Case presentation

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A case presentation is a formal communication between health care professionals (doctors, pharmacists, nurses, therapists, nutritionist etc.) regarding a patient's clinical information. Essential parts of a case presentation include:

  • Identification
  • Reason for consultation/admission
  • Chief complaints (CC) - what made patients seek medical attention.
  • History of present illness (HPI) - circumstances relating to chief complaints.
  • Past medical history (PMHx)
  • Past surgical history
  • Current medications
  • Allergies
  • Family history (FHx)
  • Social history (SocHx)
  • Physical examination (PE)
  • Laboratory results (Lab)
  • Other investigations (imaging, biopsy etc.)
  • 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.

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