patient case presentation example

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The Ultimate Patient Case Presentation Template for Med Students

• by Neelesh Bagrodia
• Apr 06, 2024
• Reviewed by: Amy Rontal, MD

Knowing how to deliver a patient presentation is one of the most important skills to learn on your journey to becoming a physician. After all, when you’re on a medical team, you’ll need to convey all the critical information about a patient in an organized manner without any gaps in knowledge transfer.

One big caveat: opinions about the correct way to present a patient are highly personal and everyone is slightly different. Additionally, there’s a lot of variation in presentations across specialties, and even for ICU vs floor patients.

My goal with this blog is to give you the most complete version of a patient presentation, so you can tailor your presentations to the preferences of your attending and team. So, think of what follows as a model for presenting any general patient.

Here’s a breakdown of what goes into the typical patient presentation.

7 Ingredients for a Patient Case Presentation Template

1. the one-liner.

The one-liner is a succinct sentence that primes your listeners to the patient.

A typical format is: “[Patient name] is a [age] year-old [gender] with past medical history of [X] presenting with [Y].

2. The Chief Complaint

This is a very brief statement of the patient’s complaint in their own words. A common pitfall is when medical students say that the patient had a chief complaint of some medical condition (like cholecystitis) and the attending asks if the patient really used that word!

An example might be, “Patient has chief complaint of difficulty breathing while walking.”

3. History of Present Illness (HPI)

The goal of the HPI is to illustrate the story of the patient’s complaint.

I remember when I first began medical school, I had a lot of trouble determining what was relevant and ended up giving a lot of extra details. Don’t worry if you have the same issue. With time, you’ll learn which details are important. 

The OPQRST Framework

In the beginning of your clinical experience, a helpful framework to use is OPQRST:

Describe when the issue started, and if it occurs during certain environmental or personal exposures.

P rovocative

Report if there are any factors that make the pain better or worse. These can be broad, like noting their shortness of breath worsened when lying flat, or their symptoms resolved during rest. 

Relay how the patient describes their pain or associated symptoms. For example, does the patient have a burning versus a pressure sensation? Are they feeling weakness, stiffness, or pain?

R egion/Location

Indicate where the pain is located and if it radiates anywhere.

Talk about how bad the pain is for the patient. Typically, a 0-10 pain scale is useful to provide some objective measure.

Discuss how long the pain lasts and how often it occurs.

A Case Study

While the OPQRST framework is great when starting out, it can be limiting.

Let’s take an example where the patient is not experiencing pain and comes in with altered mental status along with diffuse jaundice of the skin and a history of chronic liver disease. You will find that certain sections of OPQRST do not apply.

In this event, the HPI is still a story, but with a different framework. Try to go in chronological order. Include relevant details like if there have been any changes in medications, diet, or bowel movements.

Pertinent Positive and Negative Symptoms

Regardless of the framework you use, the name of the game is pertinent positive and negative symptoms the patient is experiencing.

I’d like to highlight the word “pertinent.” It’s less likely the patient’s chronic osteoarthritis and its management is related to their new onset shortness of breath, but it’s still important for knowing the patient’s complete medical picture. A better place to mention these details would be in the “Past Medical History” section, and reserve the HPI portion for more pertinent history.

As you become exposed to more illness scripts, experience will teach you which parts of the history are most helpful to state. Also, as you spend more time on the wards, you will pick up on which questions are relevant and important to ask during the patient interview.  

By painting a clear picture with pertinent positives and negatives during your presentation, the history will guide what may be higher or lower on the differential diagnosis.

Some other important components to add are the patient’s additional past medical/surgical history, family history, social history, medications, allergies, and immunizations.

The HEADSSS Method

Particularly, the social history is an important time to describe the patient as a complete person and understand how their life story may affect their present condition.

One way of organizing the social history is the HEADSSS method:

– H ome living situation and relationships – E ducation and employment – A ctivities and hobbies – D rug use (alcohol, tobacco, cocaine, etc.) Note frequency of use, and if applicable, be sure to add which types of alcohol consumption (like beer versus hard liquor) and forms of drug use. – S exual history (partners, STI history, pregnancy plans) – S uicidality and depression – S piritual and religious history  

Again, there’s a lot of variation in presenting social history, so just follow the lead of your team. For example, it’s not always necessary/relevant to obtain a sexual history, so use your judgment of the situation.

4. Review of Symptoms

Oftentimes, most elements of this section are embedded within the HPI. If there are any additional symptoms not mentioned in the HPI, it’s appropriate to state them here.

5. Objective

Vital signs.

Some attendings love to hear all five vital signs: temperature, blood pressure (mean arterial pressure if applicable), heart rate, respiratory rate, and oxygen saturation. Others are happy with “afebrile and vital signs stable.” Just find out their preference and stick to that. 

Physical Exam  

This is one of the most important parts of the patient presentation for any specialty. It paints a picture of how the patient looks and can guide acute management like in the case of a rigid abdomen. As discussed in the HPI section, typically you should report pertinent positives and negatives. When you’re starting out, your attending and team may prefer for you to report all findings as part of your learning.

For example, pulmonary exam findings can be reported as: “Regular chest appearance. No abnormalities on palpation. Lungs resonant to percussion. Clear to auscultation bilaterally without crackles, rhonchi, or wheezing.”

Typically, you want to report the physical exams in a head to toe format: General Appearance, Mental Status, Neurologic, Eyes/Ears/Nose/Mouth/Neck, Cardiovascular, Pulmonary, Breast, Abdominal, Genitourinary, Musculoskeletal, and Skin. Depending on the situation, additional exams can be incorporated as applicable.

Now comes reporting pertinent positive and negative labs. Several labs are often drawn upon admission. It’s easy to fall into the trap of reading off all the labs and losing everyone’s attention. Here are some pieces of advice: 

You normally can’t go wrong sticking to abnormal lab values. 

One qualification is that for a patient with concern for acute coronary syndrome, reporting a normal troponin is essential. Also, stating the normalization of previously abnormal lab values like liver enzymes is important.

Demonstrate trends in lab values.

A lab value is just a single point in time and does not paint the full picture. For example, a hemoglobin of 10g/dL in a patient at 15g/dL the previous day is a lot more concerning than a patient who has been stable at 10g/dL for a week.

Try to avoid editorializing in this section.

Save your analysis of the labs for the assessment section. Again, this can be a point of personal preference. In my experience, the team typically wants the raw objective data in this section.

This is also a good place to state the ins and outs of your patient (if applicable). In some patients, these metrics are strictly recorded and are typically reported as total fluid in and out over the past day followed by the net fluid balance. For example, “1L in, 2L out, net -1L over the past 24 hours.”

6. Diagnostics/Imaging

Next, you’ll want to review any important diagnostic tests and imaging. For example, describe how the EKG and echo look in a patient presenting with chest pain or the abdominal CT scan in a patient with right lower quadrant abdominal pain.

Try to provide your own interpretation to develop your skills and then include the final impression. Also, report if a diagnostic test is still pending.

7. Assessment/Plan

This is the fun part where you get to use your critical thinking (aka doctor) skills! For the scope of this blog, we’ll review a problem-based plan.

It’s helpful to begin with a summary statement that incorporates the one-liner, presenting issue(s)/diagnosis(es), and patient stability.

