Case presentation
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A formal communications between health care professionals (doctors, nurses, therapists, nutrientist etc.) 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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