The Art of Presenting

The house officer is required to present the case he or she has reviewed in the morning to either the medical officer or the clinical specialist. Only by doing this does the house officer learn the pertinent and important points of the case. He or she will also learn what is to be discarded and what must be included. When a senior doctor ask a house officer if he or she knows a case, what is meant is not whether he or she can rattle off the problem list brainlessly but to know a case one must not only be able list out the problems but he or she must be able to tell:

1. How the diagnosis is reached
2. What was done
3. What you are doing
4. What you are planning to do

   When presenting for the first time more information is presented for the pre-morbids, presenting complaints and history of presenting complaint.
   To start a presentation mention:

1. Age and sex
2. Pre-morbids including duration, follow-up and treatment
3. Presenting complaint
4. Relevant negatives if this is a presentation for the first time
5. The examination and investigations leading to the main diagnosis
6. What was done, what you are doing
7. Other diagnosis in the same format
8. Patient's current condition: asking how are the presenting symptoms now, any adverse effects of treatment, and the basic functions which are eat, drink, sleep, bowel motion and passing urine.
9. Latest vital signs
10. Latest examination findings
11. Latest investigation results with comments on whether they are improving or not.
12. What you will be doing

Example:
" This is a 74 Chinese gentleman. He has diabetes mellitus for 7 years on OHA, hypertension for 2 years on treatment; both under MOPD, gastritis for 5 years no OGDS done, and IHD for 3 years under IJN; angiogram done in 2011 showing 3 vessel disease,"
" He presented to us with a 3 day history of cough, fever and greenish sputum. Chest examination revealed bibasal crepitations, CXR showed bihilar haziness with total white count of 13, CRP of 100 temperature of 38 degrees,"
"He was treated for community-acquired pneumonia. He was started of IV ceftriaxone 2g OD and tab azithromycin 500mg OD on 19 February. Currently day 2. On admission it was noted that he was hypotensive. He was started on IVI noradrenaline on the 19th until today the 20th which we just taken off because the BP has stabilised. Blood culture and sensitivity taken on 19th for which results are still pending,"
" It was also noted that his creatinine has jumped to 300 from a baseline of 180 3 months ago. We are treating for AKI secondary to sepsis and dehydration with 2 pints of normal saline over 24 hours. Glucose was persistently more than 15 but there was no acidosis, ketones was negative and serum osmolarity was normal. He was treated for uncontrolled DM for which we started IVI insulin on the 19th also,"
" Currently, the fever has resolved, cough has reduced and the sputum has turn from green to white. He had no symptoms of hypoglycaemia. He is able to tolerate orally, sleep well and have no problems with either bowel motion or passing urine,"
" His blood pressure is 130/80 without inotrope, heart 70, temperature afebrile, glucometer showed sugar of 8.0"
" Lungs are much clearer but still some residual left basal crepitations,"
" TWC has reduced to 8, creatinine improved from 285 to 230"
" I am planning to continue the current antibiotics, trace the blood culture and sensitivity, his appetite has also improved so I am planning to take off the drip."
  I don't know about you but this is how I like it presented so house officers please take note if you are in my ward. Anyone would care to share how they present and can it top this for completeness?