Then, go through all the problems relevant to the admission. You can impress your audience by casting a wide differential diagnosis and going through the elements of your patient presentation that support one diagnosis over another. 

Following your assessment, try to suggest a management plan. In a patient with congestive heart failure exacerbation, initiating a diuresis regimen and measuring strict ins/outs are good starting points.

You may even suggest a follow-up on their latest ejection fraction with an echo and check if they’re on guideline-directed medical therapy. Again, with more time on the clinical wards you’ll start to pick up on what management plan to suggest.

One pointer is to talk about all relevant problems, not just the presenting issue. For example, a patient with diabetes may need to be put on a sliding scale insulin regimen or another patient may require physical/occupational therapy. Just try to stay organized and be comprehensive.

A Note About Patient Presentation Skills

When you’re doing your first patient presentations, it’s common to feel nervous. There may be a lot of “uhs” and “ums.”

Here’s the good news: you don’t have to be perfect! You just need to make a good faith attempt and keep on going with the presentation.

With time, your confidence will build. Practice your fluency in the mirror when you have a chance. No one was born knowing medicine and everyone has gone through the same stages of learning you are!

Practice your presentation a couple times before you present to the team if you have time. Pull a resident aside if they have the bandwidth to make sure you have all the information you need. 

One big piece of advice: NEVER LIE. If you don’t know a specific detail, it’s okay to say, “I’m not sure, but I can look that up.” Someone on your team can usually retrieve the information while you continue on with your presentation.

Example Patient Case Presentation Template

Here’s a blank patient case presentation template that may come in handy. You can adapt it to best fit your needs.  

Chief Complaint:

History of Present Illness:

Past Medical History:

Past Surgical History:

Family History:

Social History:

Medications:

Immunizations:

Vital Signs : Temp ___ BP ___ /___ HR ___ RR ___ O2 sat ___

Physical Exam:

General Appearance:

Mental Status:

Neurological:

Eyes, Ears, Nose, Mouth, and Neck:

Cardiovascular:

Genitourinary:

Musculoskeletal:

Most Recent Labs:

Previous Labs:

Diagnostics/Imaging:

Impression/Interpretation:

Assessment/Plan:

One-line summary:

#Problem 1:

Assessment:

#Problem 2:

Final Thoughts on Patient Presentations

I hope this post demystified the patient presentation for you. Be sure to stay organized in your delivery and be flexible with the specifications your team may provide.  

Something I’d like to highlight is that you may need to tailor the presentation to the specialty you’re on. For example, on OB/GYN, it’s important to include a pregnancy history. Nonetheless, the aforementioned template should set you up for success from a broad overview perspective.  

Stay tuned for my next post on how to give an ICU patient presentation. And if you’d like me to address any other topics in a blog, write to me at [email protected] !

Looking for more (free!) content to help you through clinical rotations? Check out these other posts from Blueprint tutors on the Med School blog:

• How I Balanced My Clinical Rotations with Shelf Exam Studying
• How (and Why) to Use a Qbank to Prepare for USMLE Step 2
• How to Study For Shelf Exams: A Tutor’s Guide

About the Author

Hailing from Phoenix, AZ, Neelesh is an enthusiastic, cheerful, and patient tutor. He is a fourth year medical student at the Keck School of Medicine of the University of Southern California and serves as president for the Class of 2024. He is applying to surgery programs for residency. He also graduated as valedictorian of his high school and the USC Viterbi School of Engineering, obtaining a B.S. in Biomedical Engineering in 2020. He discovered his penchant for teaching when he began tutoring his friends for the SAT and ACT in the summer of 2015 out of his living room. Outside of the academic sphere, Neelesh enjoys surfing at San Onofre Beach and hiking in the Santa Monica Mountains. Twitter: @NeeleshBagrodia LinkedIn: http://www.linkedin.com/in/neelesh-bagrodia

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How to present patient cases

• Related content
• Peer review
• Mary Ni Lochlainn , foundation year 2 doctor 1 ,
• Ibrahim Balogun , healthcare of older people/stroke medicine consultant 1
• 1 East Kent Foundation Trust, UK

A guide on how to structure a case presentation

This article contains...

-History of presenting problem

-Medical and surgical history

-Drugs, including allergies to drugs

-Family history

-Social history

-Review of systems

-Findings on examination, including vital signs and observations

-Differential diagnosis/impression

-Investigations

-Management

Presenting patient cases is a key part of everyday clinical practice. A well delivered presentation has the potential to facilitate patient care and improve efficiency on ward rounds, as well as a means of teaching and assessing clinical competence. 1

The purpose of a case presentation is to communicate your diagnostic reasoning to the listener, so that he or she has a clear picture of the patient’s condition and further management can be planned accordingly. 2 To give a high quality presentation you need to take a thorough history. Consultants make decisions about patient care based on information presented to them by junior members of the team, so the importance of accurately presenting your patient cannot be overemphasised.

As a medical student, you are likely to be asked to present in numerous settings. A formal case presentation may take place at a teaching session or even at a conference or scientific meeting. These presentations are usually thorough and have an accompanying PowerPoint presentation or poster. More often, case presentations take place on the wards or over the phone and tend to be brief, using only memory or short, handwritten notes as an aid.

Everyone has their own presenting style, and the context of the presentation will determine how much detail you need to put in. You should anticipate what information your senior colleagues will need to know about the patient’s history and the care he or she has received since admission, to enable them to make further management decisions. In this article, I use a fictitious case to show how you can structure case presentations, which can be adapted to different clinical and teaching settings (box 1).

Box 1: Structure for presenting patient cases

Presenting problem, history of presenting problem, medical and surgical history.

Drugs, including allergies to drugs

Family history

Social history, review of systems.

Findings on examination, including vital signs and observations

Differential diagnosis/impression

Investigations

Case: tom murphy.

You should start with a sentence that includes the patient’s name, sex (Mr/Ms), age, and presenting symptoms. In your presentation, you may want to include the patient’s main diagnosis if known—for example, “admitted with shortness of breath on a background of COPD [chronic obstructive pulmonary disease].” You should include any additional information that might give the presentation of symptoms further context, such as the patient’s profession, ethnic origin, recent travel, or chronic conditions.

“ Mr Tom Murphy is a 56 year old ex-smoker admitted with sudden onset central crushing chest pain that radiated down his left arm.”

In this section you should expand on the presenting problem. Use the SOCRATES mnemonic to help describe the pain (see box 2). If the patient has multiple problems, describe each in turn, covering one system at a time.

Box 2: SOCRATES—mnemonic for pain

Associations

Time course

Exacerbating/relieving factors

“ The pain started suddenly at 1 pm, when Mr Murphy was at his desk. The pain was dull in nature, and radiated down his left arm. He experienced shortness of breath and felt sweaty and clammy. His colleague phoned an ambulance. He rated the pain 9/10 in severity. In the ambulance he was given GTN [glyceryl trinitrate] spray under the tongue, which relieved the pain to 5/10. The pain lasted 30 minutes in total. No exacerbating factors were noted. Of note: Mr Murphy is an ex-smoker with a 20 pack year history”

Some patients have multiple comorbidities, and the most life threatening conditions should be mentioned first. They can also be categorised by organ system—for example, “has a long history of cardiovascular disease, having had a stroke, two TIAs [transient ischaemic attacks], and previous ACS [acute coronary syndrome].” For some conditions it can be worth stating whether a general practitioner or a specialist manages it, as this gives an indication of its severity.

