Case presentations

A consultant usually presents the details of a patient's case to colleagues at a clinical meeting in a hospital. Below you can see a typical case presentation example divided into the following sections:

Section	An example of language
Introduction	I'd like to present Mr Brown,
Age and occupation of a patient	a 44-year-old manager,
Symptom(s) and duration	He had a one-month history of breathlessness.
Acompanied symptoms	He also complained of ankle swelling which he'd had for two weeks.
Past medical history	There was no relevant past history.
Social history	He was married and had one daughter. He smoked 25 cigarettes a day and drank about 40 units of alcohol per week.
Family history	His father died of myocardial infarction at the age of 42. His mother was alive and well.
Findings on examination	On examination, he was obese ...
Investigation results	We did a chest X-ray which showed ...
Diagnosis	So we thought he had ...
Treatment	He was given intravenous ...
Outcome - what happened	He was restored and discharged home.

Bedside presentation in the ward

Bedside presentation in the ward looks like a less formal type of case presentation. And it can be taken place at a patient's bed, for example during ward rounds. When the house officer introduces a new patient to the consultant; or in a teaching ward round, when a medical student presents a case to the tutor. This type of presentation starts less formally:

This is Mr Brown. He's 44, and he's a manager. He was admitted to hospital yesterday, having been sent by his GP. He's complaining of breathlessness, which he's had for one month ...

Slides

The main components are usually summarized on slides in a formal presentation as the following:

Mr Brown 44, manager

c/o dyspnoea 1/12; ankle swelling 2/52

SH married with 1 daughter; 25 cigs/day; 40 units alcohol/week

PH nil relevant

FH father d. 42 Ml; mother a&w

OE obese; 2 spider naevi on chest; P 110/min reg.; BP 100/60

CXR enlarged heart and bilat. pleural effusions

Exercises

13.1 Write the abbreviations in words being used in this unit.

c/o ...............................................................

2/52 ...............................................................

PH ...............................................................

FH ...............................................................

MI ...............................................................

BP ...............................................................

1/12 ...............................................................

nil ...............................................................

SH ...............................................................

a&w ...............................................................

OE ...............................................................

CXR ..............................................................

13.2 Write down other most commonabbreviations from patients’ case histories in your specialty and present before classmates.

13.3 Put the sections of a short informal case presentation in the correct order.

1 Mr Howard is a 57-year-old accountant.

2 There was no considerable preceding medical history.

3 22 cigarettes were smoked by him per day and 10-15 units of alcohol were drunk by him each week.

4 He had marked pain around the lower extremities above the ankles and knees on examination. There was crepitation at the left base in the chest. He didn’t have anything else abnormal to find on examination except for clubbing of the fingers.

5 He showed a five-week history of pain in the legs.

6 X-ray of the chest showed carnification in the left lobe of the lung. Bronchoscopy and biopsy revealed adenocarcinoma of the lung and computed tomography (CT) scan showed that there was no way to operate.

7 Chemotherapy treatment has given temporary improvement in the chest X-ray but the pain in the leg has continued.

8The pain located around the ankles, had been accelerating severely and it was associated with local tenderness.

9 On consulting, he said that he had had a morning cough with small amounts of white sputum for many years. Once he produced some blood in the sputum.

13.4Read the presentation below and make notes for a slide.

I'd like to present Mr McMillan, he is a 60-year-old carpenter. He complains of a three-month history of increasing shortness of breath and ankle swelling. He had a chronic cough with purulent sputum and occasional haemoptysis. In his past medical history it was mentioned that he'd had a partial gastrectomy in 1982.

On examination, he was pale. He was apyrexial. He had oedema of the leg, but there was no clubbing or lymphadenopathy. And examination of his chest was entirely normal. When the doctor palpated his liver 5 centimetres below the costal edge, it was smooth and non-tender, and there was also a scar from his previous operation.

13.5 Make a case presentation of a patient you have already known.

13.6 Make a bedside presentation.

13.7 Make a slide presentation.

13.8 Learn case history questions in surgery which can help you to make your own dialogue.

1. When did the illness begin?

When were you taken ill?

When did you become ill?

2. What medicine did you take? (pills, drugs).

What medication did they treat you by?

3. Has the pain increased? Is the pain getting worse?

4. Have the pains subsided?

Did the pains go away?

5. Had you had similar pain before?

Had you been feeling such pain before?

Has this happened before?

6. When was the last attack of similar pain?

7. What diagnosis was made?

What was the diagnosis?

8. How long did the pain persist

9. What stopped the pain?

What provided relief from the pain?

What controlled the pain?

10. What therapy were you administered?

What treatment did you have?

11. Did you have a film stomach made?

Have you done X-ray of the stomach?

Have you done roentgen studies of the abdomen?

Have you had your stomach X-rayed?