How Should a Case Presentation Be Structured?

A case presentation refers to the methodical and interactive communication process that provides extensive details regarding the topic, which could be anything from a person, community, organisation, an event or even a phenomenon. This method is different from ordinary report writing or white paper writing in that the main objective here is not to present the information but to engage the audience. In medicine, it proves quite useful when it comes to conveying patient data to peers or superiors, but it can prove equally effective in other professions too. A well-prepared, structured case report ensures clarity and a logical flow for both medical and professional audiences. [1]

1. Case presentation

The Introduction introduces your case presentation. First, state who you are and your position, then proceed to present an overview of the topic of discussion. If you are talking about a medical case, include information about the patient, such as age and gender, among others. The introduction gives background information about your topic, hence making your listeners appreciate why the case is important. Mentioning the objectives at this stage makes the listeners know what you expect them to get from the case study presentation.[1]

2. Chief Complaint (CC)

Chief Complaint refers to the main reason why the patient sought consultation. Whenever possible, use the words of the patients in describing their chief complaint. Also, indicate the length of time and any related complaints. The chief complaint sets up the groundwork in which the rest of the discussion will be based. This is where the initial problem of the patient can be understood. [2]

3. History of Present Illness (HPI)

HPI is a narrative describing the start, evolution, and management of the current illness. Relevant positives or negatives should be included, for example, symptoms experienced by the patient or not experienced yet, but can help make a diagnosis. The HPI shows proper clinical judgment on the part of the physician and helps the reader understand the clinical observation case report.

4. Past Medical History (PMH), Medications, and Allergies

Past Medical History (PMH): Provide a summary of past medical diseases, surgery, admissions, or illness.
Medication: Note down the current medications the patient is using, dose, and frequency because all these things can affect the diagnosis and therapy.
Allergy: Mention the allergy of the patient if he has any; otherwise, write “No known allergy. [3]

5. Social and Family History

Social History: Lifestyle issues, occupations, habits like smoking, alcohol use, recreational drugs, etc., should be mentioned as these have a lot of bearing on the health of patients and treatment plans.
Family history: Hereditary/genetic diseases in the patient’s family should be emphasised. This ensures the healthcare case report is comprehensive.

6. Review of Systems (ROS)

ROS, which stands for review of systems, involves a thorough evaluation of all organ systems to look out for any symptoms associated with the case. It encompasses positive as well as negative symptoms to gain a complete picture of the situation. Documentation of ROS helps improve diagnostic reasoning and enhances the quality of clinical cases in medicine.[4]

7. Physical Examination and Diagnostic Tests

Physical Exam Findings: Describe relevant physical exam findings that include vital signs and other quantifiable measurements made during the assessment.
Diagnostics Findings: Provide any diagnostic findings from tests that have been done. Provide normal reference values along with test results to help your reader understand their meaning. [5]

8. Assessment and Plan

Assessment: Write an assessment of the health status of the client and highlight the most important points. You need to use relevant terms and present your line of reasoning.
Plan: State what actions you are going to take in response to the health problem. This will include a short-term plan as well as a long-term one. The structured case report format is useful here for clarity.

9. Discussion and Impressions

The discussion part is where the presenter evaluates the case. It should include:

Differential diagnoses explored and reasons why the presenter chose that diagnosis.
Problems experienced while carrying out evaluations or treatment.
How it is related to other pieces of literature.
The take-home message.

It is evidence of how the presenter thinks critically, clinically and how he synthesises knowledge for educational purposes.

Conclusion

A conclusion is created to wrap up the main ideas discussed within the presentation by highlighting the main 1-2 bullet points for each of these areas: (i) summary; (ii) analysis; (iii) recommendation(s). The conclusion of the presentation will reinforce the educational value of the case study presentation, improve the understanding of the subject matter, and create a final or lasting impression with the audience. This ensures the clinical cases in medicine are documented effectively and can serve as a reference for future learning.

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References

Guidelines To Writing A Clinical Case Report. (2017). Heart views : the official journal of the Gulf Heart Association, 18(3), 104–105. https://doi.org/10.4103/1995-705X.217857
Chait, R., Donini, G., & Flynn, M. G. (2023). A Guide to Writing Quality Case Reports. HCA healthcare journal of medicine, 4(1), 61–68. https://doi.org/10.36518/2689-0216.1485
Ali, S., Ullah, S., Aslam, S., Muhammad, S., Ahmad, M., & Asim, M. (2025). From History to Plan: A Comprehensive Audit of Admission Documentation Practices in the Pulmonology Department at Medical Teaching Institute (MTI) Mardan Medical Complex, Pakistan. Cureus, 17(9), e92860. https://doi.org/10.7759/cureus.92
Okland, T. S., Gonzalez, J. R., Ferber, A. T., & Mann, S. E. (2017). Association Between Patient Review of Systems Score and Somatization. JAMA otolaryngology– head & neck surgery, 143(9), 870–875. https://doi.org/10.1001/jamaoto.20
Campbell EW JR, Lynn CK. The Physical Examination. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 4. Available from: https://www.ncbi.nlm.nih.gov/

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