PHARM 305- ClinPharm

Ms. Ivory Dianne C. Amancio RPh,CPh

Patient Case Presentation

IMPORTANCE OF CASE PRESENTATION:

Preceptor Students Clinicians
A tool to assess To help develop Recipient of
student’s student’s patient
understanding of sophisticated information
the case clinical reasoning
skills.
An evaluation tool
to measure the
clinical reasoning
skills of students

4 Stages of Patient Case Presentation Skills:

RIME
Stage 1: Reporter
 Able to obtain and communicate correct facts.
Stage 2: Interpreter
 Able to apply information to specific patients.
Stage 3: Manager
 Able to create patient-specific plans GENERAL INFORMATION
Stage 4: Educator Includes the following:
 With continued experience, the advanced trainee  Date and time of arrival in the hospital or clinic
is able to teach the team.  Patient’s Name, Age and Gender
Example:
IMPORTANT REMINDER: Mr. Howard Roth is a 58 years old WM who
 Students tend to focus on structure and presents to clinic today refills of his antihypertensive
content medication
o The primary focus of the presentation is
to communicate patient information CHIEF COMPLAINT (CC)
effectively and efficiently  The reason why the patient is seeking medical
 Presenter present most of the case from attention.
Memory IMPORTANT NOTE:
o Reference notes are needed for complex o Documented in the Patient’s Own
cases Words.
 Presenter uses slang words (e.g. Lab wise, o This provides important information on
Kinda, you know, like) the level of education and medical
o The presenter should present the case sophistication
logically and reasonably without SAMPLE CC
editorializing facts or data or “I think I am having a myocardial infarction”
commenting on what's normal or “I have a heavy, squeezing, and crushing chest pain”
abnormal “I’m here for my check-up”
“My doctor sent me here because I am taking warfarin”
COMPONENTS of Case Presentation
 Patient case presentation provides a summary of
all known Patient Information. If the patient is comatose:
 Considered an up-to-date “Snapchat” of the “The patient’s wife found him unconscious on the living
patient room floor”
o Provide a thorough and detailed picture
of the patient at the time of the If the patient is referred for specific test: “Referred for
presentation. medication therapy management.”
 Summarizes pertinent positive and pertinent
negative data of the Patient: HISTORY OF PRESENT ILLNESs (HPI)
o Pertinent Positive – Abnormal Data  A narrative that describes the story of the current
o Pertinent Negative – Normal Data problem.
Details include:
SEQUENCE OF CASE PRESENTATION 1. How the problem begun or was first recognized
 A good patient case presentation provides all the 2. Duration of symptoms
information needed to understand the patient 3. Test results from previous evaluation of the
cases but spares the listeners from duplicative, same problem
trivial, or irrelevant information. 4. Activities and treatments that ease or worsen the
problem
 PHARM 305- ClinPharm
Ms. Ivory Dianne C. Amancio RPh,CPh

Examine the details included in the HPI: Example:

12 days PTA, patient delivered via NSVD to a live baby CC: Dizziness
boy at Tecarro Birthing Home, delivered by MD. As HPI: includes all the conditions relating to CC.
claimed, there was no post-partum complications (-) PMH: brief description of patient problems
bleeding, (-) infection, (-) fever. However, patient was unrelated to the present Illness.
not able to sleep because of personal problem. 6 days ROS: Chronic Constipation (a condition not related
PTA, patient had onset of dizziness, (-) vomiting, (-) to CC and was not included to the HPI)
decreased appetite, (-) blurring of vision, (-) fever. No
consultation done initially and no meds were taken. Physical Examination (PE)
Night PTA, patient had onset of productive cough with 1. Begins with a short description of the Patient:
yellowish/ whitish phlegm associated w/ DOB and 1  Helps listeners visualize the patient and
episode of vomiting. Morning PTA, consultation was begin to anticipate pertinent findings
done at a local clinic. Persistence of condition prompted 2. Vital signs values
admission 3. Pertinent positive and negative findings
Case
Past Medical History (PMH)  Awake, afebrile, in respiratory distress
 Prior medical history includes a brief description  Vital Sign: BP 140/90, RR 36, PR 109, T 36.4 C
of patient problems (current or historical) (Normal)
unrelated to the present Illness.  Skin is moist, anicteric sclera , pale palpebral
 SAMPLE Past Medical History (-) HTN, (-) conjunctivae, equal chest expansion, decreased
DM, (-) BA, (-) CA breath sounds, crackles in both lung fields
 Adynamic precordium, regular cardiac rhythm,
Social History (SH) Soft, normative bowel sounds, non-tender
 Contains information about patient’s use of : abdomen, (-) edema, full equal pulse , prolonged
1. Tobacco – Packs per day and packs per capillary refill time.
year
2. Alcohol ingestion – “A case of beer LABORATORY AND DIAGNOSTIC TEST
every weekend for 6 years” 1. 2. “ RESULTS
Social drinker” – drink by occasion
“Binge drinker” – heavy drinker LAB WORKS / DIAGNOSTICS
3. Illicit/recreational/street drugs – note the  Test results depend in the severity and
amount, pattern and duration complexity of the patient’s medical problem.
a. Smokes marijuana every Sequence to present:
weekend and has done for 8 1. Serum electrolytes ( Na, K, Cl, CO2, Nitrogen
years. content)
b. Uses crack cocaine daily and 2. Clinical Chemistry: Glucose, BUN, and Creatinine
has done for 3 years 3. Hematology: Complete Blood count
c. Last used cocaine this morning 4. Other electrolyte and serum chemistry tests
 Patients occupation (Biomarkers)
o Both important in diagnostic reason and 5. Macroscopic and Microscopic Urine Analysis
therapeutic planning. 6. Results of diagnostic procedures (ECG
o Example: 40 years working as Radiographs. Etc.)
construction worker
 Patients living condition Important Laboratory Test
Example: The patient lives in a single-family Blood Electrolytes
two-story house with his wife and youngest
child. He is a semi-retired accountant. He used
to smoke (2 ppd for 38 years) but quit 3 years
ago. He has drunk two to three beers per week
for 40+ years and denies using illicit drugs.

Family History (FH)

 Consist of a brief summary of the medical
histories of the Patient’s first degree relatives. Clinical Chemistry
Example: The patient’s mother is alive and well
at the age of 78. His father died at 66 of
myocardial infraction. His three children (ages
35, 32, 23) are alive and well.

Review of System (ROS)

 Summarizes the patient complaints not included
in the HPI.
 Typically it follows an organ system approach (
Head, Heart, lung and kidneys)
 PHARM 305- ClinPharm
Ms. Ivory Dianne C. Amancio RPh,CPh

Hematology Patient Problem List

PROBLEM LIST
 Presented after lab and diagnostic tests
 Brief enumeration of the patient’s problems,
starting with the most acute problem.
Sample Problem list for Pharmacists may include:
 Patient nonadherence
 Need for preventive health measures
(Immunization)
 Health screenings (cancer screenings, BP
screening, Diabetes Screening)
Biomarkers for Kidney Function

HBA1C- Blood Glucose Biomarker

Urinalysis (01-16-19)

Urine Sediment (01-16-19)

Microbiology