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Case presentation
A
case presentation
is a formal
communication
between
health care professionals
regarding a patient's clinical
information
.
Essential
parts of a case presentation include:
Identification
Reason for consultation/admission
Chief
complaints - what made patients seek
medical attention
.
History of present illness
- circumstances relating to chief complaints.
Past medical history
Past surgical history
Current medications
Allergies
Family history
Social history
Physical examination
Laboratory results
Other investigations
Case summary and
impression
Management plans
follow up
in clinic or hospital
Adherence
of the patient to
treatment
success
of the treatment or failure.
causes of success or failure.