In a surgical case, colleagues will be interested in exercise tolerance and any comorbidity that could affect the patient’s fitness for surgery and anaesthesia. If the patient has had any previous surgical procedures, mention whether there were any complications or reactions to anaesthesia.

“Mr Murphy has a history of type 2 diabetes, well controlled on metformin. He also has hypertension, managed with ramipril, and gout. Of note: he has no history of ischaemic heart disease (relevant negative) (see box 3).”

Box 3: Relevant negatives

Mention any relevant negatives that will help narrow down the differential diagnosis or could be important in the management of the patient, 3 such as any risk factors you know for the condition and any associations that you are aware of. For example, if the differential diagnosis includes a condition that you know can be hereditary, a relevant negative could be the lack of a family history. If the differential diagnosis includes cardiovascular disease, mention the cardiovascular risk factors such as body mass index, smoking, and high cholesterol.

Highlight any recent changes to the patient’s drugs because these could be a factor in the presenting problem. Mention any allergies to drugs or the patient’s non-compliance to a previously prescribed drug regimen.

To link the medical history and the drugs you might comment on them together, either here or in the medical history. “Mrs Walsh’s drugs include regular azathioprine for her rheumatoid arthritis.”Or, “His regular drugs are ramipril 5 mg once a day, metformin 1g three times a day, and allopurinol 200 mg once a day. He has no known drug allergies.”

If the family history is unrelated to the presenting problem, it is sufficient to say “no relevant family history noted.” For hereditary conditions more detail is needed.

“ Mr Murphy’s father experienced a fatal myocardial infarction aged 50.”

Social history should include the patient’s occupation; their smoking, alcohol, and illicit drug status; who they live with; their relationship status; and their sexual history, baseline mobility, and travel history. In an older patient, more detail is usually required, including whether or not they have carers, how often the carers help, and if they need to use walking aids.

“He works as an accountant and is an ex-smoker since five years ago with a 20 pack year history. He drinks about 14 units of alcohol a week. He denies any illicit drug use. He lives with his wife in a two storey house and is independent in all activities of daily living.”

Do not dwell on this section. If something comes up that is relevant to the presenting problem, it should be mentioned in the history of the presenting problem rather than here.

“Systems review showed long standing occasional lower back pain, responsive to paracetamol.”

Findings on examination

Initially, it can be useful to practise presenting the full examination to make sure you don’t leave anything out, but it is rare that you would need to present all the normal findings. Instead, focus on the most important main findings and any abnormalities.

“On examination the patient was comfortable at rest, heart sounds one and two were heard with no additional murmurs, heaves, or thrills. Jugular venous pressure was not raised. No peripheral oedema was noted and calves were soft and non-tender. Chest was clear on auscultation. Abdomen was soft and non-tender and normal bowel sounds were heard. GCS [Glasgow coma scale] was 15, pupils were equal and reactive to light [PEARL], cranial nerves 1-12 were intact, and he was moving all four limbs. Observations showed an early warning score of 1 for a tachycardia of 105 beats/ min. Blood pressure was 150/90 mm Hg, respiratory rate 18 breaths/min, saturations were 98% on room air, and he was apyrexial with a temperature of 36.8 ºC.”

Differential diagnoses

Mentioning one or two of the most likely diagnoses is sufficient. A useful phrase you can use is, “I would like to rule out,” especially when you suspect a more serious cause is in the differential diagnosis. “History and examination were in keeping with diverticular disease; however, I would like to rule out colorectal cancer in this patient.”

Remember common things are common, so try not to mention rare conditions first. Sometimes it is acceptable to report investigations you would do first, and then base your differential diagnosis on what the history and investigation findings tell you.

“My impression is acute coronary syndrome. The differential diagnosis includes other cardiovascular causes such as acute pericarditis, myocarditis, aortic stenosis, aortic dissection, and pulmonary embolism. Possible respiratory causes include pneumonia or pneumothorax. Gastrointestinal causes include oesophageal spasm, oesophagitis, gastro-oesophageal reflux disease, gastritis, cholecystitis, and acute pancreatitis. I would also consider a musculoskeletal cause for the pain.”

This section can include a summary of the investigations already performed and further investigations that you would like to request. “On the basis of these differentials, I would like to carry out the following investigations: 12 lead electrocardiography and blood tests, including full blood count, urea and electrolytes, clotting screen, troponin levels, lipid profile, and glycated haemoglobin levels. I would also book a chest radiograph and check the patient’s point of care blood glucose level.”

You should consider recommending investigations in a structured way, prioritising them by how long they take to perform and how easy it is to get them done and how long it takes for the results to come back. Put the quickest and easiest first: so bedside tests, electrocardiography, followed by blood tests, plain radiology, then special tests. You should always be able to explain why you would like to request a test. Mention the patient’s baseline test values if they are available, especially if the patient has a chronic condition—for example, give the patient’s creatinine levels if he or she has chronic kidney disease This shows the change over time and indicates the severity of the patient’s current condition.

“To further investigate these differentials, 12 lead electrocardiography was carried out, which showed ST segment depression in the anterior leads. Results of laboratory tests showed an initial troponin level of 85 µg/L, which increased to 1250 µg/L when repeated at six hours. Blood test results showed raised total cholesterol at 7.6 mmol /L and nil else. A chest radiograph showed clear lung fields. Blood glucose level was 6.3 mmol/L; a glycated haemoglobin test result is pending.”

Dependent on the case, you may need to describe the management plan so far or what further management you would recommend.“My management plan for this patient includes ACS [acute coronary syndrome] protocol, echocardiography, cardiology review, and treatment with high dose statins. If you are unsure what the management should be, you should say that you would discuss further with senior colleagues and the patient. At this point, check to see if there is a treatment escalation plan or a “do not attempt to resuscitate” order in place.

“Mr Murphy was given ACS protocol in the emergency department. An echocardiogram has been requested and he has been discussed with cardiology, who are going to come and see him. He has also been started on atorvastatin 80 mg nightly. Mr Murphy and his family are happy with this plan.”

The summary can be a concise recap of what you have presented beforehand or it can sometimes form a standalone presentation. Pick out salient points, such as positive findings—but also draw conclusions from what you highlight. Finish with a brief synopsis of the current situation (“currently pain free”) and next step (“awaiting cardiology review”). Do not trail off at the end, and state the diagnosis if you are confident you know what it is. If you are not sure what the diagnosis is then communicate this uncertainty and do not pretend to be more confident than you are. When possible, you should include the patient’s thoughts about the diagnosis, how they are feeling generally, and if they are happy with the management plan.

“In summary, Mr Murphy is a 56 year old man admitted with central crushing chest pain, radiating down his left arm, of 30 minutes’ duration. His cardiac risk factors include 20 pack year smoking history, positive family history, type 2 diabetes, and hypertension. Examination was normal other than tachycardia. However, 12 lead electrocardiography showed ST segment depression in the anterior leads and troponin rise from 85 to 250 µg/L. Acute coronary syndrome protocol was initiated and a diagnosis of NSTEMI [non-ST elevation myocardial infarction] was made. Mr Murphy is currently pain free and awaiting cardiology review.”

