FORMAL AND INFORMAL CASE PRESENTATIONS
Laura A. Perry, PharmD, BCPS
CASE
E.S. is a pharmacy student arriving on her first APPE rotation. Her preceptor has just reviewed her expectations for this rotation. E.S. is nervous because her first assignment is a case presentation, and she has been given very little direction. Her preceptor has only advised her to follow F.S., a patient in room 474, who was admitted last night for elevated blood pressure and to prepare for a formal case presentation to the pharmacy staff the following week. Two days have passed and E.S. has been gathering large amounts of information on the patient, but she is unsure of how to begin organizing the information for her formal case presentation.
WHY IT’S ESSENTIAL
Case presentations are an essential component of student learning because they allow you to strengthen your verbal communication, critical thinking, and clinical reasoning skills. Preceptors use case presentations as a way to evaluate your ability to provide patient care. Once the transition is made from student to practitioner, case presentations become an excellent tool for providing education to pharmacists and other healthcare providers. Furthermore, informal case presentations are part of the daily routine of many healthcare providers. A well-done informal case presentation allows healthcare providers to communicate patient information effectively between one another, learn about unique patient cases, and facilitate collaborative development of care plans. The style and content of case presentations varies according to the purpose of the presentation, the audience, and the amount of time allotted. One approach is described in this chapter.
GENERAL COMPONENTS OF A CASE PRESENTATION
The general components of a case presentation include a discussion of pertinent patient information and current drug therapy and a summary of patient-specific recommendations. The most widely accepted format for organizing a case presentation is the SOAP format, consisting of a presentation of the case information in the following order: subjective, objective, assessment, and plan. Presenting a case utilizing this structured approach ensures the audience is able to follow and comprehend the wealth of information presented, orienting them to who the patient is, the illnesses the patient has, and how they are being managed. The degree of detail provided varies for formal and informal presentations, with more detail being included for formal case presentations than for informal case presentations. Preceptors may have differing opinions of how to best organize patient information into the SOAP format, but a general approach is outlined below.
Introduction of the patient case involves presenting a variety of information, some of which must be gathered thorough a patient interview at the time of hospital admission or during an outpatient office visit. If the patient is unavailable to communicate, a caregiver may also respond in place of the patient. Subjective information includes the background information necessary to determine possible differential diagnoses, which then direct a thorough patient work up. Table 6-1 outlines example subjective information that should be obtained and evaluated from the patient’s chart.
TABLE 6-1. SUBJECTIVE INFORMATION
| SUBJECTIVE INFORMATION | EXAMPLES |
| Chief Complaint | |
| The patient’s primary concern upon presentation. | “I feel very dizzy.” |
| History of Present Illness A chronological account of events since the onset of the problem, including significant detail of symptoms and any other pertinent subjective information that may be relevant to the primary problem. | The patient is a 63-year-old man brought in by EMS for altered mental status. According to the family, the patient became dizzy and fell this morning and had an episode of vomiting, after which they called emergency services. EMS reports a systolic blood pressure in the 240s upon their arrival. In the emergency department, the patient was started on a nitroglycerin drip and is being transferred to the medical intensive care unit. |
| Past Medical and Surgical History | CAD with history of STEMI and stent placement |
| A list of previously diagnosed medical conditions and procedures. | CHF (diagnosed 6 months ago) |
| Type 2 DM | |
| HTN | |
| Appendectomy at age 10 | |
| Family History | |
| Family history of first-degree relatives. | Both parents had HTN; mother had DM. Father had a heart attack in his early 50s and died in his 70s of a second heart attack. His mother died a few years later of a stroke. One brother, age 60, has HTN, DM, and had CABG 3 years ago. |
| Social History | |
| Information relating to socioeconomic status, alcohol, tobacco, illicit drug use, and lifestyle. | Retired automotive maintainer. Denies tobacco or illicit drug use; drinks one to two beers per day. He has a history of not taking his medications as directed. |
| Review of Systems | |
| A list of questions asked of every patient to uncover clinical symptoms not reported in the initial chief complaint. | Patient denies double or blurry vision, shortness of breath, or abdominal pain. Patient does admit to mild heart palpitations and general weakness. |
Abbreviations: CABG = coronary artery bypass graft; CAD = coronary artery disease; CHF = congestive heart failure; DM = diabetes mellitus; EMS = emergency medical services; HTN = hypertension; STEMI = ST-elevation myocardial infarction.
Objective Information
Presented in conjunction with the subjective information, objective evidence is measured by the healthcare team on the patient’s arrival to the medical facility. The amount and type of objective information the healthcare team collects will vary depending on the suspected diagnosis. Table 6-2 outlines example objective information that should be obtained from the patient’s chart and evaluated.
QUICK TIP
Students often make the mistake of including only abnormal laboratory results in the objective section of the case presentation. It is important to note that normal laboratory results, often called pertinent negatives, can be important pieces of information used to rule out potential problems and to assess the appropriateness of drug therapy.
CASE QUESTION
To prepare her assigned patient case for presentation, what information will E.S. need to gather and how should she begin organizing this information?
TABLE 6-2. OBJECTIVE INFORMATION
| OBJECTIVE INFORMATION | EXAMPLES |
| Patient Demographics | F.S. is a 63-year-old Caucasian male, 66 inches tall, weighing 105 kg. |
| Age | |
| Sex | |
| Race | |
| Height | |
| Weight | |
| Medication List | |
| Inpatient medications | Hospital medications |
| Nitroglycerin infusion at 200 mcg/min | |
| Hydralazine 20 mg q 6 hr prn SBP >160 mmHg | |
| Famotidine 20 mg IV q 12 hr | |
| Insulin aspart sliding scale q 6 hr | |
| Furosemide 20 mg IV q 12 hr | |
| 0.9% NS at 50 mL/hr | |
| Home medications | Home medications |
| Hydralazine 100 mg tid | |
| Procardia XL 60 mg once daily | |
| Catapres TTS-1 one patch weekly | |
| Simvastatin 20 mg daily | |
| Spironolactone 50 mg daily | |
| Isosorbide mononitrate 60 mg daily | |
| Clopidogrel 75 mg daily | |
| Humulin 70/30 50 units bid | |
| Allergies (including reactions) | |
| Drug or drug class | Penicillin (rash on trunk and extremities) |
| Inactive ingredients | Latex (hives) |
| Vital Signs | |
| Blood pressure | BP 222/170 |
| Heart rate | P 116 |
| Respiratory rate | RR 16 |
| Pulse oximetry | O2 saturation 98% |
| Temperature | Temperature 37.3°C |
| Physical Exam | General: Patient appears comfortable but remains confused |
| Examination by inspection, palpation, percussion, or auscultation | HEENT: Normal conjunctivae, pupils 3 mm and reactive |
| Respiratory: Clear to auscultation, no wheezes, rhonchi, or rales | |
| Cardiovascular: Tachycardic, no murmurs or rubs | |
| Abdominal: Obese, abdomen soft, nontender, positive bowel sounds | |
