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🔷 STRUCTURED GUIDELINES FOR MEDICAL CASE PRESENTATION
🧾 1.
Opening Slide
Age, sex (use gentleman / man / boy or lady / woman / girl), occupation (including employment history or “retired [former occupation]”), and major presenting symptoms. Do not use male or female as these may be considered as impolite.
Presenter name and hospital.
Avoid “Chief Complaint”; instead use Presenting Complaints. Chief complaint suggests only one major symptom. This is not realistic. Instead, listing all of the acute symptoms that brought them to seek medical attention as ‘presenting symptoms’ is a better way to begin the presentation.
🧾 2.
Presenting Complaint(s)
Clearly list the presenting symptom(s).
Use clinical terminology (e.g., “right lower quadrant abdominal pain”).
State duration (e.g., “1 day prior to admission”). If the symptoms began e.g. 23 days before admission, instead approximate the timing to 3 weeks beforehand. It is not necessary to have such precision when it comes to weeks, months or years.
🧾 3.
History of Present Illness (HPI)
Provide a chronological narrative of each symptom.
Describe in full: Pain - Site, Onset, Character, Radiation, Alleviating factors, Timing, Exacerbating factors, Symptoms (associated) / Severity of Pain / Social effect (SOCRATES)
Positive findings (which are considered acute rather than chronic and unrelated to the current problem) from the Review of Systems should be incorporated into this section with detail.
Do not include vague phrases such as “occasional pain” without quantification.
Pain should be explained in detail according to SOCRATES (above).
🧾 4.
Past Medical History
Document chronic illnesses, prior infections (e.g., tuberculosis - what age, which anti-TB meds were prescribed and how long was the treatment course), malignancies (with staging and treatment; are they currently under treatment or in remission?).
Include prior surgeries - give as much detail as possible; note that gastrectomy patients should taking vitamin B12 replacement; that means assessing the medication list later.
Use approximate dates (e.g., “Age 33:”) or timing (e.g., “10 years ago:”).
Do not anonymise the dates in the presentation with “Year X” when presenting the case — use actual years when relevant. Using years does not disclose anonymous information.
🧾 5.
Medications and Allergies
Use chemical (generic) names only e.g. bisoprolol, ampicillin, azilsartan, vonoprazam.
Provide dose and frequency (e.g., “amoxicillin 500 mg three times daily”). Do not write the number of tablets per dosing interval. Just provide the total dose per interval as listed above.
Include both current and recently discontinued medications.
Include over the counter medicines, vitamin supplements, and herbal remedies.
Remember to include diabetes medicines which are often forgotten such as insulin (type and dose per injection interval) and inhalers for asthma / COPD.
Include allergies in this section: name of drug, type of reaction, severity. Do not write ‘food allergies’ here. These should be listed under the past medical history section.
🧾 6.
Family History
Restrict to first-degree relatives and hereditary conditions (e.g., cancers, cardiovascular disease, diabetes).
Do not include irrelevant details (e.g., “husband had stroke”) unless contextually pertinent (e.g., infectious disease exposure). Non-blood relatives e.g. spouse, do not transmit inherited diseases to their partner; these may be transmitted to their progeny.
🧾 7.
Social History
Must include:
Smoking: pack-years, quit date and reason.
Alcohol: type, quantity per session, frequency; avoid “social drinker” or “occasional drink” - these are meaningless terms that are devoid of detail.
CAGE questionnaire:
C: Have you felt you should Cut down?
A: Have people Annoyed you by criticising your drinking?
G: Have you felt Guilty?
E: Eye-opener in the morning?
Recreational drug use
Sexual history: number/gender of partners, practices (vaginal/oral/anal), condom use, STI history. For more details please see the 5Ps for taking a sexual history from the CDC website.
Occupation: including exposures (e.g., asbestos, dust, solvents).
Living situation: alone, with partner, family, care home; what type of home to they dwell in? Are there stairs? How many? Where does the patient sleep?
Travel history, especially abroad or to endemic areas.
Social support and economic constraints if relevant.
🧾 8.
Review of Systems (ROS)
Include only relevant negatives.
Grouped by systems (General, HEENT, CV, Resp, GI, GU, Neuro, MSK, Endocrine, Psych, etc.).
Do not list hundreds of negatives. Ask focused questions based on the clinical scenario (and which were actually asked!)
E.g., breathlessness → ask about respiratory, cardiovascular, neuromuscular, haematological, metabolic, and psychiatric systems.
On the slide: state “As you can see from the review of systems, no other pertinent information was derived.”
🧾 9.