Originally published as: Student BMJ 2017;25:i4406

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed

• ↵ Green EH, Durning SJ, DeCherrie L, Fagan MJ, Sharpe B, Hershman W. Expectations for oral case presentations for clinical clerks: opinions of internal medicine clerkship directors. J Gen Intern Med 2009 ; 24 : 370 - 3 . doi:10.1007/s11606-008-0900-x   pmid:19139965 . OpenUrl CrossRef PubMed Web of Science
• ↵ Olaitan A, Okunade O, Corne J. How to present clinical cases. Student BMJ 2010;18:c1539.
• ↵ Gaillard F. The secret art of relevant negatives, Radiopedia 2016; http://radiopaedia.org/blog/the-secret-art-of-relevant-negatives .

Tools for the Patient Presentation

The formal patient presentation.

• Posing the Clinical Question
• Searching the Medical Literature for EBM

Sources & Further Reading

First Aid for the Wards

Lingard L, Haber RJ.  Teaching and learning communications in medicine: a rhetorical approach .  Academic Medicine. 74(5):507-510 1999 May.

Lingard L, Haber RJ.  What do we mean by "relevance"? A clinical and rhetorical definition with implications for teaching and learning the case-presentation format . Academic Medicine. 74(10):S124-S127.

The Oral Presentation (A Practical Guide to Clinical Medicine, UCSD School of Medicine)  http://meded.ucsd.edu/clinicalmed/oral.htm

"Classically, the formal oral presentation is given in 7 minutes or less. Although it follows the same format as a written report, it is not simply regurgitation. A great presentation requires style as much as substance; your delivery must be succinct and smooth. No time should be wasted on superfluous information; one can read about such matters later in your admit note. Ideally, your presentation should be formulated so that your audience can anticipate your assessment and plan; that is, each piece of information should clue the listener into your thinking process and your most likely diagnosis."  [ Le, et al, p. 15 ]

Types of Patient Presentations

New Patient

New patients get the traditional H&P with assessment and plan.  Give the chief complaint and a brief and pertinent HPI.  Next give important PMH, PSH, etc.  The ROS is often left out, as anything important was in the HPI.  The PE is reviewed.  Only give pertinent positives and negatives.  The assessment and plan should include what you think is wrong and, briefly, why.  Then, state what you plan to do for the patient, including labs.  Be sure to know why things are being done: you will be asked.

The follow-up presentation differs from the presentation of a new patient.  It is an abridged presentation, perhaps referencing major patient issues that have been previously presented, but focusing on new information about these issues and/or what has changed. Give the patient’s name, age, date of admission, briefly review the present illness, physical examination and admitting diagnosis.  Then report any new finding, laboratory tests, diagnostic procedures and changes in medications.

The attending physician will ask the patient’s permission to have the medical student present their case.  After making the proper introductions the attending will let the patient know they may offer input or ask questions at any point.  When presenting at bedside the student should try to involve the patient.

Preparing for the Presentation

There are four things you must consider before you do your oral presentation

• Occasion (setting and circumstances)

Ask yourself what do you want the presentation to do

• Present a new patient to your preceptor : the amount of detail will be determined by your preceptor.  It is also likely to reflect your development and experience, with less detail being required as you progress.
• Present your patient at working or teaching rounds : the amount of detail will be determined by the customs of the group. The focus of the presentation will be influenced by the learning objectives of working responsibilities of the group.
• Request a consultant’s advice on a clinical problem : the presentation will be focused on the clinical question being posed to the consultant.
• Persuade others about a diagnosis and plan : a shorter presentation which highlights the pertinent positives and negatives that are germane to the diagnosis and/or plan being suggested.
• Enlist cooperation required for patient care : a short presentation focusing on the impact your audience can have in addressing the patient’s issues.

Preparation

• Patient evaluation : history, physical examination, review of tests, studies, procedures, and consultants’ recommendations.
• Selected reading : reference texts; to build a foundational understanding.
• Literature search : for further elucidation of any key references from selected reading, and to bring your understanding up to date, since reference text information is typically three to seven years old.
• Write-up : for oral presentation, just succinct notes to serve as a reminder or reference, since you’re not going to be reading your presentation.

Knowledge (Be prepared to answer questions about the following)

• Pathophysiology
• Complications
• Differential diagnosis
• Course of conditions
• Diagnostic tests
• Medications
• Essential Evidence Plus

Template for Oral Presentations

Chief Complaint (CC)

The opening statement should give an overview of the patient, age, sex, reason for visit and the duration of the complaint. Give marital status, race, or occupation if relevant.  If your patient has a history of a major medical problem that bears strongly on the understanding of the present illness, include it.  For ongoing care, give a one sentence recap of the history.

History of Present Illness (HPI)

This will be very similar to your written HPI. Present the most important problem first. If there is more than one problem, treat each separately. Present the information chronologically.  Cover one system before going onto the next. Characterize the chief complaint – quality, severity, location, duration, progression, and include pertinent negatives. Items from the ROS that are unrelated to the present problem may be mentioned in passing unless you are doing a very formal presentation. When you do your first patient presentation you may be expected to go into detail.  For ongoing care, present any new complaints.

Review of Systems (ROS)

Most of the ROS is incorporated at the end of the HPI. Items that are unrelated to the present problem may be briefly mentioned.  For ongoing care, present only if new complaints.  

Past Medical History (PMH)

Discuss other past medical history that bears directly on the current medical problem.  For ongoing care, have the information available to respond to questions.

Past Surgical History

Provide names of procedures, approximate dates, indications, any relevant findings or complications, and pathology reports, if applicable.  For ongoing care, have the information available to respond to questions.

Allergies/Medications

Present all current medications along with dosage, route and frequency. For the follow-up presentation just give any changes in medication.  For ongoing care, note any changes.

Smoking and Alcohol (and any other substance abuse)

Note frequency and duration. For ongoing care, have the information available to respond to questions.

Social/Work History

Home, environment, work status and sexual history.  For ongoing care, have the information available to respond to questions.

Family History Note particular family history of genetically based diseases.  For ongoing care, have the information available to respond to questions.

Physical Exam/Labs/Other Tests

Include all significant abnormal findings and any normal findings that contribute to the diagnosis. Give a brief, general description of the patient including physical appearance. Then describe vital signs touching on each major system. Try to find out in advance how thorough you need to be for your presentation. There are times when you will be expected to give more detail on each physical finding, labs and other test results.  For ongoing care, mention only further positive findings and relevant negative findings.

Assessment and Plan

Give a summary of the important aspects of the history, physical exam and formulate the differential diagnosis. Make sure to read up on the patient’s case by doing a search of the literature. 

• Include only the most essential facts; but be ready to answer ANY questions about all aspects of your patient.
• Keep your presentation lively.
• Do not read the presentation!
• Expect your listeners to ask questions.
• Follow the order of the written case report.
• Keep in mind the limitation of your listeners.
• Beware of jumping back and forth between descriptions of separate problems.
• Use the presentation to build your case.
• Your reasoning process should help the listener consider a differential diagnosis.
• Present the patient as well as the illness .
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How to make an oral case presentation to healthcare colleagues

The content and delivery of a patient case for education and evidence-based care discussions in clinical practice.

