FORMAT FOR CLINICAL CASE PRESENTATION:

Present your clinical case in the following format:

 General introduction of the case

o Introduce the case on how it came to your attention
 Chief complaint
 History of present illness
o Make it simple but filled with pertinent details that will aid in forming your initial
impression
 Review of systems
o Make it comprehensive that will aid in diagnosing the case presented
 Pertinent histories – Past medical history, Personal social history, Family history
o Give out the pertinent that will aid in diagnosing the case presented
 Physical examination
o Present physical examination that will aid in forming your initial impression and
differential diagnosis
 Initial impression
o Rationalize your history and physical examination findings in forming the initial
impression
 Differential diagnosis
o DO NOT GIVE THEORETICAL DIFFERENTIAL DIANGOSIS: Your differential diagnosis
should always be based on the data obtained in history and physical examination
 Laboratories done
o Present the laboratory work ups ordered and done – base your rationale for the work
ups done on the idea you formulated from data of history and physical examinations
 Final working impression
 Disposition
o Present what your actual disposition for the case, including the advise given
 Biopsychosocial aspect of the illness
o Present the biological issues of the case for the patient, personal psychological impact of
the disease to the patient, and societal impact of the disease to patient’s surrounding
world
 Basic family assessment tools
o Present at least family genogram (especially if you are dealing with case that has
heredofamilial traits) and family map (especially if you are dealing with the case that has
psychological impact or chronic diseases that entails family support)
 Theoretical presentation of the working impression
o Always correlate to your actual patient – for example, “Asthma symptoms vary from
person to person. You may have infrequent asthma attacks, have symptoms only at
certain times — such as when exercising — or have symptoms all the time. Asthma
signs and symptoms include: Shortness of breath, Chest tightness or pain, Wheezing
when exhaling, which is a common sign of asthma in children, Trouble sleeping caused
by shortness of breath, coughing or wheezing, Coughing or wheezing attacks that are
worsened by a respiratory virus, such as a cold or the flu. MY PATIENT EXHIBITED
SHORTNESS OF BREATH, CHEST TIGHTNESS AND WHEEZING, WHICH ARE ALL INCLUDED
 IN THE DEFINITION” - on every theoretical detail that fits your actual case, always make
mention of it
 Personalized wellness plan for the patient
o Should be evidence based, personalized wellness plan matched for age and sex of your
patient
 Learning points from the case
o Give what you learned from handling this case, not only on theoretical/medical aspect
but as trainee and person
 If the case is unresolved, the future outlook of the case
o Always make mention of what could be the turn out of your case with the disposition
that you have given, if the case is unresolved and has not followed up yet

FORMAT FOR FAMILY CASE PRESENTATION:

Present your clinical case in the following format:
Parts in pink letter should be presented briefly/ concisely and should not take most of the time of your
presentation – remember that what you are to present is a FAMILY CASE and not clinical case – although
clinical aspect of the patient’s illness is important, you would want to spend more time in presenting
about the family than about your patient and his/her case – The pink lettered area should only last for
about 5-8 minutes maximum

 General introduction of the case

o Introduce the case on how it came to your attention
 Chief complaint
 History of present illness
o Make it simple but filled with pertinent details that will aid in forming your initial
impression
 Review of systems
o In Family case presentation, this should be presented in very concise manner, just to
give an overview of the patient’s status (it may not be as extensive as that of clinical
case)
 Pertinent histories – Past medical history, Personal social history, Family history
o Give out the pertinent that will aid in diagnosing the case presented
o You may incorporate Genogram in discussing the PMHx, PSHx, and FHx since genogram
can depict the heredofamilial diseases as well as it records the other determinants of
health condition of both the patient and the family
 Physical examination
o Present physical examination that will aid in forming your initial impression and
differential diagnosis briefly and concisely
 Initial impression
o Rationalize your history and physical examination findings in forming the initial
impression
 Differential diagnosis
o DO NOT GIVE THEORETICAL DIFFERENTIAL DIANGOSIS: Your differential diagnosis
should always be based on the data obtained in history and physical examination
 Laboratories done
o Present the laboratory work ups ordered and done – base your rationale for the work
ups done on the idea you formulated from data of history and physical examinations
 Final working impression
 Disposition
o Present what your actual disposition for the case, including the advise given
 Theoretical presentation of the working impression
o In the clinical case, you have to always correlate the theoretical discussion to your actual
patient – In the family case, you have to correlate the theoretical discussion to the
illness trajectory and to impact of illness so as the discussion to be more FAMILY
CENTRIC than PATIENT CENTRIC

 Biopsychosocial aspect of the illness

o Here present the biological issues of the case for the patient, personal psychological
impact of the disease to the patient, and societal impact of the disease to patient’s
surrounding world
 Impact of the illness
o After presenting the Biopsychosocial issues of the patient on his/her personal illness,
now present the IMPACT OF THE ILLNESS TO THE PATIENT’S FAMILY – their perception
of the illness, how did it affect them, what mitigation plans have they thought or
actually tried in order to overcoming the impact that their patient’s illness caused them
 Family assessment tools
o Present deeper analysis of your patient’s family structure and dynamics using the most
appropriate family assessment tools – upon presenting the tools you utilized, you should
also give your justification on why you chose to use the tools that you are presenting
 FAMILY DIAGNOSIS
o Structure of the family with result of analysis of the dynamics presented
o Family life cycle stage
o Impact of the illness and Illness trajectory as to the disease of the index patient
o Present the characteristic PROS and CONS of the family in facing the challenge / illness
of the patient in table
o What did you do as physician upon identifying the PROS and CONS (Especially the CONS)
on order to assist the family in overcoming their life challenge? – you should have
theoretical basis in presenting this (such as using ALS, CEA method, how were you able
to correct the misperception, how were you able to motivate on the points that the
family is anxious about… etc.)
 PRESENTATION OF ACTION PLAN FOR THE FAMILY (IF THE CASE IS STILL AN ON GOING ONE) or
PRESENTATION OF ASSESSMENT OF THE ACTION APPLIED OR SUGGESTED TO THE FAMILY UPON
FOLLOW UP VISITS (IF YOU HAVE ALREADY SUGGESTED AND AGREED WITH THE FMAILY ON
ACITONS TO BE APPLIED BY THE FAMILY)
o In this part, you should present the;
 Possible turn on event if the actions is to be taken or applied and how will it
improve the initially assessed illness trajectory and impact of illness
OR
 The actual turn of events that happened upon applying the actions that is
agreed upon with the family and how did it improve or sometimes worsened
the situation based on the illness trajectory, impact of illness
 Presentation of FAMILY wellness plan for the patient
 Learning points from the case
o Give what you learned from handling this case, not only on theoretical/medical aspect
but as trainee and person
 If the case is unresolved, the future outlook of the case
o Always make mention of what could be the turn out of your case with the disposition
that you have given, if the case is unresolved and has not followed up yet