Case Presentation

Presentation of Clinical Data

• Concise, logical, accurate and timely
presentation of complex patient problems in
both verbal and written form.
 1
• Keep presentations limited to 3-5 minutes
• Start by personal data ( age, Gender) other
suspected relevant data.
 2. Presumed Top 3 Diagnoses:
• Start your presentation by listing your top 3
diagnosis. It is OK to be wrong, just be ready
to defend your hypothesis. For example,” I
believe this patient either has congestive
heart failure or pneumonia.” This introductory
list lets the resident/attending know what you
are thinking right up front.
 3. Chief Complaint:
• Patient’s chief complaint as listed on the chart
or in their own words. Be brief.
 4. HPI:
• Present a thorough but CONCISE history of
present illness. For pain (chest, head,
abdomen) perform OLDCAAR-onset, location,
duration, character, alleviating factors,
aggravating factors, radiation. Pertinent
workup, pertinent positives/negatives belong
here.
 5. Pertinent past history:
• Example: chest pain. Has the patient ever
presented with chest pain. Have they ever had
a stress test, CT scan, or cardiac
catheterization?
6. Pertinent Medications/Allergies/Family
and Social History:

• Document all of this pertinent information

BUT present only pertinent information.
 7. Review of Systems:
• Include only pertinent information. If the
patient is in the ED for a thumb injury, you
don’t need to say that the patient denies chest
pain, shortness of breath, etc. Include only the
pertinent information that helps rule in or out
the diseases on your list of differential
diagnoses.
 8. VITAL SIGNS:
• Always start your physical examination with
the vital signs. Should include pulse rate,
blood pressure, respiratory rate (20 means
nobody measured), temperature, and pulse
oximetery
 9. Physical Examination:
• Present a directed physical examination that
addresses those areas pertinent to the chief
complaint. You may be asked to present a
more in-depth examination depending on the
complaint and the attending.
 10. Differential Diagnoses:
• Present a list of the emergent causes and common
causes of the patient’s complaint. This is your chance
to list AT LEAST 5 entities. Tell the attending or resident
what you think is going on with the patient and be
ready to defend your decision. THIS IS THE MOST
IMPORTANT PART OF YOUR PRESENTATION as it shows
your ability to synthesize information and think.
WHATEVER YOU DO, DO NOT REGURGITATE A HISTORY
AND PHYSICAL AND WAIT FOR THE
RESIDENT/ATTENDING TO TELL YOU WHAT TO DO!
Think!
 11. Evaluation Plan:
• Present your evaluation plan. What tests or
imaging studies do you want to get. Be ready
to defend this. Try to determine how much or
how little you think needs to be done. Again,
THINK for yourself.
 12. Anticipated Disposition:
• Tell the attending or senior resident what you
anticipate the disposition to be based on
current findings and based on the expected
results of the tests you want to order. This will
make you think of criteria for admitting and
discharging patients.
“Rule-out-worst-
case-scenario”
Example
 Chief Complaint
• A 72 year old Caucasian gentleman
presents to Christ ED with complaint of
abdominal pain.
 History of Chief Complaint
• Six day history of increasing abdominal pain in
LLQ.
• Pain is dull and constant with N/V.
• No bowel movements or flatus for the past six
days.
• Increasing abdominal distention with lack of
appetite.
 History (Cont)
• He had a similar type of problem a couple of
months ago at Illinois Masonic Hospital.
Impacted at that time and underwent
endoscopic evaluation. Reportedly
unremarkable.
• Over the past several days he has tried
laxatives and enemas. Did not relieve his
obstipation.
 History (Cont)
• PMH: None except for a recent colon impaction.
• PSH: None
• Allergies: NKDA
• Medications: None
• Family History: Noncontributory
• Social History: Patient lives by himself. Smokes half-
a-pack for 50 years. Ocassional EtOH. Denies other
drug use.
 Review of Systems
• GENERAL
GU – Denies– Loss of 2 lbs
dysuria, over past
polyuria, week. Episodes of
hematuria.
• fever/chills
Musculoskeletal – Denies arthralgias/myalgias.
• HEENT – Denies trauma, changes in vision, hearing.
• NEURO – Denies paresthesias. CN II-XII grossly intact.
• CARDIAC – Denies chest pain, palpitations
• ENDOCRINE – Denies hot or cold intolerance.
• PULMONARY – Denies chronic cough and SOB.
• GI – As per HPI. No hematochezia/melena
 Physical Examination
• Vitals: 96.8, 102 pulse, 26 resp, 145/87, 94%
RA
• General: Well developed, but cachectic
appearing.
• HEENT: PERRLA, EOMI, mucus membranes
moist, no cervical LAD
• CARDIO: RRR, no M/R/G
• PULMONARY: CTAB
 Physical Examination
• ABD: Soft, but significantly detected. LLQ and
periumbilical tenderness w/o G/R/R.
Hyperactive/tympanic bowel sounds. Rectal exam
revealed good rectal tone. Heme-Occult neg.
• EXT: No C/C/E.
• NEURO: A & O x 4. CN II-XII grossly intact.
 Laboratory Data
• Creatinine
WBC 7.7 1.1
• Hgb 15.2103
Glucose
• Hct 43.92.0
Bilirubin
• Platelets
AST 36 417,000
• Na 138
ALT 47
• K 2.8
Alk Phos 92
• Cl 95 165
Lipase
• CO2 is30
U/A + for ketones and protein, but otherwise -
• BUN 40
Differential Diagnosis