By Kunal Sindhu
The ability to deliver oral case presentations is a core skill for any physician. Effective oral case presentations help facilitate the transfer of information 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 job of the presenter 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 strive to include details to support the proposed diagnosis and 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.
• Minimize fidgeting: Stand up straight and avoid unnecessary, distracting movements.
• Feel free to use your notes, but avoid just reading them to your team: 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 simply read your notes to them.
• Honesty: Given the importance of presentations in guiding medical care, never report false information to the team. If you are unsure about a particular detail, it is fine to say so.
The length of your presentation will depend on a variety of 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 expectations for content are generally quite similar. Thus, developing a familiarity with the core elements of a strong oral case presentation is essential.
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 the reason that 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.”
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)
• 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.
Review of Systems
The review of systems is sometimes included in the history of present illness, but it may also be seperated. 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.
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
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
• 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:
• 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.
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, nontender, and nondistended, with normoactive bowel sounds.”
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. Prior to presenting, consider which results will further support your proposed diagnosis and exclude alternatives.
Emergency Department Course
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.
Assessment and Plan
You should conclude your presentation with the assessment and plan. This is the most important part of your presentation and gives you the opportunity to show your team how much you really know. You should include:
• A brief 1-2 line summary 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 be not 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 the SOAP format as follows:
• In the Subjective section, include 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 everyday.
Presenting Patients in Different Specialties
Before you present a patient, consider your audience. Every specialty presents patients differently. In general, surgical and OBGYN 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 in a similar fashion as 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. Good luck!
About the Author
Kunal Sindhu is a resident physician in New York City. You can follow him on Twitter @sindhu_kunal.