CHPPC Module 11, Section 4: Presenting a Patient Case
MODULE 11: PROFESSIONAL PRACTICE & COMMUNICATION

Section 4: Presenting a Patient Case

Welcome to the capstone of your communication training. Every skill you have developed thus far—clarifying orders with nurses, making SBAR recommendations to physicians, and writing defensible clinical notes—culminates in this single, comprehensive act: the formal patient case presentation. This is the ultimate synthesis of your clinical knowledge and professional communication. Here, you will learn the structured, narrative art of presenting a patient’s entire story from a pharmacotherapy perspective. Mastering this skill is what transforms you from a participant in care to a leader in medication management.

4.1 Why Case Presentations Matter: The Synthesis of Your Role

Moving from discrete interventions to a holistic patient narrative.

In your daily workflow, you will make dozens of small, critical interventions: adjusting a dose, recommending a switch, clarifying a sig. A case presentation is different. It is your opportunity to step back and tell the patient’s complete medication story. It demonstrates to the entire medical team that you have a comprehensive grasp of the patient’s history, their current problems, and the rationale for every single medication they are taking. It is the most powerful tool you have to showcase your value, build trust, and influence the overall therapeutic strategy in a profound way.

Retail Pharmacist Analogy: The Comprehensive MTM Session on Steroids

Think of the most complex Medication Therapy Management (MTM) case you’ve ever handled. A patient with 25 medications from 6 different doctors, with questionable adherence and multiple drug-related problems. To prepare, you didn’t just look at one prescription. You performed a full medication reconciliation, you analyzed their conditions, you identified duplications and interactions, and you developed a concrete medication action plan. Then, you sat down with the patient and, in a structured way, presented your findings and your plan. You might have even followed up with a formal summary to their primary care physician.

A hospital case presentation is the inpatient evolution of that exact process. Your ‘MTM session’ is the daily chart review. Your ‘patient’ is the medical team. And your ‘presentation’ is a highly structured, formal narrative delivered during rounds or a case conference. You are taking all the disparate data points and weaving them into a coherent story that culminates in your expert pharmacotherapeutic plan. The core skill of systematic review and structured presentation is one you have been honing for your entire career.

The Purpose of the Formal Presentation

A formal case presentation serves several critical functions beyond simple data relay:

  • Demonstrates Ownership: It signals to the team that you have taken full professional responsibility for the patient’s medication therapy.
  • Ensures Alignment: By systematically reviewing the case, you ensure everyone on the team is operating from the same set of facts and agrees on the therapeutic goals.
  • Educates the Team: It is a primary tool for teaching medical students and junior residents about complex pharmacotherapy, solidifying your role as an educator.
  • Exposes Clinical Reasoning: It forces you to articulate your thought process, justifying your recommendations with evidence and clinical data, which sharpens your own skills.
  • Identifies Therapeutic Gaps: The structured process often reveals subtle medication problems or opportunities for optimization that might be missed in a routine daily review.

4.2 The Anatomy of a Formal Patient Case Presentation

The universal, structured format for telling the patient’s story.

A case presentation follows a rigid, universally understood structure. This is not a place for creativity; the predictability of the format is what allows listeners to easily follow along and absorb complex information. Your task is to populate this structure with the relevant details from your patient’s chart, focusing on the pharmacotherapy implications at each step.

The Standard Presentation Flow

This is the skeleton of your presentation. Commit it to memory.

Section Content Pharmacist’s Focus
One-Liner A single, concise sentence summarizing the patient. Includes age, sex, relevant PMH, and reason for admission. “Mr. Doe is a 68-year-old male with a history of CAD and HFrEF who presents with…”
Chief Complaint (CC) The main reason for seeking care, ideally in the patient’s own words. “Patient states, ‘I couldn’t catch my breath.'”
History of Present Illness (HPI) A detailed narrative of the illness from the first symptom to the present. Listen for clues about precipitating factors. Did they run out of their diuretic? Did they recently start an NSAID?
Past Medical/Surgical History (PMH/PSH) A list of active and chronic medical problems and past surgeries. Crucial for understanding comorbidities that affect drug choice (e.g., renal disease, liver disease).
Home Medications & Allergies A complete list of home meds (Rx, OTC, supplements) and all documented allergies. This is your domain. Note adherence issues. Are they on high-risk meds? Is their home regimen optimized?
Social & Family History Tobacco, alcohol, illicit drug use. Relevant family medical history. Identifies risks for drug-drug or drug-disease interactions (e.g., alcohol use with APAP, smoking’s effect on drug metabolism).
Objective Data Vitals, physical exam findings, labs, microbiology, imaging. Connect the data to drug therapy. Is the K+ low because of the diuretic? Is the WBC high despite antibiotics?
Hospital Course A brief summary of events since admission. Summarize major therapeutic interventions. “The patient was started on IV furosemide and antibiotics…”
Assessment & Plan (A&P) A problem-based list assessing each issue and outlining the plan. The heart of your presentation. This is where you make your mark with your medication-specific assessments and recommendations.

