The spoken case presentation is a concise summary of the history and physical examination. Unlike the written version in a patient's chart, the oral presentation is dynamic and ranges from a brief summary given by phone to a consultant to a more formal presentation to a large medical audience at an academic session. Succinctness and organization are especially important, as the presenter has neither the luxury of omitting important details nor time for repetition. Brevity is of paramount importance; simply reading from a chart defeats the purpose of the exercise. Highlighted in this chapter are the essential components of the presentation: the chief complaint, the history of present illness (HPI), the past medical history, the family and social history, the review of systems, and finally, the physical examination findings.
The chief complaint should be as directed and short as possible, articulating the principal subject under consideration. Invariably, there is one overriding problem in the majority of patients, and a listener is helped enormously by its identification immediately, allowing focus. Indeed, from the first words of a presentation, a listener is formulating possible diagnoses. A lengthy chief complaint including details of past history serves only to confuse and lengthens the presentation—a cardinal sin. The patient's own words need be mentioned only if they illuminate the problem under consideration. The source is always assumed to be the patient, and its content accurate; if considered otherwise by the presenter, this qualification must be made clear. The patient is best identified as a man or woman, which are more respectful designations than male or female. Mentioning the patient's occupation is often helpful medically and certainly socially, because a listener is likely to examine the patient shortly after the presentation.
The HPI is the most important part of the exercise. If the problem is not understood at the conclusion of a properly presented HPI, it is unlikely to be understood after extensive further evaluation. Instead of calendar dates, the duration of time prior to the episode of care should be specified. Calendar dates require a listener to remember the current date and subtract backwards to determine the duration of a problem, an unnecessary distraction.
The initial step in organizing the HPI is to identify the logical parts of the present illness. For example, beginning the HPI with a chronic history of hypercholesterolemia is sensible in a middle-aged man with chest pain. Thereafter, events should be given chronologically, up to the present moment. Many presentations are confusing because they include recent information first, followed by previous but relevant data. Instead, the HPI should be related like a story, with a beginning and an end. Again, the value to a listener is significant.
What about the inclusion of pertinent negative historical information in the HPI? Presenting negative data is unnecessary when positives tell the whole story. However, negative data become extremely important in narrowing the differential diagnosis when the positive information leaves ...