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A case presentation is a detailed narrative describing a specific problem experienced by one or more patients. Pharmacists usually focus on the medicines aspect , for example, where there is potential harm to a patient or proven benefit to the patient from medication, or where a medication error has occurred. Case presentations can be used as a pedagogical tool, as a method of appraising the presenter’s knowledge and as an opportunity for presenters to reflect on their clinical practice [1] .

The aim of an oral presentation is to disseminate information about a patient for the purpose of education, to update other members of the healthcare team on a patient’s progress, and to ensure the best, evidence-based care is being considered for their management.

Within a hospital, pharmacists are likely to present patients on a teaching or daily ward round or to a senior pharmacist or colleague for the purpose of asking advice on, for example, treatment options or complex drug-drug interactions, or for referral.

Content of a case presentation

As a general structure, an oral case presentation may be divided into three phases [2] :

• Reporting important patient information and clinical data;
• Analysing and synthesising identified issues (this is likely to include producing a list of these issues, generally termed a problem list);
• Managing the case by developing a therapeutic plan.

Specifically, the following information should be included [3] :

Patient and complaint details

Patient details: name, sex, age, ethnicity.

Presenting complaint: the reason the patient presented to the hospital (symptom/event).

History of presenting complaint: highlighting relevant events in chronological order, often presented as how many days ago they occurred. This should include prior admission to hospital for the same complaint.

Review of organ systems: listing positive or negative findings found from the doctor’s assessment that are relevant to the presenting complaint.

Past medical and surgical history

Social history: including occupation, exposures, smoking and alcohol history, and any recreational drug use.

Medication history, including any drug allergies: this should include any prescribed medicines, medicines purchased over-the-counter, any topical preparations used (including eye drops, nose drops, inhalers and nasal sprays) and any herbal or traditional remedies taken.

Sexual history: if this is relevant to the presenting complaint.

Details from a physical examination: this includes any relevant findings to the presenting complaint and should include relevant observations.

Laboratory investigation and imaging results: abnormal findings are presented.

Assessment: including differential diagnosis.

Plan: including any pharmaceutical care issues raised and how these should be resolved, ongoing management and discharge planning.

Any discrepancies between the current management of the patient’s conditions and evidence-based recommendations should be highlighted and reasons given for not adhering to evidence-based medicine ( see ‘Locating the evidence’ ).

Locating the evidence

The evidence base for the therapeutic options available should always be considered. There may be local guidance available within the hospital trust directing the management of the patient’s presenting condition. Pharmacists often contribute to the development of such guidelines, especially if medication is involved. If no local guidelines are available, the next step is to refer to national guidance. This is developed by a steering group of experts, for example, the British HIV Association or the National Institute for Health and Care Excellence . If the presenting condition is unusual or rare, for example, acute porphyria, and there are no local or national guidelines available, a literature search may help locate articles or case studies similar to the case.

Giving a case presentation

Currently, there are no available acknowledged guidelines or systematic descriptions of the structure, language and function of the oral case presentation [4] and therefore there is no standard on how the skills required to prepare or present a case are taught. Most individuals are introduced to this concept at undergraduate level and then build on their skills through practice-based learning.

A case presentation is a narrative of a patient’s care, so it is vital the presenter has familiarity with the patient, the case and its progression. The preparation for the presentation will depend on what information is to be included.

Generally, oral case presentations are brief and should be limited to 5–10 minutes. This may be extended if the case is being presented as part of an assessment compared with routine everyday working ( see ‘Case-based discussion’ ). The audience should be interested in what is being said so the presenter should maintain this engagement through eye contact, clear speech and enthusiasm for the case.

It is important to stick to the facts by presenting the case as a factual timeline and not describing how things should have happened instead. Importantly, the case should always be concluded and should include an outcome of the patient’s care [5] .

An example of an oral case presentation, given by a pharmacist to a doctor,  is available here .

A successful oral case presentation allows the audience to garner the right amount of patient information in the most efficient way, enabling a clinically appropriate plan to be developed. The challenge lies with the fact that the content and delivery of this will vary depending on the service, and clinical and audience setting [3] . A practitioner with less experience may find understanding the balance between sufficient information and efficiency of communication difficult, but regular use of the oral case presentation tool will improve this skill.

Tailoring case presentations to your audience

Most case presentations are not tailored to a specific audience because the same type of information will usually need to be conveyed in each case.

However, case presentations can be adapted to meet the identified learning needs of the target audience, if required for training purposes. This method involves varying the content of the presentation or choosing specific cases to present that will help achieve a set of objectives [6] . For example, if a requirement to learn about the management of acute myocardial infarction has been identified by the target audience, then the presenter may identify a case from the cardiology ward to present to the group, as opposed to presenting a patient reviewed by that person during their normal working practice.

Alternatively, a presenter could focus on a particular condition within a case, which will dictate what information is included. For example, if a case on asthma is being presented, the focus may be on recent use of bronchodilator therapy, respiratory function tests (including peak expiratory flow rate), symptoms related to exacerbation of airways disease, anxiety levels, ability to talk in full sentences, triggers to worsening of symptoms, and recent exposure to allergens. These may not be considered relevant if presenting the case on an unrelated condition that the same patient has, for example, if this patient was admitted with a hip fracture and their asthma was well controlled.

Case-based discussion

The oral case presentation may also act as the basis of workplace-based assessment in the form of a case-based discussion. In the UK, this forms part of many healthcare professional bodies’ assessment of clinical practice, for example, medical professional colleges.

For pharmacists, a case-based discussion forms part of the Royal Pharmaceutical Society (RPS) Foundation and Advanced Practice assessments . Mastery of the oral case presentation skill could provide useful preparation for this assessment process.

A case-based discussion would include a pharmaceutical needs assessment, which involves identifying and prioritising pharmaceutical problems for a particular patient. Evidence-based guidelines relevant to the specific medical condition should be used to make treatment recommendations, and a plan to monitor the patient once therapy has started should be developed. Professionalism is an important aspect of case-based discussion — issues must be prioritised appropriately and ethical and legal frameworks must be referred to [7] . A case-based discussion would include broadly similar content to the oral case presentation, but would involve further questioning of the presenter by the assessor to determine the extent of the presenter’s knowledge of the specific case, condition and therapeutic strategies. The criteria used for assessment would depend on the level of practice of the presenter but, for pharmacists, this may include assessment against the RPS  Foundation or Pharmacy Frameworks .

Acknowledgement

With thanks to Aamer Safdar for providing the script for the audio case presentation.

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[1] Onishi H. The role of case presentation for teaching and learning activities. Kaohsiung J Med Sci 2008;24:356–360. doi: 10.1016/s1607-551x(08)70132–3

[2] Edwards JC, Brannan JR, Burgess L et al . Case presentation format and clinical reasoning: a strategy for teaching medical students. Medical Teacher 1987;9:285–292. doi: 10.3109/01421598709034790

[3] Goldberg C. A practical guide to clinical medicine: overview and general information about oral presentation. 2009. University of California, San Diego. Available from: https://meded.ecsd.edu/clinicalmed.oral.htm (accessed 5 December 2015)

[4] Chan MY. The oral case presentation: toward a performance-based rhetorical model for teaching and learning. Medical Education Online 2015;20. doi: 10.3402/meo.v20.28565

[5] McGee S. Medicine student programs: oral presentation guidelines. Learning & Scholarly Technologies, University of Washington. Available from: https://catalyst.uw.edu/workspace/medsp/30311/202905 (accessed 7 December 2015)

[6] Hays R. Teaching and Learning in Clinical Settings. 2006;425. Oxford: Radcliffe Publishing Ltd.

