Dr. Alberto J. Muniagurria

Numerous writings have been devoted to describing the paths to follow to obtain a medical history. Obtaining it is a fact and learning to write it is another. But perhaps most difficult is acquiring the ability to verbally present this information.

Presenting a clinical case is a permanent activity of the medical professional. In faculty exams, in hospital wards to department heads during ward passes, in guard changes for fellow doctors, with paramedical staff, in interconsultations, in anatomical clinical meetings, in audits medical, etc., etc.

Types of presentations

There are generally two forms of presentation:

The brief presentation that takes place in the hall passages and the formal presentation addressed to another doctor in an interconsultation, to a teacher in an examination, or in a conference. You need to be familiar with both types of presentations.

Presenting a clinical case is an art, and as such can be described only partially and learned only with practice, and improved with time and experience.

General plan for the presentation of a clinical case

I) Initial Concepts

The logical flow of the presentation will come from a good debriefing and physical exam with prewriting. This point hierarchies the importance of using the previous writing in the preparation of the presentations, and this should be done if possible the day before so that it gives a time of elaboration.

II) Preparation of Data for Presentation

a) Patient card (memory aid): It is a very useful element, since it allows summarizing the most important ideas in the medical history. It must be summarized, organized and recorded in an accessible and easy way to be transported from one side to the other. It should be written at the end of obtaining the medical history while the case is newly evaluated, or fresh in the memory. Especially at the beginning of the clinical experience, the patient's card can be used for presentation, unless the teacher requires to present the clinical case without memory aid notes.

b) Information to write down: At the beginning, it is useful to have a quantity of data on the card. Later, when the memory presentation runs more smoothly, it will still be helpful to carry the information listed below on a tab.


Patient Information

(age, sex, profession, religion and place of residence, etc.)


Introduction Phrase


Reason for Consultation and its duration (hours, days, months, etc.)


Current illness

  1. Write down important points using unique words that stimulate memory and allow you to tell the patient's story as you wish.
  2. Present the relevant negatives (eg, non-smoker).
  3. Exposing risk factors.
  4. Positive family history

Personal history

Record only active problems


Record and explain all kinds of reactions in case of drug allergy

Medications and habits

List all (including ethanol and tobacco), with doses

Interrogation by apparatus

Record only positive data that is significant (these will generally have been covered in the current disease)

Physical Examination findings

  1. Introductory phrase
  2. Vital signs
  3. Relevant positive findings only. 

Laboratory results

Expose all positive findings

List of Problems

Obtained from the corresponding section of the Medical Record

The above information should fit on an easily transportable index card unless the case is very complicated or the author has large print.

III) Presentation

The "synthetic" presentation is a quick 1-2 minute summary very often used in hall passages. It should be considered as a brief, guiding introduction for those members of the medical team who do not know the patient at all. Consider the "synthetic" presentation a summary of the patient card: it is the distillation of the first distillation.

Synthetic presentation in practical form

Practical points 

Introductory phrase


Reason for consultation and duration


Current illness

  • Often very condensed
  • Expand it if the teacher or head wishes
  • Summarize the current illness in a few sentences
  • Be guided by the symptoms and the times


  • Name the present and previous active medication with importance in relation to the history. 

Physical examination findings

  • Give the general condition of the patient: eg. good, favorable, stable, dangerous, comatose.
  • Establish: "stable vital signs" or comment on those that are not
  • Name only the definitive positive findings.

Positive laboratory tests that are linked to the table

  • Be brief: if there are laboratory tests that the teacher, head, or medical team wants to know, they will ask later. 


  • If the case is complicated, give a summary in one or two sentences

General principles concerning the short presentation

  1. Presentation is the skeleton or framework that enables those who receive the information to think intelligently about the case.
  2. Someone will always ask about something important missing from the presentation. As long as the above steps have been accomplished, a good job has been accomplished.
  3. Speak decisively and accurately.
  4. Mention current and probable problems: This is the time when the members of the medical staff in charge of the patient hear about them.
  5. When the information obtained has been provided to a third person, data should be provided, never conclusions such as "normal", or qualifying adjectives such as large, small, etc.

Using conclusions deprives listeners of the information they need to draw their own inferences and conclusions. You should not "influence" the idea itself, the information must be concrete, direct, objective, orderly, without leaving room for verbiage.


I will present the case of Mrs. Pérez, formally if you wish, but to give those who have not seen her a brief introduction: she is a 55-year-old white patient, seamstress, with a history of well-controlled diabetes, hypertension , hyperlipidemia, and rheumatoid arthritis that was admitted for weakness, cough, and fever for 2-3 days. At home she was receiving 80 units of NPH insulin and 15 units of crystalline per day. Take 120 mg. Verapamil per day, and Atromid S three times per day.

On physical examination today he shows a good general condition, with stable vital signs, a temperature of 38 ° C, isolated crackles in the right armpit. The rest of the physical examination is without particularities.

The laboratory includes a blood count with 12,000 white blood cells without deviation to the left, gram-negative cocci in a non-centrifuged urine sample (despite showing no symptoms of infection) and an infiltrate is observed radiologically in the right lower pulmonary lobe.

