OCPs

The purpose of the oral case presentation is:

• To concisely communicate the findings of your history and exam to other members of your team
• To formulate and address the clinical questions that are important to your patient’s care

On completion of Foundations of Clinical Medicine, students should be able to perform an accurate, complete and well organized comprehensive oral case presentation for a new clinic or hospital patient, and adapt the case presentation to different clinical settings.   A comprehensive OCP includes each of these sections:

The oral case presentation is a mechanism for communicating with your team, which may include residents, attending physicians, nurses, social workers, pharmacists. Your audience may also include the patient and family if it is presented at the hospital bedside.

An oral case presentation includes only a SUBSET of the information that you record in your write-up, the information the team needs to provide care.  The write-up contains ALL the facts while the OCP includes the facts needed to understand and address the current issues.

Purpose and format of each section

Identifying information & chief concern (ID/CC)

Purpose: Sets the stage and gives a brief synopsis of the patient’s major problem.

Format: Same as in your writeup!

• Identify the patient by name and age. You can also include gender identity, if confirmed.
• Include no more than four medical problems (sometimes there are zero) that are highly relevant   to the chief concern. List only the diagnoses here, and elaborate on them in the HPI or PMH.
• Report the chief concern and duration of symptoms

Template: “___ is a ___ year-old with a history of ___ who presents with ___ of ___ duration.”

History of present illness (HPI)

Purpose: Provides a complete account of the presenting problem, including any information from the past medical, family and social history related to that problem.

Content: The same as the HPI in the write up! Most new diagnoses are made based on the HPI so this is the most important part.  It should take up 1/3 to 1/2 of your presentation time.

• Background health. If the presenting problem is related to a chronic illness, summarize that illness here.
• Detailed, chronologic description of the presenting problem
• Predisposing conditions and risk factors (a.k.a ‘pertinent positives’)
• Pertinent negatives.  Symptoms from the affected organ system and risk factors that the patient doesn’t have
• Optional: Evaluation or hospital course to date

Past Medical History (PMH)

Purpose: To provide a succinct overview of other important medical and surgical history that will aid in the care of the patient.

Format: Report ONLY active medical problems and other medical history that is pertinent to evaluation or ongoing management. Medical or surgical history that is relevant to the chief concern should be included in the HPI.

If a past diagnosis or surgery is not active or relevant, it is included in the write-up but NOT in the OCP.

Template: Include a brief synopsis of each active major problem – remember POTS

• P roblem
• O nset
• T reatment
• S ymptoms and control

Medications and Allergies

• List all prescribed medications (by generic name if possible) and doses
• List all non-prescription medications and complementary/alternative therapies
• Report any drug allergies and the type of reaction

Social History

Purpose: To provide your listener with the social context of the illness and its impact on ongoing care

Format: In 2-3 sentences summarize the patient’s living situation and support systems, occupation, identity, and any social issues that could impact care.

Health Related Behaviors

• Summarize substance use not already mentioned in HPI, including tobacco, alcohol, drug use
• Risk factors relevant to the presenting concern should be included in the HPI

Physical Examination

Purpose: Succinctly and accurately describe the patient’s physical examination, emphasizing pertinent findings

Format: Begin with general appearance and vital signs. Name each organ system in order, and report the relevant exam:

• HEENT and Neck
• Chest
• Cardiac
• Abdomen
• Neurologic
• Musculoskeletal
• Skin

Report all pertinent physical examination findings, both normal and abnormal:

• Complete exam of the organ system(s) relevant to the chief concern
• Other findings (normal or abnormal) that help your listener answer a clinical question.

Use concise but complete descriptions of positive findings.

• Report all abnormal findings regardless of organ system.
• If the examination of a system NOT relevant to the chief concern was normal, you may say “Normal”.

Summary Statement: The lead in to your assessment

Purpose: To synthesize the important history and exam findings, to frame the clinical problem and to lead your listener into your assessment.  This is NOT simply a restatement of the ID chief concern.

Format: Restate the identifying data and summarize the key features from the patient’s history and physical exam.

Template: “In summary, NAME is a AGE year old patient who presents with a history of PRESENTING CONCERN AND MAJOR ASSOCIATED SYMPTOMS. Their history is notable for KEY ELEMENTS OF HISTORY THAT IMPACT YOUR ASSESSMENT. Physical exam is notable for KEY FINDINGs THAT IMPACT YOUR ASSESSMENT.

Assessment

Purpose: Address the clinical problem and demonstrate your clinical reasoning.  The clinical problem may range from a new and undiagnosed problem to routine follow-up of a chronic problem. The format varies for each.

For an undiagnosed problem.

Your assessment would address the top 3-4 items on the differential diagnosis suggested by your patient’s history and exam findings

Example: The most likely reason for Lily’s rash is eczema. Her skin dryness and pruritis, and her family history of atopy are all consistent with eczema, as is the history of worsening in the winter and after frequent swimming. She also has a classic distribution on the hands and elbow creases. A less likely possibility is scabies, which frequently affects the hands. However, Lily’s skin between the wrists and elbows is spared, which would be atypical for scabies.

For an exacerbation of a chronic problem.

Your assessment would address the most likely reasons for the exacerbation, as suggested by your patient’s history and exam findings.

Example: The most likely reason for Mr. C’s CHF exacerbation is medication nonadherence due to both costs and confusion. He reports filling his medications less often than monthly because even the co-pay is expensive, which is confirmed by his pharmacy. Although he manages his own medications, he is unable to accurately describe what each is for, or his dosing schedule. A second possibility is new ischemia; however, he’s had no chest pain or tightness, and initial ECG and enzymes were negative. Finally, a URI could have precipitated this exacerbation, as he had low grade fever, cough, and rhinorrhea last week. However, those symptoms have resolved as his edema and shortness of breath have progressed, making this possibility less likely.

Routine follow-up of a chronic problem.

Your assessment would address current control of the problem, evidence of complications, and adequacy of current education and treatment.

Example:  Ms. B’s type 2 diabetes is well controlled, with most recent HgbA1c of 6.8. She reports excellent adherence to diet and exercise, as well as metformin. She has no evidence of retinopathy or neuropathy on exam and urine for microalbumin was negative.

Plan

Purpose: To outline your next steps in addressing your patient’s clinical problem(s).

Format: The plan is usually presented as a bulleted list, and may include interventions in these categories:

Delivery Tips for Oral Case Presentations:

• At the bedside, introduce your patient and any family members to all members of your team.
• Establish eye contact with your team and your patient, glancing at your notes only as necessary.
• Present with a clear, energetic, and interested voice.
• When presenting at the bedside, recognize the impact of your choice of words on your patient. Avoid medical language that might frighten your patient, unless he has used it. Examples: “End-stage liver disease” and “Another possibility is lung cancer…”
• Avoid language your patient might find insulting. Examples: “Obese” and “Pleasantly confused elderly woman.”
• Follow the standard format of the OCP precisely.
• Orient your listeners to the next section of the OCP with a brief pause followed by the title of that section.
• Use precise language.
• Do not rationalize, editorialize, or justify as you present. Just present the “facts”.
• Be aware of your patient’s confidentiality, especially if the patient is in a shared room.

References & resources

The FCM OCP Benchmark is adapted from Dr. Steve McGee’s Guidelines for OCPs on the Third Year Internal Medicine Clerkship.  These guidelines are too advanced for what you know at the beginning of medical school but by the time you reach the Patient Care Phase, you should be able to follow them. Current version is available here. Oral Case Presentation (uw.edu)