Case Presentation Name: xxxxx (Do not give complete name.) Chart # Bed # Age: Gender: Date of Admission: Do not read these two items in the presentation

Present Illness CC: PI: Include all relevant information that will help us understand what is happening to the patient. –Do not list all previous diseases. Mention only those related to the PI. Include relevant FH, risk factors, etc. –Include relevant negative information, e.g., the absence of relevant risk factors

PMH Summarize the status of any other known diseases Purpose: to tell us what we need to do to manage any of these other problems. Be prepared to state the evidence that the patient really has the diagnoses that are listed.

PHH, SH, FH, ROS Mention any positive findings that are relevant to the patient’s state of health--but nothing that explains the PI. That should already be in the PI Do not list negative information on the slide or mention it in the report (All that information belongs in the Admission Note but not the Case Report. Be prepared to answer any questions about those items.)

PE Give the vital signs Report a focused PE, i.e., physical findings related to the patient’s problems, positive or negative Do not show irrelevant parts of the PE. However, be prepared to answer any questions about those parts of the PE.

Lab data Show and comment on relevant lab data and imaging studies Bring x-rays if possible. Be prepared to point out the relevant findings

Problem List List all medical problems the patient has, usually beginning with the PI. Number each problem The problem title should state what you know, not what you intend to “rule out.” Give an appropriate differential diagnosis for undiagnosed problems –Appropriate means diagnoses that ought to be considered for this particular patient at this particular time. Do not list or discuss all possible diagnoses.

Plan List specific plans for the main problem (s), using the same numbers as in the Problem List. Be prepared to explain your diagnostic and therapeutic plans