Case presentation

A case presentation is a formal communication between health care professionals (doctors, pharmacists, nurses, therapists, nutritionist etc.) regarding a patient's clinical information. Essential parts of a case presentation include:

• Identification
• Reason for consultation/admission
• Chief complaints (CC) - what made patients seek medical attention.
• History of present illness (HPI) - circumstances relating to chief complaints.
• Past medical history (PMHx)
• Past surgical history
• Current medications
• Allergies
• Family history (FHx)
• Social history (SocHx)
• Physical examination (PE)
• Laboratory results (Lab)
• Other investigations (imaging, biopsy etc.)
• Case summary and impression
• Management plans
• follow up in clinic or hospital
• Adherence of the patient to treatment
• success of the treatment or failure.
• causes of success or failure.

References