A generally healthy 59-year old post-menopausal woman has had incrementally increasing LDL levels in blood test results over the past few years. You had warned her of the need to get this under control as she had been on HRT for severe vasomotor complications during menopause which could have increased her overall risk for cardiovascular complications. At her last visit, you recommended diet changes and increased exercise as a means to naturally bring her hyperlipidemia under control. Being a diligent patient, she has made these changes, e.g., cutting back to 1% milk and increasing the length of her evening walk. But today, with her LDL still high, you have suggested she add a low-dose statin. She accepts your recommendation, puts the prescription in her pocketbook but just before leaving, she says “what about avocados?” She goes on to say that she was at a Mexican restaurant recently and overheard a group of women at the table behind her talking about cholesterol. One of the women said “I saw on the Internet that avocado can help lower cholesterol so I am going to eat a lot more guacamole!” Your patients asks “is this for real?”
Is there any indication that avocado can be effective for lowering cholesterol?
What, if any, is the strength of evidence supporting this?
Is the efficacy clinically significant?
How much avocado would one need to take to attain a therapeutic level?
In what form, e.g., raw fruit, extract, guacamole with nachos, is the appropriate mechanism for action?
Source: BSIP SA / Alamy Stock Photo
A case presentation is a narrative of a patient’s care, so it is vital the presenter has familiarity with the patient, the case and its progression
A case presentation is a detailed narrative describing a specific problem experienced by one or more patients. Pharmacists usually focus on the medicines aspect, for example, where there is potential harm to a patient or proven benefit to the patient from medication, or where a medication error has occurred. Case presentations can be used as a pedagogical tool, as a method of appraising the presenter’s knowledge and as an opportunity for presenters to reflect on their clinical practice.
The aim of an oral presentation is to disseminate information about a patient for the purpose of education, to update other members of the healthcare team on a patient’s progress, and to ensure the best, evidence-based care is being considered for their management.
Within a hospital, pharmacists are likely to present patients on a teaching or daily ward round or to a senior pharmacist or colleague for the purpose of asking advice on, for example, treatment options or complex drug-drug interactions, or for referral.
Content of a case presentation
As a general structure, an oral case presentation may be divided into three phases:
- Reporting important patient information and clinical data;
- Analysing and synthesising identified issues (this is likely to include producing a list of these issues, generally termed a problem list);
- Managing the case by developing a therapeutic plan.
Specifically, the following information should be included:
Patient and complaint details
Patient details: name, sex, age, ethnicity.
Presenting complaint: the reason the patient presented to the hospital (symptom/event).
History of presenting complaint: highlighting relevant events in chronological order, often presented as how many days ago they occurred. This should include prior admission to hospital for the same complaint.
Review of organ systems: listing positive or negative findings found from the doctor’s assessment that are relevant to the presenting complaint.
Past medical and surgical history
Social history: including occupation, exposures, smoking and alcohol history, and any recreational drug use.
Medication history, including any drug allergies: this should include any prescribed medicines, medicines purchased over-the-counter, any topical preparations used (including eye drops, nose drops, inhalers and nasal sprays) and any herbal or traditional remedies taken.
Sexual history: if this is relevant to the presenting complaint.
Details from a physical examination: this includes any relevant findings to the presenting complaint and should include relevant observations.
Laboratory investigation and imaging results: abnormal findings are presented.
Assessment: including differential diagnosis.
Plan: including any pharmaceutical care issues raised and how these should be resolved, ongoing management and discharge planning.
Any discrepancies between the current management of the patient’s conditions and evidence-based recommendations should be highlighted and reasons given for not adhering to evidence-based medicine (see ‘Locating the evidence’).
Locating the evidence
The evidence base for the therapeutic options available should always be considered. There may be local guidance available within the hospital trust directing the management of the patient’s presenting condition. Pharmacists often contribute to the development of such guidelines, especially if medication is involved. If no local guidelines are available, the next step is to refer to national guidance. This is developed by a steering group of experts, for example, the British HIV Association or the National Institute for Health and Care Excellence. If the presenting condition is unusual or rare, for example, acute porphyria, and there are no local or national guidelines available, a literature search may help locate articles or case studies similar to the case.