Vital Signs (THRO₂BS Format)
List clearly and consistently:
T: Temperature (°C)
H: Heart rate (/min)
R: Respiratory rate (/min)
O₂: Oxygen saturation (%)
: Orientation e.g. AOTPP (Alert, and Oriented, to Time, Place and Person) and/or GCS e.g. 15/15; Do not write E4, V5, M6 when the GCS is 15. It is meaningless.
B: Blood pressure (mmHg)
S: Severity of pain on a numerical rated scare (NRS) from 0–10.
🧾 10.
Physical Examination
Must be detailed, complete and systematic.
Do not omit essential examinations (e.g., rectal exam for GI complaints).
If not performed, clearly state so.
Follow this order:
General appearance
HEENT
Neck (lymphadenopathy, thyroid)
Cardiovascular
Respiratory
Abdomen (including liver/spleen)
Rectal
Back
Genitals (if relevant)
Musculoskeletal
Skin
Neurological
🧾 11.
Problem List
Include the presenting complaints, important information from past medical hx, medicines, family hx, social hx, vital sign abnormalities, and physical exam abnormalities.
List each problem separately.
Group problems by system or symptom pattern.
E.g., cough, fever, pleuritic pain, crackles → respiratory clustering.
Shortness of breath + leg edema + orthopnea → cardiac clustering.
Do not ignore incidental or overlooked issues (e.g., fractures in elderly suggesting undiagnosed osteoporosis).
🧾 12.
Differential Diagnosis
Based on the history and physical exam alone (otherwise how can you decide on what tests to do without thinking of the differential diagnosis beforehand!?)
Categorise:
Common
Must-not-miss
Rare
If features are atypical or misleading (e.g., abdominal pain caused by pneumonia), explain diagnostic reasoning.
🧾 13.
Investigations
Labs, imaging, ECG, cultures.
Do not use red/blue colour coding on lab tables.
Always show reference ranges.
Let the reader interpret abnormalities independently.
Use clean tabular format (e.g., three-column layout: test, value, units/reference).
ECG - this should be interpreted by the presenter in a step by step manner e.g. axis; heart rate; P wave shape; P-R interval; QRS width, shape, and height; ST segment; T wave; U wave; grouped lead abnormalities; final interpretation.
Radiographs e.g. chest X-ray must be interpreted in a stepwise manner e.g. patient name (if relevant), date of obtaining the images, AP or PA view, rotation?, bone and soft tissue, mediastinum width, heart size, hilar regions, costophrenic angles, and lungs. Behind the heart and below the diaphragms must also be assessed including the upper abdomen on a CXR.
Advanced imaging such as CT and MRI scans should have the radiologist interpretation available to review.
🧾 14.
Updated problem list and assessment
The problem list must be updated with the new information obtained from the investigations by adding pertinent lab data abnormalities based on the differential diagnosis, and other tests e.g. abnormalities of the ECG, CXR, CT, MRI, etc.
Assessment of each disorder can then be updated or new problems can be added to the list for further plan determination.
🧾 15.
Final Diagnoses
Include:
Precise terminology (e.g., “Right pleurisy secondary to right lower lobe pneumonia”).
All new / active diagnoses must be listed e.g. 1) polymyositis, 2) newly diagnosed type 2 diabetes mellitus, 3) poorly treated hypertension, 4) untreated osteoporosis
Chronic stable / inactive diagnoses should be listed e.g 1) hyperlipidemia - stable under treatment, 2) chronic obstructive pulmonary disease - stable under treatment.
🧾 16.
Clinical Course
Summarise interventions (e.g., drainage, antibiotic choice).
Note patient response e.g. improvement of symptoms and physical examination findings. These take preference over lab data changes and radiology.
Include complications or evolving findings.
📊 SLIDE PRESENTATION ADVICE
🟢 Format
No more than 7 lines per slide and no more than 7 words per sentence (7x7 rule).
Use large, clear font.
Titles: Bold, capitalised first letter only (DO NOT USE ALL CAPS or [square brackets]). Square brackets are used in Japanese presentations, not English ones.
Italics: avoid in headings. The can be used in subheadings and when writing out the name of bacteria in full e.g. streptococcus pneumoniae.
Underlining: optional but not excessive.
🟢 Presenter Notes - spoken to the audience but not shown.
Main slides: concise summaries.
Presenter notes: use full sentences, detailed analysis, clinical commentary. Use ChatGPT or other AI to improve your English.
Clearly separate audience-visible slides from presenter notes.
HACK!
Copy and paste this page into a Word Document. Then upload the Word file into ChatGPT and ask it to follow these instructions herein to improve your written content (also uploaded at the same time) so that they conform with the above advice. Once ChatGPT has improved the information, and it is agreed by your advisor, then copy and paste the information onto the slides and also create your separate speaker notes.
Version 1: 27th July 2025
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