Clerkship Pearls - How to Present a Patient Case Effectively

Presenting a case is an essential skill every medical student will have to master. In fact, it is one of the few things you can easily do to impress your preceptors and staff doctors. It’s a visible and tangible thing that can set you apart from your peers and can distinguish you from an average medical student to an outstanding one. A lot of students, and even some residents, struggle with presenting a case. When it’s done properly, the audience is engaged and their minds are stimulated but if done poorly, people may zone out and patient care might even be compromised.

We are taught a lot about taking histories and physicals, but we rarely get any formal teaching on presentations. I wouldn’t say I’m the best at presentations, but I think I’ve picked up a lot of useful tips. I’ve gotten a lot of help along the way to get to where I am. I can only hope to pass down some of that wisdom. So here is a list of things I learned in this last year on how to give effective patient case presentations.

Preparing to Present a Patient Case

1. Know your Patient - Before you present your patient during rounds, or to a consultation service, or to the handover staff, you have to know your patient. If it’s a patient you admitted, you should know all the details about the patient. Your history and physical should be thorough. You should know what investigations and treatments have been done. Knowing everything about your patient will make you more confident in presenting your case. You should be able to answer all questions about your patient if asked during your presentation.
2. Practice  - If the patient history is complex, or if things are a bit confusing, practice, practice, practice. If you’re rehearsing the case and things don’t make sense, go back and clarify with the patient and. Preparation really shows. Especially if you’re presenting multiple cases in a row after a night of call.
3. Know your Audience - Whether you’re talking to an internist or a surgeon, resident or junior student, you should tailor your presentation accordingly. If there are other health care team members who aren’t familiar with the acronyms, use the full terminology. Speak with the right level of language as your audience.
4. Know the Situation - There’s a big difference between presenting a patient’s complicated social situation and presenting a perforated bowel that needs emergency surgery. Present according to the context of the situation. If it’s an emergency resuscitation, only the immediate pertinent information will be required. If it’s a geriatrics consult for a stable patient, there would be a different level of detail and thoroughness.
5. Ask how you should present your case - This is a simple tip that really made a big difference in meeting expectations. I had preceptors who wanted every last detail and investigation done and then I had preceptors who only wanted three grammatically correct sentences. Ask ahead of time how your preceptors/audience would like a case presented and then do so accordingly!

Presenting the Case

1. Be Organized - Whenever you present a case, the format of your presentation should make sense. Most of the time you’ll have about 5-7 minutes (maybe 3 minutes in surgery) to summarize a whole story. You want the whole story to flow and make sense to whoever is listening. You should group all the HPI , medical/surgical history, medications, physical findings, investigations and etc. together. I recommend you writing your notes in a similarly organized fashion.
2. Tell a Story - Everything you say in a patient presentation should contribute to a larger story. You need to engage the audience with relevant details that will help paint a more vivid story. Although you’ll see the same diseases over and over again, each patient is unique and each disease unique to that patient at least. Try to tell your audience why this information matters and link it all together for them to appreciate.
   
3. Start with a strong opening sentence - Your first sentence should be a succinct yet informative sentence that should tell us over almost all we need to know about the patient. That means you’ll have to summarize just the most important facts into this one sentence. Don’t mention details unless they are relevant.
   A good summary sentence could go something like this, “Mr. A is a 19 years old male previously healthy, who comes in with first time seizures and atrial fibrillation secondary to alcohol/withdrawal, and cocaine abuse.” In this one sentence, you would have told probably over 80% of the story and it helps listeners focus on what’s important. An example of a bad introductory sentence would be, “Mr. A comes in feeling unwell for the last day, had some shakes and chills and came in with seizures.” Although that might have been his original chief complaint, it really doesn’t help listeners know what is happening. At this point, it could be anything including meningitis, epilepsy, hypoglycemia, etc etc. You want your first sentence to start with a bang!
4. Present a Patient, not just a disease - Mr. G isn’t just another COPD who came in through the ER, he’s a retired pilot who flew in the war and has been smoker since. It’s too easy and too boring to just present a disease. After all, we are treating patients and although at times we focus on their diseases, they are human beings with a life outside their sickness.
5. Present in a logical sequence: For most cases, the order will go something like this. ID, Chief complaint, (reason for referral), HPI, Past Med Hx, Past Surg Hx, Meds, Allergies, Social Hx (include Smoke, EtOH, drugs, living situation), Family Hx, ROS, Physical Exam, Lab work, Imaging, Other Investigations, Assessment and Plan. All my rotations have followed that format. As long as you’re not jumping around from labs to social history to treatment plan, you should be ok. The HPI should also be in a chronological order, either starting from the oldest information, or the most recent information.
6. Include Pertinent Positives and Pertinent Negatives - Only discuss information that is relevant to the case. You may have completed a thorough history, but you don’t have to present every last detail you collected. Only present what matters. Sometimes you may be asked about certain details, and that’s when knowing everything about your patient will save your butt. Be ready to answer any questions you may be asked about your patient.
7. Summarize the case - Before you go onto management plans, you should summarize the case using a similar sentence as your opening sentence. Just like writing an essay, say what you’re going to say and then say it again!
8. Include a Differential Diagnosis - Even if the diagnosis is as clear as night and day, having a differential always help. What else could it be? is a favorite question to ask at the end of the case. Remember to talk about findings that rule in or rule out diseases, and what investigations you would like to do to narrow your differential.
9. Include your Management Plans - For new learners, your management will likely be wrong, but you should get in the habit of including what you’re going to do early. Don’t be afraid to be corrected, that’s one of the ways you’ll learn and remember. Your senior resident or staff will correct you or at the most fine-tune your management. Taking the initiative and taking an educated guess is one of the best ways to show you’re more than just an information gatherer and that you can think independently. It also helps to do some background reading on the disease and management before presenting.

Improving Your Presentation

1. Be Enthusiastic - even if you’re post call. A lively presentation will capture people’s attention much better, and will make you more confident in your presentation.
2. Use a Loud Voice - be visible, be heard. Don’t be timid. Be confident with your presentation, even if you’re getting a stone face from your preceptor.
3. Do NOT READ your presentation -  I see this mistake done over and over again! it’s one of the easiest things to do that has the most impact in how you come off in your presentation. Eye contact is a powerful device for capturing someone’s attention. Presenting your case from memory may take some preparation and knowing your patient well, but it will make your presentation that much better. I want to repeat it again DO NOT READ FROM YOUR NOTES
4. Be Honest - If you forgot to ask a question, or do an examination, don’t lie. Instead be honest and say you did not do it. Preceptors will often test their students to see if they are telling the truth. Integrity matters. You’re doing yourself, your preceptors and your patient a disservice when you make up information.
5. Ask for feedback - no one gets everything right the first time. Ask for feedback from your peers and from your staff doctor. They’ll point out things you can improve on and things you should stop doing. I still get feedback and I appreciate it a lot. Because one day, when you’re finally done all your training, you’ll be on the other side listening with attentive ears and giving feedback too!

Additional Resources

• http://student.bmj.com/student/view-article.html?id=sbmj.c1539
• http://www.umdnj.edu/camlbweb/patient/presentation.html
• First Aid for the Wards - they have an excellent section on presentation skills, along with other ward tips

Let me know if you have any additional tips you found useful when you had to present a patient case!

Related posts:

Clerkship Pearls – Writing a Note Pt 2 Clerkship Pearls - Introduction Clerkship Pearls - Writing a Note Pt 1 The Difficult Patient