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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Case study: 60-year-old female presenting with shortness of breath.

Deepa Rawat ; Sandeep Sharma .

Affiliations

Last Update: February 20, 2023 .

• Case Presentation

The patient is a 60-year-old white female presenting to the emergency department with acute onset shortness of breath.  Symptoms began approximately 2 days before and had progressively worsened with no associated, aggravating, or relieving factors noted. She had similar symptoms approximately 1 year ago with an acute, chronic obstructive pulmonary disease (COPD) exacerbation requiring hospitalization. She uses BiPAP ventilatory support at night when sleeping and has requested to use this in the emergency department due to shortness of breath and wanting to sleep.

She denies fever, chills, cough, wheezing, sputum production, chest pain, palpitations, pressure, abdominal pain, abdominal distension, nausea, vomiting, and diarrhea.

She reports difficulty breathing at rest, forgetfulness, mild fatigue, feeling chilled, requiring blankets, increased urinary frequency, incontinence, and swelling in her bilateral lower extremities that are new-onset and worsening. Subsequently, she has not ambulated from bed for several days except to use the restroom due to feeling weak, fatigued, and short of breath.

There are no known ill contacts at home. Her family history includes significant heart disease and prostate malignancy in her father. Social history is positive for smoking tobacco use at 30 pack years. She quit smoking 2 years ago due to increasing shortness of breath. She denies all alcohol and illegal drug use. There are no known foods, drugs, or environmental allergies.

Past medical history is significant for coronary artery disease, myocardial infarction, COPD, hypertension, hyperlipidemia, hypothyroidism, diabetes mellitus, peripheral vascular disease, tobacco usage, and obesity.  Past surgical history is significant for an appendectomy, cardiac catheterization with stent placement, hysterectomy, and nephrectomy.

Her current medications include fluticasone-vilanterol 100-25 mcg inhaled daily, hydralazine 50 mg by mouth, 3 times per day, hydrochlorothiazide 25 mg by mouth daily, albuterol-ipratropium inhaled every 4 hours PRN, levothyroxine 175 mcg by mouth daily, metformin 500 mg by mouth twice per day, nebivolol 5 mg by mouth daily, aspirin 81 mg by mouth daily, vitamin D3 1000 units by mouth daily, clopidogrel 75 mg by mouth daily, isosorbide mononitrate 60 mg by mouth daily, and rosuvastatin 40 mg by mouth daily.

Physical Exam

Initial physical exam reveals temperature 97.3 F, heart rate 74 bpm, respiratory rate 24, BP 104/54, HT 160 cm, WT 100 kg, BMI 39.1, and O2 saturation 90% on room air.

Constitutional:  Extremely obese, acutely ill-appearing female. Well-developed and well-nourished with BiPAP in place. Lying on a hospital stretcher under 3 blankets.

HEENT: 

• Head: Normocephalic and atraumatic
• Mouth: Moist mucous membranes 
• Macroglossia
• Eyes: Conjunctiva and EOM are normal. Pupils are equal, round, and reactive to light. No scleral icterus. Bilateral periorbital edema present.
• Neck: Neck supple. No JVD present. No masses or surgical scarring. 
• Throat: Patent and moist

Cardiovascular:  Normal rate, regular rhythm, and normal heart sound with no murmur. 2+ pitting edema bilateral lower extremities and strong pulses in all four extremities.

Pulmonary/Chest:  No respiratory status distress at this time, tachypnea present, (+) wheezing noted, bilateral rhonchi, decreased air movement bilaterally. The patient was barely able to finish a full sentence due to shortness of breath.

Abdominal:  Soft. Obese. Bowel sounds are normal. No distension and no tenderness

Skin: Skin is very dry

Neurologic: Alert, awake, able to protect her airway. Moving all extremities. No sensation losses

• Initial Evaluation

Initial evaluation to elucidate the source of dyspnea was performed and included CBC to establish if an infectious or anemic source was present, CMP to review electrolyte balance and review renal function, and arterial blood gas to determine the PO2 for hypoxia and any major acid-base derangement, creatinine kinase and troponin I to evaluate the presence of myocardial infarct or rhabdomyolysis, brain natriuretic peptide, ECG, and chest x-ray. Considering that it is winter and influenza is endemic in the community, a rapid influenza assay was obtained as well.

Largely unremarkable and non-contributory to establish a diagnosis.

Showed creatinine elevation above baseline from 1.08 base to 1.81, indicating possible acute injury. EGFR at 28 is consistent with chronic renal disease. Calcium was elevated to 10.2. However, when corrected for albumin, this corrected to 9.8 mg/dL. Mild transaminitis is present as seen in alkaline phosphatase, AST, and ALT measurements which could be due to liver congestion from volume overload.

