As a medical student, presenting history and physical exam of a patient to the attending can be nerve-wracking. In the ED, physicians typically prefer an even more succinct presentation than usual, ideally less than 3 min. Case presentations are a great opportunity to show that you understand what the pertinent positives and negatives for the patient’s presenting complaint are and that you can summarize a large amount of information collected in an organized manner. Case presentations are your opportunity to impress your preceptor, so it is an important skill to master. It will also be the mode of communicating with the rest of the healthcare team throughout your career in medicine. Better communication = better patient care!
Before we get started, it is important to recognize that every physician may have their own preference for how they would like case presentations organized. Some prefer more details, and some prefer a specific order. Therefore, it is always a smart idea to ask your preceptor at the beginning of your ED shift if they have a preference for how they like cases to be presented.
The One Liner
State the patient’s name, age, sex, chief complaint, and any pertinent medical history. E.g., John Doe is a 16-year-old male with a history of eczema presenting with wheezing.
History of Presenting Illness (HPI)
- Why did this patient present to the ED today?
- What are the details of the chief complaint? I.e. Onset, Duration, Progression, Alleviating and Aggravating Factors, Causes/Triggers, Changes with Position, etc.
- For pain, it is helpful to describe OPQRSTU – Onset, Position, Quality, Radiation, Severity, Temporal, déjà vU (has it ever happened before).
- Any associated symptoms
- Any risk factors?
- Any relevant past medical history (e.g. chronic conditions, hospitalizations, surgeries, etc.), family history, or social history (e.g. habits, living situation, alcohol consumption, smoking history, illicit drug usage)?
Review of Systems
Describe any other symptoms here.
- Note that some ED physicians may not want a review of systems included in the oral case presentation if it does not include any additional pertinent information, but a review of systems should always be included in your written patient note.
if the patient states that they do not have any allergies, this can be recorded and/or stated as “NKDA” which stands for No Known Drug Allergies.
Physical Exam Findings
- Start off by stating the most updated set of vitals.
- Next, state the patient’s general appearance as this helps decide between sick vs. not sick. E.g., patient is alert, oriented, and in no apparent respiratory distress.
- Then, delve into the pertinent details of the physical exam. E.g. for a cardiac complaint, it is important to include the specific details of the cardiovascular exam and respiratory exam, but not of all the other systems.
- A brief overview of the other systems that a physical exam was conducted for can be useful, but be as concise as possible, and organize information in a head-to-toe fashion if needed. If there were no other findings, you can state that the remainder of the physical exam was unremarkable.
In 2-3 sentences, gather the main findings of your history and physical exam. Be sure to restate the initial one-liner sentence, other pertinent positives and negatives, and any important test results so far.
State your differential diagnosis for each problem.
- Start off by stating what you think the most likely diagnosis is, and why you think it is the most likely.
- Then, state any other likely diagnoses you are suspecting.
- Lastly, state the deadly diagnoses that could be possible with this patient’s chief complaint. In some cases, this can be the first thing you may want to say. It is important to specify why you do or do not feel confident in ruling these out. E.g., in a baby presenting with fever of unknown origin, it is important to state why you are not (or are) suspecting meningitis, encephalitis, malignancy, or autoimmune conditions.
- Many medical students will shy away from stating their impression of what could be going on in terms of differential diagnosis, but this is an important thing to attempt. Preceptors will appreciate your effort in synthesizing what could be going on and be impressed by it, even if your impression is incorrect. This is often what sets apart students that “meet expectations” vs. students that are considered “outstanding”.
What do you want to do next?
- Plan includes anything from the tests you want to order (including repeat vitals, bloodwork, and imaging), immediate treatment (including analgesics and fluids), and referrals you want to make (including consults, admission/discharge plan, and referral to allied health professionals such as social work, speech-language pathology, occupational therapy, and physiotherapy).
- Do not forget to take the patient’s social history into account when deciding what to do next.
Congrats – you have now completed your oral case presentation! This is a skill you will continue to develop with practice, so do not worry and keep working at it. It is also a good idea to always ask your preceptor for feedback on your case presentation once it is complete, as that will help you identify your strengths and weaknesses.
References and Further Reading
- Davenport C, Honigman B, Druck J. The 3-minute emergency medicine medical student presentation: a variation on a theme. Acad Emerg Med. 2008 Jul;15(7):683-7. doi: 10.1111/j.1553-2712.2008.00145.x. PMID: 18691216.
- Oral Presentations in Emergency Medicine. FlippedEM Classroom. 2013. https://flippedemclassroom.files.wordpress.com/2013/08/acem_145_sm_datasupplements1.pdf
- Ramsden S. How to Present a Case in the Emergency Department. CanadiEM. 2020. https://canadiem.org/how-to-present-a-case-in-the-emergency-department/ Accessed 08 November, 2020.
- Williams DE, Surakanti S. Developing Oral Case Presentation Skills: Peer and Self-Evaluations as Instructional Tools. Ochsner J. 2016;16(1):65-69.