: Focus is on heritable illness amongst first degree relatives
  • Physical Exam: VS and relevant findings (or their absence)
  • Key labs, imaging: For a cardiology clinic patient, this would include echos, catheterizations, coronary interventions, etc.
  • Summary, assessment & plan(s) by organ system and/or problems. As many systems/problems as is necessary to cover all of the active issues that are relevant to that clinic.
Example Presentation to an Outpatient Cardiology Clinic
  • Reason for visit: Patient is a 67 year old male presenting for first office visit after admission for STEMI. He was referred by Dr. Goins, his PMD.
  • HPI:
    • The patient initially presented to the ER 4 weeks ago with acute CP that started 1 hour prior to his coming in. He was found to be in the midst of a STEMI with ST elevations across the precordial leads.
    • Taken urgently to cath, where 95% proximal LAD lesion was stented
    • EF preserved by Echo; Peak troponin 10
    • In-hospital labs were remarkable for normal cbc, chem; LDL 170, hdl 42, nl lfts
    • Uncomplicated hospital course, sent home after 3 days.
  • ROS:
    • Since home, he states that he feels great.
    • Denies chest pain, sob, doe, pnd, edema, or other symptoms.
    • No symptoms of stroke or TIA.
    • No history of leg or calf pain with ambulation.
  • PMH/PSH:
    • Prior to this admission, he had a history of hypertension which was treated with lisinopril
    • 40 pk yr smoking history, quit during hospitalization
    • No known prior CAD or vascular disease elsewhere. No known diabetes, no family history of vascular disease; He thinks his cholesterol was always “a little high” but doesn’t know the numbers and was never treated with meds.
    • History of depression, well treated with prozac
  • Meds and Allergies
    • Discharge meds included: aspirin, metoprolol 50 bid, lisinopril 10, atorvastatin 80, Plavix; in addition he takes Prozac for depression
    • Taking all of them as directed.
    • No allergies
  • Social/Habits/Other
    • Patient lives with his wife; they have 2 grown children who are no longer at home
    • Works as a computer programmer
    • Smoking as above
    • ETOH: 1 glass of wine w/dinner
    • No drug use
  • Family history
    • No known history of cardiovascular disease among 2 siblings or parents.
  • Physical Exam
    • Well appearing; BP 130/80, Pulse 80 regular, 97% sat on Room Air, weight 175lbs, BMI 32
    • Lungs: clear to auscultation
    • CV: s1 s2 no s3 s4 murmur
    • No carotid bruits
    • ABD: no masses
    • Ext; no edema; distal pulses 2+
  • Labs and Imaging of note:
    • Cath from 4 weeks ago: R dominant; 95% proximal LAD; 40% Cx.
    • EF by TTE 1 day post PCI with mild Anterior Hypokinesis, EF 55%, no valvular disease, moderate LVH
    • Labs of note from the hospital following cath: hgb 14, plt 240; creat 1, k 4.2, lfts normal, glucose 100, LDL 170, HDL 42.
    • EKG today: SR at 78; nl intervals; nl axis; normal r wave progression, no q waves
  • Assessment/Plan:
    1. S/P STEMI: Proximal LAD disease which was appropriately treated with a stent. No immediate complications and now doing well. No other critical lesions which require intervention at the moment.
      • Plan: aspirin 81 indefinitely, Plavix x 1y
      • Given nitroglycerine sublingual to have at home.
      • Reviewed symptoms that would indicate another MI and what to do if occurred
    2. Hypertension: now well treated with metoprolol and lisinopril. No problems with adherence. Blood pressure on target.
      • Plan: continue with current dosages of meds
      • Chem 7 today to check k, creatinine
    3. Lipids: On high potency statin. No side effects
      • Plan: Continue atorvastatin 80mg for life
    4. Smoking cessation: Doing well since discharge without adjuvant treatments, aware of supports.
    5. Vascular Screening: Known vascular disease and history of smoking
      • Plan: AAA screening ultrasound
      Disposition: Return to clinic 6 months.

Copyright © 2015, The Regents of the University of California.
All rights reserved.
Last updated 10/15.

If you are scheduled to make a presentation of a clinical vignette, reading this article will improve your performance. We describe a set of practical, proven steps that will guide your preparation of the presentation. The process of putting together a stellar presentation takes time and effort, and we assume that you will be willing to put forth the effort to make your presentation successful. This and subsequent articles will focus on planning, preparation, creating visual aids (slides), and presentation skills. The intent of this series of articles is to help you make a favorable impression and reap the rewards, personal and professional, of a job well done.

The process begins with the creation of an outline of the topics that might be presented at the meeting. Your outline should follow the typical format and sequence for this type of communication: history, physical examination, investigations, patient course, and discussion. This format is chosen because your audience understands it and uses it every day. If you have already prepared a paper for publication, it can be a rich source of content for the topic outline.

To get you started, we have prepared a generic outline to serve as an example. Look over the generic outline to get a sense of what might be addressed in your presentation. We realize that the generic outline will not precisely fit all of the types of cases; nevertheless, think about the larger principle and ask yourself, "How can I adapt this to my situation?" In order to help you visualize the type of content you might include in the outline, an example of a topic outline for a clinical vignette is presented.