Initial arterial blood gas with pH 7.491, PCO2 27.6, PO2 53.6, HCO3 20.6, and oxygen saturation 90% on room air, indicating respiratory alkalosis with hypoxic respiratory features.

Creatinine kinase was elevated along with serial elevated troponin I studies. In the setting of her known chronic renal failure and acute injury indicated by the above creatinine value, a differential of rhabdomyolysis is determined.

Influenza A and B: Negative

Normal sinus rhythm with non-specific ST changes in inferior leads. Decreased voltage in leads I, III, aVR, aVL, aVF.

Chest X-ray

Findings: Bibasilar airspace disease that may represent alveolar edema. Cardiomegaly noted. Prominent interstitial markings were noted. Small bilateral pleural effusions

Radiologist Impression: Radiographic changes of congestive failure with bilateral pleural effusions greater on the left compared to the right

• Differential Diagnosis
• Acute on chronic COPD exacerbation
• Acute on chronic renal failure
• Bacterial pneumonia
• Congestive heart failure
• Pericardial effusion
• Hypothyroidism
• Influenza pneumonia
• Pulmonary edema
• Pulmonary embolism
• Confirmatory Evaluation

On the second day of the admission patient’s shortness of breath was not improved, and she was more confused with difficulty arousing on conversation and examination. To further elucidate the etiology of her shortness of breath and confusion, the patient's husband provided further history. He revealed that she is poorly compliant with taking her medications. He reports that she “doesn’t see the need to take so many pills.”

Testing was performed to include TSH, free T4, BNP, repeated arterial blood gas, CT scan of the chest, and echocardiogram. TSH and free T4 evaluate hypothyroidism. BNP evaluates fluid load status and possible congestive heart failure. CT scan of the chest will look for anatomical abnormalities. An echocardiogram is used to evaluate left ventricular ejection fraction, right ventricular function, pulmonary artery pressure, valvular function, pericardial effusion, and any hypokinetic area.

• TSH: 112.717 (H)
• Free T4: 0.56 (L)
• TSH and Free T4 values indicate severe primary hypothyroidism. 

BNP can be falsely low in obese patients due to the increased surface area. Additionally, adipose tissue has BNP receptors which augment the true BNP value. Also, African American patients with more excretion may have falsely low values secondary to greater excretion of BNP. This test is not that helpful in renal failure due to the chronic nature of fluid overload. This allows for desensitization of the cardiac tissues with a subsequent decrease in BNP release.

Repeat arterial blood gas on BiPAP ventilation shows pH 7.397, PCO2 35.3, PO2 72.4, HCO3 21.2, and oxygen saturation 90% on 2 L supplemental oxygen.

CT chest without contrast was primarily obtained to evaluate the left hemithorax, especially the retrocardiac area.

Radiologist Impression: Tiny bilateral pleural effusions. Pericardial effusion. Coronary artery calcification. Some left lung base atelectasis with minimal airspace disease.

Echocardiogram

The left ventricular systolic function is normal. The left ventricular cavity is borderline dilated.

The pericardial fluid is collected primarily posteriorly, laterally but not apically. There appeared to be a subtle, early hemodynamic effect of the pericardial fluid on the right-sided chambers by way of an early diastolic collapse of the RA/RV and delayed RV expansion until late diastole. A dedicated tamponade study was not performed. 

The estimated ejection fraction appears to be in the range of 66% to 70%. The left ventricular cavity is borderline dilated.

The aortic valve is abnormal in structure and exhibits sclerosis.

The mitral valve is abnormal in structure. Mild mitral annular calcification is present. There is bilateral thickening present. Trace mitral valve regurgitation is present.

• Myxedema coma or severe hypothyroidism
• Pericardial effusion secondary to myxedema coma
• COPD exacerbation
• Acute on chronic hypoxic respiratory failure
• Acute respiratory alkalosis
• Bilateral community-acquired pneumonia
• Small bilateral pleural effusions
• Acute mild rhabdomyolysis
• Acute chronic, stage IV, renal failure
• Elevated troponin I levels, likely secondary to Renal failure 
• Diabetes mellitus type 2, non-insulin-dependent
• Extreme obesity
• Hepatic dysfunction

The patient was extremely ill and rapidly decompensating with multisystem organ failure, including respiratory failure, altered mental status, acute on chronic renal failure, and cardiac dysfunction. The primary concerns for the stability of the patient revolved around respiratory failure coupled with altered mental status. In the intensive care unit (ICU), she rapidly began to fail BiPAP therapy. Subsequently, the patient was emergently intubated in the ICU.  A systemic review of therapies and hospital course is as follows:

