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Communicating to Other Health Professionals About Your Patient:

Doing Case Presentations

HAIVN Harvard Medical School AIDS

Initiative in Vietnam

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Learning Objectives

By the end of this session, participants should be able to:

Outline the key elements of a case presentation about a person living with HIV/AIDS (PLHIV)

Explain how to prepare and deliver a case presentation about a PLHIV

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What is a Case Presentation?

Presentation which gives all the information necessary for a colleague to understand a patient’s situation

Patient’s “story”: why patient is being seen in clinic or hospital, what has happened until present time

May be long or short, depending upon:• where story is being told• who it is being told to

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Elements of the Case Presentation

Introduction & Chief Complaint History of Present Illness (HPI) Past Medical History

• medical, surgical, including meds and allergies Social History Review of Systems (ROS) Physical examination Laboratory and diagnostic studies Clinical Assessment Treatment Plan Evolution of signs and symptoms and lab tests of

patients after treating

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HIV Case Presentations: Suggestions (1)

Mention most recent known CD4 count and ARV status within the first or second sentence • “Mai, is a 2year old girl who presents

with a chief complaint of cough and fever. She has been on ART for two weeks and her most recent CD4 cell count was 11% three months ago.”

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HIV Case Presentations: Suggestions (2)

Make sure to include pertinent negatives as well as positives.• “Medications include AZT, 3TC, NVP, and

cotrimoxazole..” • “On examination, there was no thrush,

lymphadenopathy, or skin rash.”

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HIV Case Presentations: Suggestions (3)

When discussing past medical history, include intervention for PMTC and any prior OIs and the most common co-morbidities.• “Past medical history includes herpes six

months ago. There is no prior history of TB, HBV infection.”

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HIV Case Presentations: Suggestions (4)

Provide a summary statement (s) as part of your clinical assessment • “In summary, the patient is a 2 year girl

with a CD4 11% who presents with signs and symptoms of respiratory infection after two weeks of ARV therapy.”

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HIV Case Presentations: Suggestions (5)

Evolution followed up on a table ( if long time)

Date 16/10/08 19/02/09 10/9/09 25//5/10

Weight 8.6 kg 9kg 11kg 11.5kg

Height 80cm 82cm 84cm 87cm

Symptom Oral thrush, vomiting , dyspepsia

cough+ fever, hospitalized

Lymph node TB, treated with RHZE

Completion of Anti TB

course

ARVd4T/3TC/NVP

d4T/3TC/NVP

d4T/3TC/EFV D4/3TC/EFV

CD4 0.38%7

4.74%50

12.71%508

20.84%642

ALT 89/70 60/53 27/14

Hb 9.3 8.9 9.1 12

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HIV Case Presentations: Suggestions (6)

Providing some pictures

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Suggested issues to discuss

Besides showed information do you think that the patient has any more clinical matter/ any matter is not clear:• Symptom, diagnosis, tratment, follow

up,…? Do you have any plan for the patient?

• Any more lab test?• Plan for treatment ? How to follow up?

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Pair Activity: Practice Delivering Case Presentations

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Key Points

Goal of case presentation is to present clinical scenario in a clear, concise manner

Case presentations may be used to:• consult with a colleague on a difficult case or • present a case in a conference or workshop

Case presentation should:• include all relevant information• not include facts or details not pertinent to

case After presentation, listener should have a

clear understanding of the case and be able to make a treatment plan for the patient

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Thank you!

Questions?