Transcript Case Presentation

Communicating to Other Health
Professionals About Your Patient:
Doing Case Presentations
HAIVN
Harvard Medical School AIDS
Initiative in Vietnam
1
Learning Objectives
By the end of this session, participants
should be able to:
 Outline the key elements of a case
presentation about a person living
with HIV/AIDS (PLHIV)
 Explain how to prepare and deliver a
case presentation about a PLHIV
2
What is a Case Presentation?
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Presentation which gives all the
information necessary for a colleague
to understand a patient’s situation
Patient’s “story”: why patient is being
seen in clinic or hospital, what has
happened until present time
May be long or short, depending upon:
• where story is being told
• who it is being told to
3
Elements of the Case
Presentation
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Introduction & Chief Complaint
History of Present Illness (HPI)
Past Medical History
• medical, surgical, including meds and allergies
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Social History
Review of Systems (ROS)
Physical examination
Laboratory and diagnostic studies
Clinical Assessment
Treatment Plan
Evolution of signs and symptoms and lab tests of
patients after treating
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HIV Case Presentations:
Suggestions (1)

Mention most recent known CD4
count and ARV status within the first
or second sentence
• “Mai, is a 2year old girl who presents
with a chief complaint of cough and
fever. She has been on ART for two
weeks and her most recent CD4 cell
count was 11% three months ago.”
5
HIV Case Presentations:
Suggestions (2)

Make sure to include pertinent
negatives as well as positives.
• “Medications include AZT, 3TC, NVP,
and cotrimoxazole..”
• “On examination, there was no thrush,
lymphadenopathy, or skin rash.”
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HIV Case Presentations:
Suggestions (3)

When discussing past medical
history, include intervention for
PMTC and any prior OIs and the
most common co-morbidities.
• “Past medical history includes herpes six
months ago. There is no prior history of
TB, HBV infection.”
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HIV Case Presentations:
Suggestions (4)

Provide a summary statement (s) as
part of your clinical assessment
• “In summary, the patient is a 2 year girl
with a CD4 11% who presents with
signs and symptoms of respiratory
infection after two weeks of ARV
therapy.”
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HIV Case Presentations:
Suggestions (5)

Evolution followed up on a table ( if long time)
16/10/08
19/02/09
10/9/09
25//5/10
Weight
8.6 kg
9kg
11kg
11.5kg
Height
80cm
82cm
84cm
87cm
Oral thrush, vomiting ,
dyspepsia
cough+ fever,
hospitalized
Lymph node
TB, treated
with RHZE
Completion
of Anti TB
course
d4T/3TC/EFV
D4/3TC/EFV
12.71%
508
20.84%
642
60/53
27/14
9.1
12
Date
Symptom
ARV
d4T/3TC/NVP
d4T/3TC/N
VP
CD4
0.38%
7
ALT
89/70
Hb
9.3
4.74%
50
8.9
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HIV Case Presentations:
Suggestions (6)
Providing some pictures
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Suggested issues to discuss

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Besides showed information do you think
that the patient has any more clinical
matter/ any matter is not clear:
• Symptom, diagnosis, tratment, follow
up,…?
Do you have any plan for the patient?
• Any more lab test?
• Plan for treatment ? How to follow up?
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Pair Activity:
Practice Delivering Case Presentations
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Key Points
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Goal of case presentation is to present
clinical scenario in a clear, concise manner
Case presentations may be used to:
• consult with a colleague on a difficult case or
• present a case in a conference or workshop

Case presentation should:
• include all relevant information
• not include facts or details not pertinent to
case
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After presentation, listener should have a
clear understanding of the case and be able
to make a treatment plan for the patient
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Thank you!
Questions?
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