How to present a patient: the oral case presentation

• Identifying statement and chief complaint: age, sex, relevant background, and why they are here
• History of present illness, in chronological order, including the pertinent negatives
• Past medical and surgical history, relevant to the problem
• Medications and allergies, with the reaction
• Social and family history, briefly and relevantly
• Review of systems: only the positives and the negatives that matter
• Examination: vital signs first, then the relevant findings
• Results: labs, imaging and other tests
• Assessment: a one-line summary, the most likely diagnosis and the differential, with your reasons
• Plan, problem by problem

The opening sentence frames everything that follows. It gives the age, sex, the background that matters for this problem, and the chief complaint with its duration. For example: "Mr. Smith is a 64-year-old man with hypertension and a 40 pack-year smoking history, presenting with two hours of central, pressure-like chest pain radiating to his left arm."

Repeat a sharpened version at the start of the assessment, adding the key findings: "In summary, a 64-year-old smoker with typical ischemic chest pain and ST depression in the lateral leads, most consistent with a non-ST-elevation acute coronary syndrome."

Include whatever supports or argues against your differential. Pertinent negatives belong in the history of present illness, not at the end: in a patient with chest pain, "no pain radiating to the back" and "no recent travel or surgery" tell the listener you considered dissection and pulmonary embolism. Leave out normal findings that do not bear on the problem.

Commit to a most likely diagnosis and say why, then give one or two alternatives and what would separate them. Present the plan by problem: the investigations, the treatment and the monitoring for each. Supervisors expect students to make a call; being wrong with reasons teaches more than staying vague.

A new admission on rounds usually takes three to five minutes; a follow-up on an established patient, one to two. Follow-up presentations often use the SOAP format: Subjective (how the patient feels and any events overnight), Objective (vital signs, examination and new results), Assessment and Plan. Ask your team how long they like presentations to be, and practice out loud.

• Reading the whole history aloud instead of selecting what matters.
• Telling events out of order, so the listener cannot follow the timeline.
• Mixing examination findings into the history.
• Ending without an assessment, or listing a differential without saying which is most likely.
• Saying "labs were normal" without saying which ones.