Considering the primary diagnosis of myxedema coma, early supplementation with thyroid hormone is essential. Healthcare providers followed the American Thyroid Association recommendations, which recommend giving combined T3 and T4 supplementation; however, T4 alone may also be used. T3 therapy is given as a bolus of 5 to 20 micrograms intravenously and continued at 2.5 to 10 micrograms every 8 hours. An intravenous loading dose of 300 to 600 micrograms of T4 is followed by a daily intravenous dose of 50 to 100 micrograms. Repeated monitoring of TSH and T4 should be performed every 1 to 2 days to evaluate the effect and to titrate the dose of medication. The goal is to improve mental function. Until coexistent adrenal insufficiency is ruled out using a random serum cortisol measurement, 50 to 100 mg every 8 hours of hydrocortisone should be administered. In this case, clinicians used hydrocortisone 100 mg IV every 8 hours. Dexamethasone 2 to 4 mg every 12 hours is an alternative therapy.

The patient’s mental status rapidly worsened despite therapy. In the setting of her hypothyroidism history, this may be myxedema coma or due to the involvement of another organ system. The thyroid supplementation medications and hydrocortisone were continued. A CT head without contrast was normal.

Respiratory

For worsening metabolic acidosis and airway protection, the patient was emergently intubated. Her airway was deemed high risk due to having a large tongue, short neck, and extreme obesity. As the patient’s heart was preload dependent secondary to pericardial effusion, a 1-liter normal saline bolus was started. Norepinephrine was started at a low dose for vasopressor support, and ketamine with low dose Propofol was used for sedation. Ketamine is a sympathomimetic medication and usually does not cause hypotension as all other sedatives do. The patient was ventilated with AC mode of ventilation, tidal volume of 6 ml/kg ideal body weight, flow 70, initial fio2 100 %, rate 26 per minute (to compensate for metabolic acidosis), PEEP of 8.

Cardiovascular

She was determined to be hemodynamically stable with a pericardial effusion. This patient’s cardiac dysfunction was diastolic in nature, as suggested by an ejection fraction of 66% to 70%. The finding of posterior pericardial effusion further supported this conclusion. The posterior nature of this effusion was not amenable to pericardiocentesis. As such, this patient was preload dependent and showed signs of hypotension. The need for crystalloid fluid resuscitation was balanced against the impact increased intravascular volume would have on congestive heart failure and fluid overload status. Thyroid hormone replacement as above should improve hypotension. However, vasopressor agents may be used to maintain vital organ perfusion targeting a mean arterial pressure of greater than 65 mm Hg as needed. BP improved after fluid bolus, and eventually, the norepinephrine was stopped. Serial echocardiograms were obtained to ensure that the patient did not develop tamponade physiology. Total CK was elevated, which was likely due to Hypothyroidism compounded with chronic renal disease.

Infectious Disease

Blood cultures, urine analysis, and sputum cultures were obtained. The patient's white blood cell count was normal. This is likely secondary to her being immunocompromised due to hypothyroidism and diabetes. In part, the pulmonary findings of diffuse edema and bilateral pleural effusions can be explained by cardiac dysfunction. Thoracentesis of pleural fluid was attempted, and the fluid was analyzed for cytology and gram staining to rule out infectious or malignant causes as both a therapeutic and diagnostic measure. Until these results return, broad-spectrum antibiotics are indicated and may be discontinued once the infection is ruled out completely.

Gastrointestinal

Nasogastric tube feedings were started on the patient after intubation. She tolerated feedings well. AST and ALT were mildly elevated, which was thought to be due to hypothyroidism, and as the TSH and free T4 improved, her AST and ALT improved. Eventually, these values became normal once her TSH level was close to 50.

Her baseline creatinine was found to be close to 1.08 in prior medical records. She presented with a creatinine of 1.8 in the emergency department. Since hypothyroidism causes fluid retention in part because thyroid hormone encourages excretion of free water and partly due to decreased lymphatic function in returning fluid to vascular circulation.  Aggressive diuresis was attempted. As a result, her creatinine increased initially but improved on repeated evaluation, and the patient had a new baseline creatinine of 1.6. Overall she had a net change in the fluid status of 10 liters negative by her ten days of admission in the ICU.

Mildly anemic otherwise, WBC and platelet counts were normal. Electrolyte balance should be monitored closely, paying attention to sodium, potassium, chloride, and calcium specifically as these are worsened in both renal failure and myxedema. 

