Why is it important to learn to present the case?

A case presentation in veterinary medicine is a structured method of sharing clinical experiences, observations, and decision-making processes regarding a specific animal patient. It serves as a valuable tool for education, collaboration, and professional growth within the veterinary community. 

A well-structured case presentation is essential for effective communication in veterinary medicine. Whether it’s for academic purposes, clinical rounds, or client discussions, follow this format:

 

Case  presentation  Structure

1.       SIGNALMENT

Describe your patient using a key informations: species, breed, age, sex, reproductive status, and weight.

EXAMPLE

“Luna, a 5-year-old spayed female Labrador Retriver, weighing 25kg.”

2.      PRESENTING COMPLAINT

 

The reason the animal was brought to the hospital.

EXAMPLE

“Luna was presented with a 48-hour history of vomiting and lethargy.”

3.     HISTORY

 

Medical history: Prior illnesses, surgeries, or ongoing treatments, vaccination and deworming status.

Diet and lifestyle: Food, enviroment, activity level, exposure to toxins or infect agents.

History of present illnesses: Detailed account or symptom onset, duration, and progression.

EXAMPLE

“Luna is fed a commercial kibble diet, has no prior illnesses, regularly vaccinated and dewormed (including dates) and is kept indoors. Vomiting started two days ago after a walk in a wooded area without a leash.”

4.     PHYSICAL EXAMINATION

 

 

Triage values and status: Heart rate, breathing frequence, mucose membranes, capillary refill time, body temperature (always say numbers). Based on triage values distinguish if the patient is stable or critical.

Blood pressure measurement: It provides vital information about the patient’s circulatory function, which can support or refute certain differentials (e.g., hypovolemic shock, hypertension, etc.).

Systematic approach: Describe findings head-to-tail or by organ system keeping in mind presenting complain.

EXAMPLE

“Patient is critical since physical exam reveals tachycardia (HR 130/min), tachypnoe (RR 48/min), pale mucous membranes but CRT possible to be measured as prolonged-3 seconds, mild dehydration. Hypotensive with a systolic pressure of 80mmHg. Mild bloated and painful abdomen.”

5.     PROBLEM LIST

 

Summarize the abnormalities observed in history and examination. 

EXAMPLE

1. Vomiting (primary complaint and likely the initiating cause of the other findings)

2. Hypovolemic Shock (encompasses clinical: dehydration, pale mucous membranes, hypotension and tachycardia)

3. Lethargy (a secondary finding likely resulting from vomiting and shock)

6.     DIFFERENTIAL DIAGNOSES

 

Prioritize by likelihood: Based on history, signalment and clinical findings.

EXAMPLE

1. Gastrointestinal foreign body obstruction

2. Acute pancreatitis

3. Hemorrhagic gastroenteritis

4. Toxin ingestion (e.g. rodenticides)

7.      DIAGNOSTIC PLAN

 

Outline tests performed and their justification:

·      Bloodwork: Blood gas, CBC, biochemistry or coagulation profile.

·      Imaging: Radiographs, ultrasound.

·      Additional: Fecal tests, cytology or advanced diagnostics.

EXAMPLE

“Radiographs reveales a linear foreign body extending into the small intestine.”

8.     TREATMENT PLAN

 

Detail interventions, including medical or sugical procedures.

EXAMPLE

“After stabilisation with painkillers, fluids and antinausea medication Luna underwent exploratory laparotomy from foreign body removal. Post-op, she received IV-fluids, antiemetics and pain management.”

9.     OUTCOME

 

Summarize the animal’s response to treatment, prognosis and follow-up.

EXAMPLE

“Luna recovered uneventfully and resumed normal activity within 5 days."

10.    KEY LEARNING POINTS

 

Highlight takeaways for clinical practice or case management.

EXAMPLE

“This case emphasis the importance of early imaging in vomiting patients to rule out surgical emergencies.”

     


Mastering the structured presentation of a case is more than just a professional skill-it is a fundamental aspect of effective veterinary practice. A well-structured case presentation ensures that key details are not overlooked, facilitates logical clinical reasoning, and ultimately leads to more accurate diagnoses and better treatment decisions for our patients.

     However, learning how to present a case effectively is not something that happens overnight. It takes practice, experience, and a willingness to refine the way we communicate complex medical information. As veterinary professionals, we all share the common goal of providing the best possible care for our patients, and strong case presentation skills are a key component of that mission. I encourage my colleagues to embrace structured case presentations as a tool for growth-both for themselves and for making it easier for mentors, supervisors and colleagues to understand and discuss the case effectively.

     By supporting one another in mastering this skill, we enhance teamwork, elevate the standard of veterinary care, and ensure that our patients receive the most informed and well-coordinated treatment possible.

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