A case presentation is a formal communication between
health care professionals such as doctors and nurses regarding a patient's clinical information.
Essential parts of a case presentation include:
* Identification
* Reason for consultation/admission
* Chief complaints (CC) - what made patients seek medical attention.
* History of present illness (HPI) - circumstances relating to chief complaints.
* Past medical history (PMHx)
* Past surgical history
* Current medications
*
Allergies
* Family history (FHx)
* Social history (SocHx)
*
Physical examination (PE)
*
Laboratory results
A laboratory (; ; colloquially lab) is a facility that provides controlled conditions in which scientific or technological research, experiments, and measurement may be performed. Laboratory services are provided in a variety of settings: physicia ...
(Lab)
* Other investigations (
imaging,
biopsy etc.)
* Case summary and impression
*
Management plans
Management (or managing) is the administration of an organization, whether it is a business, a nonprofit organization, or a government body. It is the art and science of managing resources of the business.
Management includes the activities o ...
* follow up in clinic or hospital
* Adherence of the patient to treatment
* success of the treatment or failure.
* causes of success or failure.
References
Medical terminology
{{Treatment-stub