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Format for a Pediatric Outpatient Case Presentation

An outpatient case presentation differs greatly from an inpatient presentation. Your precepting physician will not have the time during clinic to go over a lengthy presentation–besides, the patient is waiting!  To provide the time for learning, try to follow these guidelines when presenting a patient:

1. The actual case presentation should be less than 2 minutes long. The longer you take for the presentation, the less time there will be for discussion. On the other hand, the case presentation must be informative.
2. The first sentence of the case presentation should provide identifying information, the patient’s/parent’s primary concern, and the question(s) (if any) you may have. An example would be:

“I’m seeing Howdy Doody, a 2 year-old boy with a chief complaint of runny nose and cough for 5 days; I’m not sure whether I should prescribe antibiotics, but his mother thinks they are needed.”

3. The History of Present Illness should take at least half of the total presentation time. This part should:

• Be organized logically and chronologically: correctly describe the sequence and rhythm of illness. If today’s problem relates to an ongoing chronic condition, provide a brief description of the condition, using these “key items”:

1. Date of original diagnosis

2. Usual symptoms

3. Current treatment

4. Complications (if any)

• Be attentive to detail in your descriptions:  e.g. don’t just say “abdominal pain,” but rather; “periumbilical, crampy, abdominal pain, 3-4 times a day, worse after meals, relieved by lying down.”  

• Include pertinent negative findings.

“Howdy was in good health until 5 days ago, when he developed a fever of 102ºF and a clear runny nose. His fever resolved in several days, but his runny nose has persisted, today turning a greenish color, prompting his mother to bring him in. He has had a nonproductive cough, which seems to be worse at night.  Initially he was pretty fussy and didn’t have much of an appetite, but this has improved in the past few days. He has had no vomiting, diarrhea, rashes, or difficulty breathing.  He has had problems with recurrent colds and ear infections since beginning day care 18 months ago. He had PE tubes placed 6 months ago, with no further episodes of otitis media since then.  He has never been hospitalized, and has no chronic medical conditions. The only medications he has taken for this illness have been acetaminophen and an over-the-counter cough and cold preparation.” 

4. Briefly summarize any other major ongoing medical problems (fortunately, these are not as common in children as they are in adults)

5. Briefly summarize medications and allergies.

6. The physical examination should only include pertinent positive findings.  Relevant negative findings should be briefly summarized.  Vital signs should be mentioned if they are pertinent.  Growth parameters (expressed as percentiles on the growth curve) are important in infants and children presenting for check-ups.  A brief “word picture” of the patient’s appearance is extremely helpful in providing your preceptor with an idea of how ill the patient is.  

School of Medicine | Medical College of Georgia

Please email comments, suggestions or questions to
Kenda Rindt, krindt@mail.mcg.edu.
June 29, 2006