Transcript Case Presentation

Communicating to Other Health
Professionals About Your Patient:
Doing Case Presentations
HAIVN
Harvard Medical School AIDS
Initiative in Vietnam
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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
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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
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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
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HIV Case Presentations:
Suggestions (1)

Mention most recent known CD4
count and ARV status within the first
or second sentence
• “Tuan is a 29 year old HIV+ male who
presents with a chief complaint of
dyspnea on exertion. He has been on
ART for one year and his most recent
CD4 cell count was 280 three months
ago.”
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HIV Case Presentations:
Suggestions (2)

Make sure to include pertinent
negatives as well as positives.
• “Medications include d4T, 3TC, NVP, and
cotrimoxazole. He denies any use of
private or traditional medications.”
• “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 any prior OIs and the
most common co-morbidities.
• “Past medical history includes cerebral
toxoplasmosis. There is no prior history
of TB, HBV, or HCV 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 26 year
old man with a CD4 count of 212 who
presents with recurrent signs and
symptoms of pneumonia despite two
weeks of antibiotic therapy.”
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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
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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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