Introduction

The main purpose of the introduction is to place the case in a clinical context and explain the importance or relevance of the case. Some case reports begin immediately with the description of the case, and this is perfectly acceptable.

1. Describing the clinical context and relevance

i. Ergotism is characterized by intense, generalized vasoconstriction of small and large blood vessels.
ii. Ergotism is rare and therefore difficult to diagnose.
iii. Failure to diagnose can lead to significant morbidity.

Case Presentation

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

1. History

i. A 34-year-old female smoker has chronic headaches, dyspnea, and burning leg pain.
ii. Clinical diagnosis of mitral valve stenosis is made.
iii. She returns in one week because of burning pain in the legs.
iv. One month after presentation, cardiac catheterization demonstrates severe mitral valve stenosis.
v. Elective mitral valve commisurotomy is scheduled, but the patient is admitted to hospital early because of increased burning pain in her feet and a painful right leg.

2. Physical Examination

i. Normal vital signs.
ii. No skin findings.
iii. Typical findings of mitral stenosis, no evidence of heart failure.
iv. Cool, pulseless right leg.
v. Normal neurological examination.

3. Investigations

i. Normal laboratory studies.
ii. ECG shows left atrial enlargement.
iii. Arteriogram of right femoral artery shows subtotal stenosis, collateral filling of the popliteal artery, and pseudoaneurysm formation.

4. Hospital Course

i. Mitral valve commisurotomy is performed, as well as femoral artery thombectomy, balloon dilation, and a patch graft repair.
ii. On the fifth postoperative day, the patient experienced a return of burning pain in the right leg. The leg was pale, cool, mottled, and pulseless.
iii. The arteriogram of femoral arteries showed smooth segmental narrowing and bilateral vasospasm suggesting large-vessel arteritis complicated by thrombosis.
iv. Treatment was initiated with corticosteroids, anticoagulants, antiplatelet drugs, and oral vasodilators.
v. The patient continued to deteriorate with both legs becoming cool and pulseless.
vi. Additional history revealed that the patient abused ergotamine preparations for years (headaches). She used 12 tables daily for the past year and continued to receive ergotamine in hospital on days 2, 6, and 7.
vii. Ergotamine preparations were stopped, intravenous nitroprusside was begun, and she showed clinical improvement within 2 hours. Nitroprusside was stopped after 24 hours, and the symptoms did not return.
viii. The remainder of hospitalization was uneventful.

Discussion

The main purpose of the discussion section is to articulate the lessons learned from the case. It should describe how a similar case should be approached in the future. It is sometimes appropriate to provide background information to understand the pathophysiological mechanisms associated with the patient's presentation, findings, investigations, course, or therapy.

1. Discussion

i. The most common cause of ergotism is chronic poisoning found in young females with chronic headaches.
ii. Manifestations can include neurological, gastrointestinal, and vascular (list each in a table).
iii. Ergotamine poisoning induces intense vasospasm, and venous thrombosis may occur from direct damage to the endothelium.
iv. Vasospasm is due primarily to the direct vasoconstrictor effects on the vascular smooth muscle.
v. Habitual use of ergotamine can lead to withdrawal headaches leading to a cycle of greater levels of ingestion.
vi. In addition to stopping ergotamine, a direct vasodilator is usually prescribed.
vii. Lesson 1: Physicians should be alert to the potential of ergotamine toxicity in young women with chronic headaches that present with neurological, gastrointestinal, or ischemic symptoms.
viii. Lesson 2: The value of a complete history and checking the medication list.

Creating a topic outline will provide a list of all the topics you might possibly present at the meeting. Since you will have only ten minutes, you will prioritize the topics to determine what to keep and what to cut.

How do you decide what to cut? First, identify the basic information in the three major categories that you simply must present. This represents the "must-say" category. If you have done your job well, the content you have retained will answer the following questions:

What happened to the patient?
What was the time course of these events?
Why did management follow the lines that it did?
What was learned?

After you have identified the "must-say" content, identify information that will help the audience better understand the case. Call this the "elaboration" category. Finally, identify the content that you think the audience would like to know, provided there is enough time, and identify this as the "nice-to-know" category.

Preparing a presentation is an iterative process. As you begin to "fit" your talk into the allotted time, certain content you originally thought of as "elaboration" may be dropped to the "nice-to-know" category due to time constraints. Use the following organizational scheme to efficiently prioritize your outline.

Prioritizing Topics in the Topic Outline

1. Use your completed topic outline.

2. Next to each entry in your outline, prioritize the importance of content.

3. Use the following code system to track your prioritization decisions:

A = Must-Say
B = Elaboration
C = Nice-to-Know

4. Remember, this is an iterative process; your decisions are not final.

5. Review the outline with your mentor or interested colleagues, and listen to their decisions.

Use the Preparing the Clinical Vignette Presentation Checklist to assist you in preparing the topic outline.

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