[7] Royal Pharmaceutical Society. Tips for assessors for completing case-based discussions. 2015. Available from: http://www.rpharms.com/help/case_based_discussion.htm (accessed 30 December 2015)

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Top 7 Medical Case Presentation Templates with Samples and Examples

Sarojit Hazra

How does information expand beyond essential recollection? Facts alone can diminish in value over time. Context and implementation are crucial to form deep connections and roots. Here comes the role of case studies for clinical personnel in the medical field.

In the always-growing healthcare industry, medical case presentation is essential as it is a suggestion for new researchers. A medical case study is a report where a medical practitioner shares a patient's case. It comprises every detail related to patients. It is beneficial for describing a new medical condition, management options, or treatment for diseases.

Medical case presentations contribute significantly to the evolution of medical knowledge and research.

Case study analysis is essential for every business or industry, like the medical industry. It helps in managing the twists and turns of the industry. Want to take some ideas? Have a look at SlideTeam’s blog Case Analysis Templates .

Let us highlight some significant benefits of medical case presentation:

• Case study presentations are extremely good at depicting realistic clinical frameworks.
• It helps to enhance student participation alongside the joy of learning.
• These are ideal for sharing the latest information on the clinical landscape.
• It promotes critical thinking.
• It can also make better clinical outcomes.

If you are in the healthcare sector, another important tool is the medical dashboard. For a deeper insight, quickly take a look at Medical dashboard Templates .

Each of the slides is 100% editable and customizable. The 100% customizable nature of the templates allows you to edit your presentations. The content-ready slides give you the much-needed structure. Below, let’s explore a wide array of ready to use, content ready medical case presentation templates fit for your organization.

Template 1: Case Study on Blockchain Application in Healthcare: Medical Staff Credential Verification

Blockchain is becoming a potential solution to verify medical credentials. Though these are open to the public, they can be restricted through permissions. Are you finding it difficult to understand and implement? SlideTeam introduces this PPT Template that highlights how to operationalize medical staff verification process using blockchain technology. It explains that healthcare-based systems can also be used to verify the credentials of medical staff. Solutions-based blockchain to track the experiences of medical professionals. The PPT slides are designed with suitable icons, designs, graphs and other relevant material. Grab it quickly and draft your case study as per the client’s requirements.

Click to Download

Template 2: Cost Benefits IOT Digital Twins Implementation Use Cases in the Medical Domain

This PPT template is designed to focus on the use cases in the medical domain, including research and development, diagnosis, surgery, medical equipment, etc. The slide offers a brief description of the mentioned use cases to understand the scenario better. Use it as an essential tool and captivate your audience. Get it Now!

Template 3: Major Use Cases for Tracking Medical Assets Asset Tracking and Management IoT 

Want to simplify medical complexities? The asset tracking solution is here to accompany you. It enables the medical sector to locate patients, clinicians, and medications more accurately and quickly. IoT development has made this task much more accessible by guiding you through every significant aspect of a medical asset-tracking solution. Introducing our slide exhibiting use cases of medical tools that can be tracked with IoT technology . Medical assets, including medical tools, medical equipment tracking, medications , etc., are shown in the layout with their use cases and impacts. Each topic is depicted in separate tables with appropriate icons.

Template 4: AIoT Healthcare Applications in Medical Imaging

AIoT is making the medical sector smarter and wiser to improve data management and human-machine interaction. When AIoT is applied to healthcare, enables virtual monitoring and accurate diagnosis of patients to develop a personalized patient experience. Here, we introduce our premium PPT Templates showcasing applications of Artificial Intelligence of Things (AIoT) in radiology. You can provide detailed information about remote diagnosis , personalized treatment , and real-time monitoring. Adapt it now to increase your presentation threshold and educate your audience.

Template 5: Case Study of Leading Medical Devices Manufacturing Organization

An array of disruptive themes is shaping the medical device industry, and cloud computing is one of them. Soon, cloud computing will have a more significant impact on this industry. So, for your convenience, we are presenting our slide covering a case study of blue cloud with lending medical devices manufacturing organization. It covers significant topics like client objective, problem, our solution, and results chronologically. Consisting of three essential stages, this template is excellent for educating and enticing your audience.

Template 6: IoT Technology Use Case for Medical Treatment

IoT, or the Internet of Things, is gaining significance across industries, and the medical sector is no exception. It has taken medical treatment to a new level. This custom-built PowerPoint Template exhibits the use of IoT technology in domains of the healthcare industry. It provides a digital solution for patient treatment. The key elements are primary care, acute care, virtual hospital, etc., which are depicted along with descriptions, benefits, and additional comments. Each illustration is highlighted, colored and has a relevant icon for instantaneous identification. 

Template 7: IoT Medical Healthcare Technology Use Cases

The transformation of healthcare into digital healthcare has resulted in the rise of IoMT, or medical IoT . It refers to connected devices in medical healthcare and has become one of the fastest-growing industries in the IoT market. It would help if you dived deeper to manage, monitor, and preserve IoT devices in medical healthcare. This PPT presentation demonstrates uses of IoT Medical Healthcare Technology in monitoring patient health. Moreover, the slide includes remote patient monitoring, reduced waiting time, identifying chronic diseases, and drug management. Download this template design and present your case study with ultimate professionalism.

HEALTH CONSULTATION WILL BE QUICKER, SAFER AND SECURE

Case studies have a great history as an educational tool for clinicians. These are highly beneficial for nurturing deeper insights and learning. Access to such visually appealing and comprehensively presented Top 7 Medical Case Presentation Templates enables medical professionals to quickly present their patients' case studies. Be it tracking of medical assets, application of IoT in the clinical field, IoT medical healthcare technology uses, and so on, these templates serve as essential equipment in implementing all.

P.S. For perfection and success, you should dig into SlideTeam's fantastic blog, Medical Report Templates .

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Patient Case Presentation

Figure 1.  Blue and silver stethoscope (Pixabay, N.D.)

Ms. S.W. is a 48-year-old white female who presented to an outpatient community mental health agency for evaluation of depressive symptoms. Over the past eight weeks she has experienced sad mood every day, which she describes as a feeling of hopelessness and emptiness. She also noticed other changes about herself, including decreased appetite, insomnia, fatigue, and poor ability to concentrate. The things that used to bring Ms. S.W. joy, such as gardening and listening to podcasts, are no longer bringing her the same happiness they used to. She became especially concerned as within the past two weeks she also started experiencing feelings of worthlessness, the perception that she is a burden to others, and fleeting thoughts of death/suicide.

Ms. S.W. acknowledges that she has numerous stressors in her life. She reports that her daughter’s grades have been steadily declining over the past two semesters and she is unsure if her daughter will be attending college anymore. Her relationship with her son is somewhat strained as she and his father are not on good terms and her son feels Ms. S.W. is at fault for this. She feels her career has been unfulfilling and though she’d like to go back to school, this isn’t possible given the family’s tight finances/the patient raising a family on a single income.