Giving a case presentation
Currently, there are no available acknowledged guidelines or systematic descriptions of the structure, language and function of the oral case presentation and therefore there is no standard on how the skills required to prepare or present a case are taught. Most individuals are introduced to this concept at undergraduate level and then build on their skills through practice-based learning.
A case presentation is a narrative of a patient’s care, so it is vital the presenter has familiarity with the patient, the case and its progression. The preparation for the presentation will depend on what information is to be included.
Generally, oral case presentations are brief and should be limited to 5–10 minutes. This may be extended if the case is being presented as part of an assessment compared with routine everyday working (see ‘Case-based discussion’). The audience should be interested in what is being said so the presenter should maintain this engagement through eye contact, clear speech and enthusiasm for the case.
It is important to stick to the facts by presenting the case as a factual timeline and not describing how things should have happened instead. Importantly, the case should always be concluded and should include an outcome of the patient’s care.
An example of an oral case presentation, given by a pharmacist to a doctor, is available here.
A successful oral case presentation allows the audience to garner the right amount of patient information in the most efficient way, enabling a clinically appropriate plan to be developed. The challenge lies with the fact that the content and delivery of this will vary depending on the service, and clinical and audience setting. A practitioner with less experience may find understanding the balance between sufficient information and efficiency of communication difficult, but regular use of the oral case presentation tool will improve this skill.
Tailoring case presentations to your audience
Most case presentations are not tailored to a specific audience because the same type of information will usually need to be conveyed in each case.
However, case presentations can be adapted to meet the identified learning needs of the target audience, if required for training purposes. This method involves varying the content of the presentation or choosing specific cases to present that will help achieve a set of objectives. For example, if a requirement to learn about the management of acute myocardial infarction has been identified by the target audience, then the presenter may identify a case from the cardiology ward to present to the group, as opposed to presenting a patient reviewed by that person during their normal working practice.
Alternatively, a presenter could focus on a particular condition within a case, which will dictate what information is included. For example, if a case on asthma is being presented, the focus may be on recent use of bronchodilator therapy, respiratory function tests (including peak expiratory flow rate), symptoms related to exacerbation of airways disease, anxiety levels, ability to talk in full sentences, triggers to worsening of symptoms, and recent exposure to allergens. These may not be considered relevant if presenting the case on an unrelated condition that the same patient has, for example, if this patient was admitted with a hip fracture and their asthma was well controlled.
The oral case presentation may also act as the basis of workplace-based assessment in the form of a case-based discussion. In the UK, this forms part of many healthcare professional bodies’ assessment of clinical practice, for example, medical professional colleges.
For pharmacists, a case-based discussion forms part of the Royal Pharmaceutical Society (RPS) Foundation and Advanced Practice assessments. Mastery of the oral case presentation skill could provide useful preparation for this assessment process.
A case-based discussion would include a pharmaceutical needs assessment, which involves identifying and prioritising pharmaceutical problems for a particular patient. Evidence-based guidelines relevant to the specific medical condition should be used to make treatment recommendations, and a plan to monitor the patient once therapy has started should be developed. Professionalism is an important aspect of case-based discussion — issues must be prioritised appropriately and ethical and legal frameworks must be referred to. A case-based discussion would include broadly similar content to the oral case presentation, but would involve further questioning of the presenter by the assessor to determine the extent of the presenter’s knowledge of the specific case, condition and therapeutic strategies. The criteria used for assessment would depend on the level of practice of the presenter but, for pharmacists, this may include assessment against the RPS Foundation or Pharmacy Frameworks.
With thanks to Aamer Safdar for providing the script for the audio case presentation.
Citation: The Pharmaceutical Journal, March 2016, Vol 296, No 7887, online | DOI: 10.1211/PJ.2016.20200876
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