2. • 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.
Introduction
3. • 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.
4. Style
• 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:
5. • 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.
6. Length
• 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.
7. Structure
• 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.
8. How to Present??
Opener
• 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: “Mrs. 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.”
9. History of Present Illness
• 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)
10. ➢ 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.
11. Review of Systems
• 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), when presenting, only report
information that is relevant to your patient’s condition.
12. Past Medical History
• 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
13. Family History
• 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
14. Social History
• 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.
15. Physical Exam
• 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)
16. • 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
➢ Upper and lower Extremity exam
➢ Neurological exam
17. • Additional relevant physical examination findings may be included,
as well.
• A 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.”
18. Results of Laboratory Testing, Imaging,
and Other Diagnostics
• 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.
19. Assessment and Plan
• 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 line) 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.
20. ➢ An example could be: “Mrs. 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.”
21. 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, Mrs. 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.
22. 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)
23. Presenting Patients Who Have Been in the
Hospital for Multiple Days
• After the initial presentation, subsequent presentations can be
delivered via the 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.
24. • 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.
25. 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.
26. 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 are challenging at first,
so remember to practice.
• In time, you will become proficient in this essential medical skill.
