Case presentation
A case presentation is a formal communication between health care professionals such as doctors and nurses regarding a patient's clinical information.
Essential parts of a case presentation include:
- Identification
- Reason for consultation/admission
- Chief complaints - what made patients seek medical attention.
- History of present illness - circumstances relating to chief complaints.
- Past medical history
- Past surgical history
- Current medications
- Allergies
- Family history
- Social history
- Physical examination
- Laboratory results
- Other investigations
- Case summary and impression
- Management plans
- follow up in clinic or hospital
- Adherence of the patient to treatment
- success of the treatment or failure.
- causes of success or failure.