4.3 The Pharmacist’s Assessment and Plan: A Problem-Based Approach

Organizing your expertise for maximum impact and clarity.

The Assessment and Plan (A&P) is where you stop being a reporter of facts and become a clinical consultant. While a physician’s A&P covers all aspects of care (diagnostics, consults, disposition), your A&P is laser-focused on pharmacotherapy. The most effective way to present this is through a numbered, problem-based list. For each of the patient’s active medical problems, you will provide a concise assessment of the current medication therapy and your plan for optimization.

Structuring Your Problem List

You should address the most acute problem first, followed by other active issues. For each problem, clearly separate your Assessment from your Plan.

  • Assessment: Briefly analyze the appropriateness of the current drug therapy for that problem. Is it effective? Is it safe? Is it optimal? Use data from your objective section to support your claims.
  • Plan: State your specific, actionable recommendations. This can include continuing, discontinuing, or modifying therapy, as well as necessary monitoring.

Deep Dive: Always Include Prophylaxis

A hallmark of a thorough pharmacist case presentation is the inclusion of medication issues that are not tied to a specific diagnosis but are critical to inpatient safety. You should always include separate “problems” for VTE (venous thromboembolism) and SUP (stress ulcer) prophylaxis.

  • VTE Prophylaxis Assessment: Based on the patient’s risk factors (e.g., Padua score), are they at high risk for a blood clot? Is the current method of prophylaxis (mechanical or pharmacological) appropriate?
  • SUP Prophylaxis Assessment: Based on risk factors (e.g., mechanical ventilation, coagulopathy), does the patient require a PPI or H2RA to prevent a stress-related bleed? Or, conversely, are they on a PPI without a valid indication that could be discontinued?

Addressing these routinely demonstrates your comprehensive approach to medication safety and your mastery of hospital-based standards of care.

Example A&P Structure

Let’s take a patient with three active problems. Your A&P section of the presentation would sound like this:

"...And that concludes the hospital course. Moving to the Assessment and Plan, from a pharmacy perspective:

#1. Acute Decompensated Heart Failure:
   Assessment: Patient presented with significant volume overload, which is improving with IV diuresis. Current furosemide dose of 40mg IV BID is effective, as evidenced by a 3kg weight loss and improving respiratory status. His home ACE inhibitor is being held appropriately in the setting of his concurrent AKI.
   Plan: Continue IV furosemide and monitor daily weights and net fluid balance. Will reassess for transitioning to PO diuretics tomorrow. Will re-evaluate for restarting his home lisinopril once his renal function has recovered.

#2. Acute Kidney Injury:
   Assessment: Patient's creatinine rose from a baseline of 1.1 to 1.9, likely pre-renal in nature due to aggressive diuresis. There are no other nephrotoxic agents on board.
   Plan: Continue holding home lisinopril. Monitor SCr daily. Ensure patient has adequate oral fluid intake as tolerated.

#3. VTE Prophylaxis:
   Assessment: Patient has a high risk of VTE due to immobility and acute illness. The current order for heparin 5000 units SUBQ TID is appropriate pharmacological prophylaxis.
   Plan: Continue heparin TID while inpatient.
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4.4 Putting It All Together: A Full Patient Case Presentation Example

From the one-liner to the final recommendation: A complete case script.

Now we will synthesize every element into a single, comprehensive example. This is the script you would use when asked to present a patient on rounds. Read it aloud to get a feel for the rhythm and flow. This example represents the gold standard for a clinical pharmacist’s case presentation.

