Delivering a clear and concise case presentation is a vital skill during clinical rotations, oral exams, and morning ward rounds. A well-organized narrative reflects solid clinical reasoning and effective communication. Here is the essential 6-step framework to structure any patient case presentation accurately.
1. Patient Demographics & Chief Complaint (CC)
- Demographics: Age, biological sex, occupation, and relevant background.
- Chief Complaint (CC): The primary reason the patient sought care, stated in their own words along with the exact duration (e.g., “Chest pain for 2 hours”).
2. History of Present Illness (HPI)
The HPI must follow a strictly chronological timeline, breaking down the primary symptom:
| Clinical Attribute | What to Assess | Example |
| Onset & Course | Sudden vs. gradual, precise duration | Sudden onset 48 hours prior to admission |
| Location & Radiation | Anatomical site and referral patterns | Epigastric pain radiating in a band to the back |
| Quality & Severity | Sharp, burning, crushing, colicky (1-10 scale) | Burning quality, severe intensity (8/10) |
| Modifying Factors | Aggravating and relieving factors | Worsened after fatty meals, alleviated by leaning forward |
| Associated Symptoms | Pertinent positive/negative symptoms | Accompanied by nausea, vomiting, and unmeasured fever |
3. Past Medical, Surgical & Social History
- Past Medical History (PMH): Hypertension, diabetes mellitus, prior surgeries, and known drug allergies.
- Current Medications: Dosages, frequencies, and compliance.
- Social History: Tobacco consumption (pack-years), alcohol intake, and relevant living conditions.
- Family History: Early cardiovascular disease, malignancies, or heritable conditions in first-degree relatives.
4. Physical Examination
- Vital Signs & General Appearance: BP, HR, RR, SpO2, temperature, hydration, and mental status.
- Systematic Exam: Targeted evaluation by organ systems (Cardiovascular, Respiratory, Abdominal, Neurological), noting key positive and pertinent negative findings.
5. Assessment & Differential Diagnoses
- Primary Working Diagnosis: The most probable syndromic or etiologic diagnosis based on initial data.
- Differential Diagnoses: 2 to 3 clinically relevant alternatives to rule out.
6. Plan & Management
- Diagnostic Workup: Targeted laboratory panels and diagnostic imaging (X-ray, Ultrasound, CT scan) with clear rationale.
- Initial Therapy: Fluid resuscitation, pharmacotherapy, monitoring parameters, and consultant requests.
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