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Case presentation

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A formal communications between health care professionals regarding a patient's clinical information. Essential parts on a case presentation includes

  • Identification
  • Reason for cosultation/admission
  • Chief complaints (CC) - what made patients to seek medical attention.
  • Past medical history (PMHx)
  • Past surgical history
  • Current medications
  • Allergies
  • Family history (FHx)
  • Social history (SocHx)
  • History of present illness (HPI) - circumstances relating to chief complainsts.
  • Physical examination (PE)
  • Laboratory results (Lab)
  • Other investigations (imaging, biopsy etc.)
  • Case summary and impression
  • Management plans
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