Ms. S.W. has experienced symptoms of depression previously, but she does not think the symptoms have ever been as severe as they are currently. She has taken antidepressants in the past and was generally adherent to them, but she believes that therapy was more helpful than the medications. She denies ever having history of manic or hypomanic episodes. She has been unable to connect to a mental health agency in several years due to lack of time and feeling that she could manage the symptoms on her own. She now feels that this is her last option and is looking for ongoing outpatient mental health treatment.

Past Medical History

• Hypertension, diagnosed at age 41

Past Surgical History

• Wisdom teeth extraction, age 22

Pertinent Family History

• Mother with history of Major Depressive Disorder, treated with antidepressants
• Maternal grandmother with history of Major Depressive Disorder, Generalized Anxiety Disorder
• Brother with history of suicide attempt and subsequent inpatient psychiatric hospitalization,
• Brother with history of Alcohol Use Disorder
• Father died from lung cancer (2012)

Pertinent Social History

• Works full-time as an enrollment specialist for Columbus City Schools since 2006
• Has two children, a daughter age 17 and a son age 14
• Divorced in 2015, currently single
• History of some emotional abuse and neglect from mother during childhood, otherwise denies history of trauma, including physical and sexual abuse
• Smoking 1/2 PPD of cigarettes
• Occasional alcohol use (approximately 1-2 glasses of wine 1-2 times weekly; patient had not had any alcohol consumption for the past year until two weeks ago)

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Case study: 33-year-old female presents with chronic sob and cough.

Sandeep Sharma ; Muhammad F. Hashmi ; Deepa Rawat .

Affiliations

Last Update: February 20, 2023 .

• Case Presentation

History of Present Illness:  A 33-year-old white female presents after admission to the general medical/surgical hospital ward with a chief complaint of shortness of breath on exertion. She reports that she was seen for similar symptoms previously at her primary care physician’s office six months ago. At that time, she was diagnosed with acute bronchitis and treated with bronchodilators, empiric antibiotics, and a short course oral steroid taper. This management did not improve her symptoms, and she has gradually worsened over six months. She reports a 20-pound (9 kg) intentional weight loss over the past year. She denies camping, spelunking, or hunting activities. She denies any sick contacts. A brief review of systems is negative for fever, night sweats, palpitations, chest pain, nausea, vomiting, diarrhea, constipation, abdominal pain, neural sensation changes, muscular changes, and increased bruising or bleeding. She admits a cough, shortness of breath, and shortness of breath on exertion.

Social History: Her tobacco use is 33 pack-years; however, she quit smoking shortly prior to the onset of symptoms, six months ago. She denies alcohol and illicit drug use. She is in a married, monogamous relationship and has three children aged 15 months to 5 years. She is employed in a cookie bakery. She has two pet doves. She traveled to Mexico for a one-week vacation one year ago.

Allergies:  No known medicine, food, or environmental allergies.

Past Medical History: Hypertension

Past Surgical History: Cholecystectomy

Medications: Lisinopril 10 mg by mouth every day

Physical Exam:

Vitals: Temperature, 97.8 F; heart rate 88; respiratory rate, 22; blood pressure 130/86; body mass index, 28

General: She is well appearing but anxious, a pleasant female lying on a hospital stretcher. She is conversing freely, with respiratory distress causing her to stop mid-sentence.

Respiratory: She has diffuse rales and mild wheezing; tachypneic.

Cardiovascular: She has a regular rate and rhythm with no murmurs, rubs, or gallops.

Gastrointestinal: Bowel sounds X4. No bruits or pulsatile mass.

• Initial Evaluation

Laboratory Studies:  Initial work-up from the emergency department revealed pancytopenia with a platelet count of 74,000 per mm3; hemoglobin, 8.3 g per and mild transaminase elevation, AST 90 and ALT 112. Blood cultures were drawn and currently negative for bacterial growth or Gram staining.

Chest X-ray

Impression:  Mild interstitial pneumonitis

• Differential Diagnosis
• Aspiration pneumonitis and pneumonia
• Bacterial pneumonia
• Immunodeficiency state and Pneumocystis jiroveci pneumonia
• Carcinoid lung tumors
• Tuberculosis
• Viral pneumonia
• Chlamydial pneumonia
• Coccidioidomycosis and valley fever
• Recurrent Legionella pneumonia
• Mediastinal cysts
• Mediastinal lymphoma
• Recurrent mycoplasma infection
• Pancoast syndrome
• Pneumococcal infection
• Sarcoidosis
• Small cell lung cancer
• Aspergillosis
• Blastomycosis
• Histoplasmosis
• Actinomycosis
• Confirmatory Evaluation

CT of the chest was performed to further the pulmonary diagnosis; it showed a diffuse centrilobular micronodular pattern without focal consolidation.

On finding pulmonary consolidation on the CT of the chest, a pulmonary consultation was obtained. Further history was taken, which revealed that she has two pet doves. As this was her third day of broad-spectrum antibiotics for a bacterial infection and she was not getting better, it was decided to perform diagnostic bronchoscopy of the lungs with bronchoalveolar lavage to look for any atypical or rare infections and to rule out malignancy (Image 1).

Bronchoalveolar lavage returned with a fluid that was cloudy and muddy in appearance. There was no bleeding. Cytology showed Histoplasma capsulatum .

Based on the bronchoscopic findings, a diagnosis of acute pulmonary histoplasmosis in an immunocompetent patient was made.

Pulmonary histoplasmosis in asymptomatic patients is self-resolving and requires no treatment. However, once symptoms develop, such as in our above patient, a decision to treat needs to be made. In mild, tolerable cases, no treatment other than close monitoring is necessary. However, once symptoms progress to moderate or severe, or if they are prolonged for greater than four weeks, treatment with itraconazole is indicated. The anticipated duration is 6 to 12 weeks total. The response should be monitored with a chest x-ray. Furthermore, observation for recurrence is necessary for several years following the diagnosis. If the illness is determined to be severe or does not respond to itraconazole, amphotericin B should be initiated for a minimum of 2 weeks, but up to 1 year. Cotreatment with methylprednisolone is indicated to improve pulmonary compliance and reduce inflammation, thus improving work of respiration. [1] [2] [3]

Histoplasmosis, also known as Darling disease, Ohio valley disease, reticuloendotheliosis, caver's disease, and spelunker's lung, is a disease caused by the dimorphic fungi  Histoplasma capsulatum native to the Ohio, Missouri, and Mississippi River valleys of the United States. The two phases of Histoplasma are the mycelial phase and the yeast phase.

Etiology/Pathophysiology 

Histoplasmosis is caused by inhaling the microconidia of  Histoplasma  spp. fungus into the lungs. The mycelial phase is present at ambient temperature in the environment, and upon exposure to 37 C, such as in a host’s lungs, it changes into budding yeast cells. This transition is an important determinant in the establishment of infection. Inhalation from soil is a major route of transmission leading to infection. Human-to-human transmission has not been reported. Infected individuals may harbor many yeast-forming colonies chronically, which remain viable for years after initial inoculation. The finding that individuals who have moved or traveled from endemic to non-endemic areas may exhibit a reactivated infection after many months to years supports this long-term viability. However, the precise mechanism of reactivation in chronic carriers remains unknown.

