A case presentation is a formal communication between health care professionals (doctors, pharmacists, nurses, therapists, nutritionist etc.) regarding a patient's clinical information. Essential parts of a case presentation include:
IdentificationReason for consultation/admissionChief complaints (CC) - what made patients seek medical attention.History of present illness (HPI) - circumstances relating to chief complaints.Past medical history (PMHx)Past surgical historyCurrent medicationsAllergiesFamily history (FHx)Social history (SocHx)Physical examination (PE)Laboratory results (Lab)Other investigations (imaging, biopsy etc.)Case summary and impressionManagement plansfollow up in clinic or hospitalAdherence of the patient to treatmentsuccess of the treatment or failure.causes of success or failure.