Question

Briefly outline the essential elements of a case presentation (summary) described in your readings and note which of the NONPF core competencies you are demonstrating in constructing an effective/profession case presentation.

Answer 1

The essential elements of a case presentation are :-

- The Introduction

Start with the patient's identifying data (name and age), chief concern, and other agenda items

Opening statement should set the stage for the rest of the presentation

- History of the Present Illness

The major focus of the presentation

Must include all essential elements

OPPQRST

When multiple problems exist, begin with the most important

- Medical History:

Past Medical History, Hospitalizations, and Surgical History

Start with most important

Use chronological order

Specialty specific (Pediatrics and OB additional info)

Medications and Allergies

Specific

Record doses/ allergies and reactions

Social History

Smoking status, alcohol and drug use, marital status and occupation

Family History

Highlight diseases that may be related to the Chief Concern

- Review of Systems

Pertinent information by system

Excluding symptoms reported in the HPI

Include pertinent positives and negatives

Will vary by presenting complaint

- Physical Examination

Start with general appearance and vital signs

Report head to toe

Focus on findings that help establish diagnosis

Pertinent present and absent findings

- Laboratory and other Test Results

Include important positive results

- Assessment

- Plan