Infection ranges from an asymptomatic illness to a life-threatening disease, depending on the host’s immunological status, fungal inoculum size, and other factors. Histoplasma  spp. have grown particularly well in organic matter enriched with bird or bat excrement, leading to the association that spelunking in bat-feces-rich caves increases the risk of infection. Likewise, ownership of pet birds increases the rate of inoculation. In our case, the patient did travel outside of Nebraska within the last year and owned two birds; these are her primary increased risk factors. [4]

Non-immunocompromised patients present with a self-limited respiratory infection. However, the infection in immunocompromised hosts disseminated histoplasmosis progresses very aggressively. Within a few days, histoplasmosis can reach a fatality rate of 100% if not treated aggressively and appropriately. Pulmonary histoplasmosis may progress to a systemic infection. Like its pulmonary counterpart, the disseminated infection is related to exposure to soil containing infectious yeast. The disseminated disease progresses more slowly in immunocompetent hosts compared to immunocompromised hosts. However, if the infection is not treated, fatality rates are similar. The pathophysiology for disseminated disease is that once inhaled, Histoplasma yeast are ingested by macrophages. The macrophages travel into the lymphatic system where the disease, if not contained, spreads to different organs in a linear fashion following the lymphatic system and ultimately into the systemic circulation. Once this occurs, a full spectrum of disease is possible. Inside the macrophage, this fungus is contained in a phagosome. It requires thiamine for continued development and growth and will consume systemic thiamine. In immunocompetent hosts, strong cellular immunity, including macrophages, epithelial, and lymphocytes, surround the yeast buds to keep infection localized. Eventually, it will become calcified as granulomatous tissue. In immunocompromised hosts, the organisms disseminate to the reticuloendothelial system, leading to progressive disseminated histoplasmosis. [5] [6]

Symptoms of infection typically begin to show within three to17 days. Immunocompetent individuals often have clinically silent manifestations with no apparent ill effects. The acute phase of infection presents as nonspecific respiratory symptoms, including cough and flu. A chest x-ray is read as normal in 40% to 70% of cases. Chronic infection can resemble tuberculosis with granulomatous changes or cavitation. The disseminated illness can lead to hepatosplenomegaly, adrenal enlargement, and lymphadenopathy. The infected sites usually calcify as they heal. Histoplasmosis is one of the most common causes of mediastinitis. Presentation of the disease may vary as any other organ in the body may be affected by the disseminated infection. [7]

The clinical presentation of the disease has a wide-spectrum presentation which makes diagnosis difficult. The mild pulmonary illness may appear as a flu-like illness. The severe form includes chronic pulmonary manifestation, which may occur in the presence of underlying lung disease. The disseminated form is characterized by the spread of the organism to extrapulmonary sites with proportional findings on imaging or laboratory studies. The Gold standard for establishing the diagnosis of histoplasmosis is through culturing the organism. However, diagnosis can be established by histological analysis of samples containing the organism taken from infected organs. It can be diagnosed by antigen detection in blood or urine, PCR, or enzyme-linked immunosorbent assay. The diagnosis also can be made by testing for antibodies again the fungus. [8]

Pulmonary histoplasmosis in asymptomatic patients is self-resolving and requires no treatment. However, once symptoms develop, such as in our above patient, a decision to treat needs to be made. In mild, tolerable cases, no treatment other than close monitoring is necessary. However, once symptoms progress to moderate or severe or if they are prolonged for greater than four weeks, treatment with itraconazole is indicated. The anticipated duration is 6 to 12 weeks. The patient's response should be monitored with a chest x-ray. Furthermore, observation for recurrence is necessary for several years following the diagnosis. If the illness is determined to be severe or does not respond to itraconazole, amphotericin B should be initiated for a minimum of 2 weeks, but up to 1 year. Cotreatment with methylprednisolone is indicated to improve pulmonary compliance and reduce inflammation, thus improving the work of respiration.

The disseminated disease requires similar systemic antifungal therapy to pulmonary infection. Additionally, procedural intervention may be necessary, depending on the site of dissemination, to include thoracentesis, pericardiocentesis, or abdominocentesis. Ocular involvement requires steroid treatment additions and necessitates ophthalmology consultation. In pericarditis patients, antifungals are contraindicated because the subsequent inflammatory reaction from therapy would worsen pericarditis.

Patients may necessitate intensive care unit placement dependent on their respiratory status, as they may pose a risk for rapid decompensation. Should this occur, respiratory support is necessary, including non-invasive BiPAP or invasive mechanical intubation. Surgical interventions are rarely warranted; however, bronchoscopy is useful as both a diagnostic measure to collect sputum samples from the lung and therapeutic to clear excess secretions from the alveoli. Patients are at risk for developing a coexistent bacterial infection, and appropriate antibiotics should be considered after 2 to 4 months of known infection if symptoms are still present. [9]

Prognosis 

If not treated appropriately and in a timely fashion, the disease can be fatal, and complications will arise, such as recurrent pneumonia leading to respiratory failure, superior vena cava syndrome, fibrosing mediastinitis, pulmonary vessel obstruction leading to pulmonary hypertension and right-sided heart failure, and progressive fibrosis of lymph nodes. Acute pulmonary histoplasmosis usually has a good outcome on symptomatic therapy alone, with 90% of patients being asymptomatic. Disseminated histoplasmosis, if untreated, results in death within 2 to 24 months. Overall, there is a relapse rate of 50% in acute disseminated histoplasmosis. In chronic treatment, however, this relapse rate decreases to 10% to 20%. Death is imminent without treatment.

• Pearls of Wisdom

While illnesses such as pneumonia are more prevalent, it is important to keep in mind that more rare diseases are always possible. Keeping in mind that every infiltrates on a chest X-ray or chest CT is not guaranteed to be simple pneumonia. Key information to remember is that if the patient is not improving under optimal therapy for a condition, the working diagnosis is either wrong or the treatment modality chosen by the physician is wrong and should be adjusted. When this occurs, it is essential to collect a more detailed history and refer the patient for appropriate consultation with a pulmonologist or infectious disease specialist. Doing so, in this case, yielded workup with bronchoalveolar lavage and microscopic evaluation. Microscopy is invaluable for definitively diagnosing a pulmonary consolidation as exemplified here where the results showed small, budding, intracellular yeast in tissue sized 2 to 5 microns that were readily apparent on hematoxylin and eosin staining and minimal, normal flora bacterial growth. 

• Enhancing Healthcare Team Outcomes

This case demonstrates how all interprofessional healthcare team members need to be involved in arriving at a correct diagnosis. Clinicians, specialists, nurses, pharmacists, laboratory technicians all bear responsibility for carrying out the duties pertaining to their particular discipline and sharing any findings with all team members. An incorrect diagnosis will almost inevitably lead to incorrect treatment, so coordinated activity, open communication, and empowerment to voice concerns are all part of the dynamic that needs to drive such cases so patients will attain the best possible outcomes.

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Histoplasma Contributed by Sandeep Sharma, MD

Disclosure: Sandeep Sharma declares no relevant financial relationships with ineligible companies.

Disclosure: Muhammad Hashmi declares no relevant financial relationships with ineligible companies.

Disclosure: Deepa Rawat declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Sharma S, Hashmi MF, Rawat D. Case Study: 33-Year-Old Female Presents with Chronic SOB and Cough. [Updated 2023 Feb 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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