Download Patient Case Presentation

Patient Case Presentation
Inpatient OSU Internal Medicine
1. The patient case should be presented using the following format. This should be
typewritten and is expected to be handed in. The presentation should not be merely
read from the handout, but more of a “story telling” approach. The patient case
should take no longer than 10-15 minutes.
Chief Complaint
Mr(s) _________________ is a ______ year old _______ _______ who
(initials)
(age)
(race)
(sex)
Presented to the hospital with a chief complaint of _______________________.
The Chief Complaint is a brief statement of the why the patient sought medical
attention, stated in the patient’s own words. No medical term or diagnosis is used.
History of Present Illness
The HPI is amore complete description of the patient’s symptoms(s). General
features included in the HPI are:





Date of onset
Precise location
Nature of onset, severity, and duration
Effect of any treatment
Degree of interference with daily activities
Past Medical History
The PMH includes serious illness, chronic diseases, surgical procedures, and
injuries the patient has experienced. Minor complaints may be omitted.
Family History
The FH includes the age and health of parents, siblings, and children. Ages and
cause of death should be recorded for deceased relatives. Only include data that is
pertinent to the patient case.
Social History
The SH included not only the social characteristics of the patient, but also the
environmental factors and behaviors that may contribute to the development of disease.
Items included are marital status, number of children, educational background,
occupation, dietary habits, use of tobacco, alcohol, or other drugs.
Medication History
The MH should include current medications prior to admission. This includes
prescription and non-prescription medications. Include name and dosing information for
each.
Allergies
Allergies to drugs, foods, pets and environmental factors should be included. An
accurate description of the reaction that occurred should be presented.
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Review of Systems and Physical Exam
In the ROS, the examiner questions the patient about the presence of symptoms
that are pertinent to each body system. Only the pertinent positive and negative findings
may be recorded.
The general sections for the PE are listed below. It is only necessary to list the
findings that are “remarkable.”
General appearance
Vital signs
Skin
Lungs
Cardiovascular
Abdomen
Genital/Rectal
Extremities
Neurological
HEENT:head, eyes, ears, nose, throat
Admission Labs
The results of lab tests should be recorded. For handout purposes, these may
be listed in table form. List all lab results but comment only on those that are abnormal
or pertinent to the case.
Admitting Impressions
Based on the above information, what are the admitting
impressions/problems/diseases. Develop a problem list according to the acuity and
significance of the patient’s conditions.
Hospital Course
Provide a detailed but concise description of the patient’s hospital course. This
can be done in a day-to-day format or by each problem. Be sure to include pertinent
changes in medications, lab values, symptoms, etc.
Case Summary
Provide a brief summary of the chief complaint and the treatment provided. List
other problems associated with hospitalization (no details)
2. After the patient presentation, the student should be prepared to discuss all aspects
of the patient case. Emphasis will be placed on the understanding of the drug
therapy for each problem and developing clinical judgment with respect to optimal
drug therapy.
3. The student should be prepared to give a 15-20 minute review/discussion of the
major problem/disease/reason for admission. A complete understanding of each
problem/disease state is expected.
4. The student should evaluate the relevant primary literature and apply the information
to the patient/problem. At least 1-2 primary literature references should be included
in each case discussion.
5. A typewritten handout is required for each component of number 2, 3, and 4 above.
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