On the other hand, his sputum contained polymorphonuclear and gram positive diplococci. We believe that he had pneumonococcal pneumonia and has been started on 500 mg. IV ampicillin every 6 hours.

• The formal presentation is essentially a presentation along the lines of the "patient card" mentioned above.


Patient information and introductory phrase (this is a 37-year-old patient, seamstress, who comes to the consultation ... the religion, place of residence, etc. are mentioned if it has any link with the HC)

If the case is complicated, you may want to insert the phrase "with multiple medical problems"

Reason for Consultation and its Duration

In presentation, unlike writing, you should avoid using the patient's words. Instead, give a description that allows listeners to quickly focus on the problem at hand.

Current illness

Present a subscribed version of it and give positive findings that were found in the device interrogation section. Mention the relevant risk factors and Family History data.

Personal history

Mention previous hospitalizations and review other active medical problems.


Comment on any drug reaction.


Detail all current medication, with doses.

Apparatus and Systems Review

Name only positives that have not been mentioned during the current illness. Supposedly not linked to the reason for consultation.

Physical Examination Findings

Introductory phrase, describing appearance and condition.

  1. Vital signs are established for all patients (weight, temperature, and respiration).
  2. Positive findings. Anyone present may require a full physical examination, system by system, to be described, even if normal, but this is not necessary unless specifically requested.

Laboratory analysis

Just name the abnormal ones in this order: CBC, Urinalysis, Chemicals, ECG, Chest Rx and Supplementary Studies. If they were made, the normals can be mentioned, if they are believed to be significant.


Give a short summary in two sentences and then stop. The discussion of the case is started at this time. Clarify with the voice and the expression that is over. The attending physicians or the teacher will ask what therapy they used in the patient, and will begin by discussing specific questions regarding the medical case.


Practical points concerning case presentations

1. Areas often discussed during the presentation

Room passages with a teacher, family doctor, department head, team leader, etc., are often started with the presentation of the interned case the night before and continues, if time permits, with the discussion about the same. The purpose of the presentation is not to anticipate yourself by answering every question that will be asked.

Take the time to reflect on the case, read what you can, and first and foremost, understand the pathophysiology.

  • Pathophysiological mechanisms
  • Symptoms associated with the disease
  • Signs associated with the disease
  • Differential Diagnosis: Other diseases that can present in a similar way and important differential characteristics between these possibilities
  • Complications associated with the disease
  • Mechanism of action and side effects of any medication that the patient is taking or administered during this period

2. Other factors to consider in the presentation

Speed, not wasting time, but also not running through the presentation so quickly that the words are confused. A good rule of thumb is to try to relax and talk as if you were explaining a topic to friends.

Tone: Do not read the presentation.This is the most common cause of monotonous speech.

Pauses and Interruptions: Remember the last idea. If a discussion occurs while the case is being presented, write down where you are, listen and perhaps participate in the conversation, and be prepared to summarize the presentation, repeating the last sentence that was said when interrupted. The caller will generally ask to continue.

Enunciation, speak accurately. Do not say, ex: "140/90 for a blood pressure of 138/87."

Brevity, the summary presentation as noted above, should be brief. However, even the formal presentation should be short enough to keep listeners interested. Up to 6-7 minutes is a reasonable amount of time to wait for people to listen; if it is prolonged more, hearing is lost.

Condensation: When it is necessary to detail one or two problems, simply mention it, say that "you would like to go deeper." Condensing the presentation is preferable to making it too long. Describe problems in greater detail only in response to an audience request.

Omissions: Only positive and negative findings relevant to the differential diagnosis being presented should be described. In other words, omit details not relevant to the "argument" being constructed.

Physical Examination Findings: It is normal, especially at the beginning of medical training, to present unclear physical findings. Point out the findings, and if others disagree or differ, simply mention: "Another observer thought ..."

Conclusion: At the end of the presentation of the story, the physical examination and the laboratory data, summarize the case in one or two sentences for the listeners, focusing on the problem that is most relevant. For example: "in summary, Ms. de Pérez is a 55-year-old white woman with a history of diabetes, hypertension, hyperlipidemia, and rheumatoid arthritis who presented last night with probable pneumonococcal pneumonia."

Hospital Course: Most of the doctors participating in the presentation will discuss certain characteristics of the patient before asking about the patient's hospital course. It is reasonable to ask the teacher or GP after the presentation if he or she would like to hear what the patient's hospital course has been. For patients with multiple and active problems (that is, they are currently inconvenient) describe the hospital course in a problem-oriented way, for example, “first, regarding the patient's pneumonia… second, regarding to the high number of blood glucose when hospitalized ... ", etc.

Refutations at the patient's bedside: Sometimes the presentation will be made at the patient's bedside, and the patient will almost always be seen after it. Patients often refute the stories being told about them, or will correct them to a greater or lesser degree. This is not a personal attack; It happens frequently to each and every one who is in charge of the sick. This can provide a valuable new key. Since the person taking the story is at an advantage, having previously heard the patient's questioning, try to decipher what the patient has corrected. How was he or she previously misinterpreted? Then consider any implications of the rebuttal on how the case has been considered. Above all, don't panic.

Great science is simplified as it progresses; new concepts should provide clarity rather than add detail