Case presentation

• The following elements are the backbone for any case presentation:
  1. Patient’s age and gender.
  2. Relative PMH/PSH/FH/SH (not all).
  3. The Chief complaint and any diagnosis or presumptive diagnosis made on admission.
  4. Treatment received on admission ( Only mention the treatment provided for the active problem).
  5. Updates on the Presenting symptoms/associated symptoms/signs.
  6. Relative physical exam findings (Don’t forget vital signs).
  7. Relative diagnostic data (Imaging, labs, EKG,…etc.)
  8. Assessment: this a one-liner that follows this format [ a…year-old lady/gentleman, day…admission, presented with “chief complaint”, and admitted with/for “reason for admission”
  9. Plan: of the active problems and discharge process.
• Relative PMH/PSH/FH/SH is the history directly related to the active problem.
• Active problems are the ones we are:
  • Starting a new treatment for.
  • Changing the course of treatment for.
  • Closely monitoring.

Case presentation example

An 80-year-old lady with PMH of diabetes, CAD, essential hypertension, and hypothyroidism presented to the ED a day earlier with lower abdominal pain, she was diagnosed with acute sigmoid diverticulitis, no history of previous diverticulitis attacks, started on IV antibiotics, her initial CBC showed WBC of 16.

• Patient age and gender: An 80-year-old pleasant lady.
• Relative PMH/PSH/FH/SH: No previous acute diverticulitis episodes.
• Presenting complaints: Lower abdominal pain
• Diagnosis/presumptive diagnosis: Acute sigmoid diverticulitis.
• Initial treatment: IV piperacillin/tazobactam
• Presenting symptom/associated symptoms update: Pain improved significantly, no associated nausea or vomiting, the patient is tolerating a clear liquid diet, no BM.
• Physical exam related to the active problem: her vital signs showed her BP was running around 180 systolic over the last 3 vital checks, her LLQ tenderness is still present but significantly better, no rebound tenderness, or distension
• Diagnostic data relative to the active problem: CT abd/pelvis on admission showed findings suggestive of acute diverticulitis. WBC today is 12 down from 16 yesterday, and the rest of CBC and CMP are unremarkable.
• Assessment: An 80-year-old lady, day 1 admission, presented with LLQ abdominal pain, and was admitted with/for acute sigmoid diverticulitis
• Plan: 
  • For the acute sigmoid diverticulitis (New treatment) : She’s clinically better with less pain and tenderness, will continue IV antibiotics for another day, advance diet as tolerated, and transition to real antibiotics in am
  • Leukocytosis (needs monitoring): resolving, repeat CBC in AM.
  • Uncontrolledessential hypertension (Needs treatment adjustment and treatment) : will readjust her meds to achieve better control “be more specific here”
  • Diabetes (Needs monitoring): adequately controlled with current insulin regimen “be more specific”.
  • Discharge: likely home in AM.

You may purchase this framework by using the following link: https://rahamneh.gumroad.com/l/presentation

Now, some attending physicians may prefer a more detailed lengthy presentation as if you are reading the full H&P! I suspect these are very few because it’s very time-consuming and unnecessarily prolongs the official rounds, anyhow I highly encourage you to check with your colleagues on your attending physician preferences and adapt to that.

Calling a consult

With this case presentation, calling a consult is pretty straightforward! The difference is that Consultants want to hear what matters to them! a very concise, focused case presentation that is relative to the consultation.

Use The following is a framework for calling a consult:

1. Greet, introduce yourself, and what’s your role.
2. I am calling you to see if you can help us with our patient [reason of consultation].
3. Concise case presentation: read the assessment.
4. Provide any diagnostic data relevant to the consultation.
5. Patient’s name and location.
6. Thank you.

Let’s assume the above diverticulitis patient had recurrent attacks of sigmoid diverticulitis and you wanted to consult general surgery:

Hi Dr.X, my name is Maher, and I am a medical resident with Dr. “so & so” team, I am calling you to see if you can help us with our patient’s recurrent diverticulitis attacks, she’s an 80-year-old lady who presented yesterday with another attack of sigmoid diverticulitis and we treated her with IV antibiotics, this is her fourth attack in one year. Her name is X and she is in room 400.

Sign off

The night team will need the following info to speed up their response to your patient’s needs and to avoid giving any undesirable orders:

1. Patient’s name and location.
2. Brief, focused history (Assessment & plan)
3. Things to watch for and what to do.
4. Diagnostic data to follow up on and what to do.

Let’s apply this framework to the same patient

1. Patient’s name and location: so & so, room 400
2. Brief, focused history (Assessment & plan): An 80-year-old lady, admission day 1, with acute sigmoid diverticulitis with significant improvement in her pain and LLQ tenderness! Will continue IV antibiotics for one more day, advance diet as tolerated, repeat CBC in AM, and discharge in AM if she is tolerating her diet without pain.
3. Things to watch for and what to do: Please refrain from giving IV narcotics if possible and rely on oral narcotics instead. Please use melatonin if she asks for a sleeping aid.
4. Diagnostic data to follow up on and what to do.Patient’s name and location:  None.

You can download all these templates using this link :https://rahamneh.gumroad.com/l/presentation