Case: Ms. Eleanor Vance

Clinical Context: You are the pharmacist rounding with the internal medicine team. You are asked to present Ms. Vance, a patient admitted two days ago.

Pharmacist Case Presentation Script: Ms. Vance

"Good morning. I'll be presenting Eleanor Vance in room 612.

(One-Liner)
Ms. Vance is a 74-year-old female with a past medical history of type 2 diabetes, hypertension, and osteoarthritis who was admitted two days ago for community-acquired pneumonia.

(HPI)
Her history of present illness is a 4-day history of productive cough, fever, and progressive shortness of breath, which worsened yesterday morning, prompting her to come to the ED. In the ED, she was found to be febrile to 38.8°C, tachycardic, and hypoxemic, requiring 2L of nasal cannula. A chest X-ray revealed a right lower lobe infiltrate.

(PMH/PSH)
Her past medical history is significant for:
- Type 2 Diabetes for 15 years, complicated by neuropathy
- Hypertension
- Osteoarthritis of both knees
She had a cholecystectomy in 2010.

(Home Meds & Allergies)
Her home medications include:
- Metformin 1000mg BID
- Lisinopril 20mg daily
- Amlodipine 10mg daily
- Ibuprofen 600mg TID PRN for knee pain, which she reports taking daily for the past 2 weeks.
She has a documented allergy to Penicillin, which she says caused a rash.

(Social/Family Hx)
Social history is negative for tobacco, alcohol, or illicit drug use. She lives alone. Family history is non-contributory.

(Objective Data)
On admission, pertinent vitals included a temp of 38.8 and BP of 155/90. Her labs were significant for a WBC of 18.5, a serum creatinine of 2.1 mg/dL, and a blood glucose of 240. Her baseline creatinine from 3 months ago was 1.0 mg/dL. Sputum and blood cultures were drawn in the ED and are pending.

(Hospital Course)
In the hospital, she was started on ceftriaxone and azithromycin for community-acquired pneumonia. Her metformin and lisinopril were held due to her acute kidney injury. She was started on an insulin sliding scale for hyperglycemia and enoxaparin for VTE prophylaxis. Over the past 48 hours, her fever has resolved, and her WBC has trended down to 12.1. Her creatinine, however, has remained elevated at 2.0 this morning.

(Assessment & Plan)
From a pharmacy perspective, my assessment and plan are as follows:

#1. Community-Acquired Pneumonia:
   Assessment: Patient is responding appropriately to ceftriaxone and azithromycin, as shown by resolution of fever and downtrending WBC. She is on day 3 of therapy. She is now tolerating a diet.
   Plan: I recommend we transition her from IV to PO antibiotics today. Specifically, discontinue IV ceftriaxone and azithromycin and start oral cefpodoxime and azithromycin to complete a 5-day course.

#2. Acute Kidney Injury:
   Assessment: The patient's AKI is likely multifactorial, secondary to dehydration from her acute illness, but almost certainly exacerbated by her recent heavy use of ibuprofen at home. Her home lisinopril could also be a contributing factor.
   Plan: Continue holding home metformin and lisinopril. Ensure the PRN order for ibuprofen on her profile is discontinued and she is counseled to avoid NSAIDs. Recommend scheduled APAP for her knee pain as a safer alternative. Continue to monitor renal function daily.

#3. Hyperglycemia:
   Assessment: Her hyperglycemia is likely a result of her acute infection and the holding of her home metformin. The current insulin sliding scale is providing adequate coverage, but she required 3 doses yesterday.
   Plan: Continue the insulin sliding scale for now. As her infection resolves and her diet normalizes, we can consider adding a long-acting basal insulin like glargine if she continues to require frequent short-acting insulin.

#4. VTE Prophylaxis:
   Assessment: She is at high risk for VTE and is on an appropriate dose of enoxaparin for prophylaxis, adjusted for her current renal dysfunction.
   Plan: Continue current dose of enoxaparin 30mg SUBQ daily.

In summary, my main recommendations are to switch antibiotics to PO, ensure NSAIDs are stopped and APAP is ordered for pain, and continue to monitor her renal function and glucose control closely.
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