How to present a case on medical rounds By: David Guidot, MD

General tips:

1. Tell a story, don’t read from cards or sheets on a clipboard.

2. Practice your presentations before attending rounds.
3. Any case can be presented in 30 seconds if you take the time to organize the most
important aspects.
4. No presentation, no matter how complicated the case, should take more than 5
minutes.
5. Prepare to be interrupted; however, if you practice and master your presentations,
you will find that there will be few interruptions.

Part I: The “overture”

An overture contains all the most important elements of the case in a single, concise
statement. It is absolutely critical that the listener know who the patient is, and why they
are being presented to them, within 20-30 seconds.

A common mistake is for presenters to begin with a long and detailed past history and
history of the present illness, and make the listener wait several minutes (or longer) to
find out why the patient is even in the hospital. This is not a mystery novel! The listener
does not want to wait until the end to find out “whodunnit”.

Examples of “overtures”:

• Mr. Smith is a 53-year-old man with longstanding hypertension,

hypercholesterolemia and type II diabetes who presents with crushing substernal
chest pain of 2 hours duration and anterior ST-segment elevation on his EKG.
• Mrs. Jones is a 49-year-old woman with a 10-year history of systemic lupus
erythematosis complicated by glomerulonephritis for which she receives monthly
cytoxan therapy who presents with massive hemoptysis and a cavitary lesion in
the right upper lobe on chest X-ray.
• Ms. Robertson is a 21-year-old woman with a 3-4 year history of depression
treated with anti-depressants with recurrent admissions for suicidal ideation found
at home obtunded and with an empty bottle of Tylenol at her bedside.

You should compose different overtures for each case and say them out loud until you are
very experienced. After 40 or 50 presentations, you will find that you compose
“overtures” quickly and naturally. Further, you will find that “overtures” are the ideal
way to communicate with colleagues such as radiologists, surgeons, consultants, etc.
Part II: The History of Present Illness (HPI)

The HPI is really nothing more than the “details” underlying the overture. It is best told
as a narrative. Start at the beginning of the story and deliver it in a natural style. Include
only the pertinent positive and negative information. Do not confuse the story with
excessive detail.
Some important tips regarding the HPI:
• Never (I repeat ‘never’) read the HPI. You should “tell” the HPI.
• If you do not know the story, you cannot “tell” the story. Make sure you have the
story straight, and review it multiple times before composing the HPI in your
mind as you prepare your presentation.
• Include those aspects of the social history, past medical history, and family
history that are pertinent to the HPI. For example, if someone presents with lung
cancer, don’t wait until the end of the presentation to discuss smoking history. On
the other hand, do not waste time or attention span on irrelevant details.
• Make eye contact, modulate your tone, and convey your interest. The audience
will enjoy your presentation rather than waiting for it to end.

Part III: The physical exam

The physical exam is usually the weakest part of the presentation. Make sure it is precise
and accurate!
A few tips:
• Provide only the pertinent positive and negative findings, but don’t be afraid to
expand on these critical findings. If a patient presents with a syndrome consistent
with sub-acute bacterial endocarditis, take the time to describe their murmur (or
absence of murmur) in detail, and carefully discuss skin and joint findings (or
their absence).
• Don’t say thinks like “The respiratory exam showed . . .”. It is more elegant to
state simply “His exam was remarkable for diffuse expiratory wheezing and
obvious use of accessory muscles”, or “Her exam was remarkable for jugular
venous distension, bibasilar rales, and a displaced PMI with a loud S3.”
• It is perfectly appropriate to ask the listener if he or she could confirm your
findings or help you explain a finding. For example: “Dr. Smith, I would
appreciate your opinion as to whether or not you think this patient has an S4, as I
was uncertain when I listened.”
Part IV: Past medical history, family history, social history
If anything was not relevant enough to include in the overture or the HPI, you can simply
skip ahead to the laboratory/X-ray studies. If something is extremely interesting, such as
“Mr. Jones is a retired astronaut who was part of the Apollo project” then this is a nice
time to “take a break” and give the listeners a “human interest story”.

Part V: Laboratory and X-ray studies

• Pertinent positives and negatives only!
• Do not read them off unless you absolutely cannot remember a critical value. It is
incredibly impressive to your listener if you can simply tell them the most
important information. More importantly, this reflects how well you know the
case.
• If the potassium was 3.7 and you say it was 3.8, it’s no big deal! However, if it
was 7.7 and you say it was 3.8, you don’t know the case and reading from a card
won’t fix that!

Part VI: Assessments and Plans

This is absolutely vital for you to demonstrate your understanding of the case.
Unfortunately, listeners are often so “fatigued” by bad presentations by this time that it is
hard to dazzle them. However, this is really the time to dazzle!

• Concisely and confidently summarize the case. Use the same approach you used
to create a compelling overture. Practice multiple versions of your summary
until it sounds really sharp.
• Organize the problems in order of importance, and then provide your differential
diagnosis for each problem. Even if the diagnosis for a given problem is fairly
obvious, show the listener that you have considered other reasonable diagnoses.
• Do not be afraid to tell the listener what you did and why, and what you plan to
do now and in the future. If the listener disagrees, they will nevertheless be
impressed that you are intellectually engaged and making decisions. More
importantly, if they agree with you, then you will get a standing ovation!

Final tip: This is one of the most important skills you can acquire as a physician,
and is far and away the most important skill you need as a medical student
and intern. Remember the old joke: “How do you get to Carnegie Hall?
Practice, practice, practice.”