Author declares no conflict of interest.

In addition to the presenter, following authors who may have helped with the content writing, review, or approval declare no conflict of interest.

  • Dr. Mobeen Syed
  • Dr. Pei Purdom (DNP)
  • Dr. Benish Zahra
  • Dr. Iqra Batool
  • Dr. Heba Alzawahri

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History of Presenting Illness

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Thank you very much Dr. Zaafran for a great presentation! I express my sincerest appreciation listening to your lecture and im very happy to review back the basics.

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In this foundational talk. Dr. Zaafran discusses the case presentation and the components of an effective clinical communication.



The following topics are discussed

Case Presentation

  1. Timing
  2. Reciting the case
  3. Using the notes

Module Overview

  • Chief complaint
  • History of the present illness
  • Past medical history
  • Medications
  • Medication allergies
  • Social history
  • Family history
  • Review of systems (specify only pertinent positive and negative findings) • Physical Exam
  • Labs and Tests
  • Assessment and Plan

Physical Examination

  • Vitals (Be sure to write 24 hour ranges) • Blood Pressure
    • Heart Rate
    • Respiratory Rate
    • O2 Saturation • Temperature • Pain (+/-)
  • Generalized

  • Focused

  • General- Normal Appearance vs. lethargic, disheveled


  • Chest- nl d1, s2 RRR no m/r/g

  • Lungs- CTA B

  • Abdomen- soft, non distended, bowel sounds regular on ascultation • Extremties- no edema, lesions, breaks, etc.

  • Neuro- A & O x 4 (Person, place, time, situation) CN II-XII intact


Laboratory Results and Studies

Assessment and Plan



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Course Objectives

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Course Outcomes

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My Notes



Ahmed Zaafran, MD

Ahmed Zaafran, M.D, is a practicing anesthesiologist at Santa Clara Valley Medical Center. He is also an adjunct clinical assistant professor of anesthesiology at Stanford University School of Medicine.

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