Daily sedation vacations were enacted, and the patient's mental status improved and was much better when TSH was around 20. The bilateral pleural effusions improved with aggressive diuresis. Breathing trials were initiated when the patient's fio2 requirements decreased to 60% and a PEEP of 8. She was eventually extubated onto BiPAP and then high-flow nasal cannula while off of BiPAP. Pericardial fluid remained stable, and no cardiac tamponade pathology developed. As a result, it was determined that a pericardial window was unnecessary. Furthermore, she was not a candidate for pericardiocentesis as the pericardial effusion was located posterior to the heart. Her renal failure improved with improved cardiac function, diuretics, and thyroid hormone replacement.

After extubation patient had speech and swallow evaluations and was able to resume an oral diet. The patient was eventually transferred out of the ICU to the general medical floor and eventually to a rehabilitation unit.

Despite the name myxedema coma, most patients will not present in a coma status. This illness is at its core a severe hypothyroidism crisis that leads to systemic multiorgan failure. Thyroid hormones T3, and to a lesser extent, T4 act directly on a cellular level to upregulate all metabolic processes in the body. Therefore, deficiency of this hormone is characterized by systemic decreased metabolism and decreased glucose utilization along with increased production and storage of osmotically active mucopolysaccharide protein complexes into peripheral tissues resulting in diffuse edema and swelling of tissue. [1]

Myxedema coma is an illness that occurs primarily in females at a rate of 4:1 compared to men. It typically impacts the elderly at the age of greater than 60 years old, and approximately 90% of cases occur during the winter months. Myxedema coma is the product of longstanding unidentified or undertreated hypothyroidism of any etiology. Thyroid hormone is necessary throughout the body and acts as a regulatory hormone that affects many organ systems. [2] In cardiac tissues, myxedema coma manifests as decreased contractility with subsequent reduction in stroke volume and overall cardiac output.  Bradycardia and hypotension are typically present also. Pericardial effusions occur due to the accumulation of mucopolysaccharides in the pericardial sac, which leads to worsened cardiac function and congestive heart failure from diastolic dysfunction. Capillary permeability is also increased throughout the body leading to worsened edema. Electrocardiogram findings may include bradycardia and low-voltage, non-specific ST waveform changes with possible inverted T waves.

Neurologic tissues are impacted in myxedema coma leading to the pathognomonic altered mental status resulting from hypoxia and decreased cerebral blood flow secondary to cardiac dysfunction as above. Additionally, hypothyroidism leads to decreased glucose uptake and utilization in neurological tissue, thus worsening cognitive function.

The pulmonary system typically manifests this disease process through hypoventilation secondary to the central nervous system (CNS) depression of the respiratory drive with blunting of the response to hypoxia and hypercapnia. Additionally, metabolic dysfunction in the muscles of respiration leads to respiratory fatigue and failure, macroglossia from mucopolysaccharide driven edema of the tongue leads to mechanical obstruction of the airway, and obesity hypoventilation syndrome with the decreased respiratory drive as most hypothyroid patients suffer from obesity.

Renal manifestations include decreased glomerular filtration rate from the reduced cardiac output and increased systemic vascular resistance coupled with acute rhabdomyolysis lead to acute kidney injury. In the case of our patient above who has a pre-existing renal disease status post-nephrectomy, this is further worsened.  The net effect is worsened fluid overload status compounding the cardiac dysfunction and edema. [3]

The gastrointestinal tract is marked by mucopolysaccharide-driven edema as well leading to malabsorption of nutrients, gastric ileus, and decreased peristalsis. Ascites is common because of increased capillary permeability in the intestines coupled with coexistent congestive heart failure and congestive hepatic failure. Coagulopathies are common to occur as a result of this hepatic dysfunction.

Evaluation: The diagnosis of myxedema coma, as with all other diseases, is heavily reliant on the history and physical exam. A past medical history including hypothyroidism is highly significant whenever decreased mental status or coma is identified. In the absence of identified hypothyroidism, myxedema coma is a diagnosis of exclusion when all other sources of coma have been ruled out. If myxedema coma is suspected, evaluation of thyroid-stimulating hormone (TSH), free thyroxine (T4), and serum cortisol is warranted. T4 will be extremely low. TSH is variable depending on the etiology of hypothyroidism, with a high TSH indicating primary hypothyroidism and a low or normal TSH indicating secondary etiologies. Cortisol may be low indicating adrenal insufficiency because of hypothyroidism.  [4]

Prognosis: Myxedema coma is a medical emergency. With proper and rapid diagnosis and initiation of therapy, the mortality rate is still as high as 25% to 50%. The most common cause of death is due to respiratory failure. The factors which suggest a poorer prognosis include increased age, persistent hypothermia, bradycardia, low score Glasgow Coma Scale, or multi-organ impairment indicated by high APACHE (Acute Physiology and Chronic Health Evaluation) II score. For these reasons, placement in an intensive care unit with a low threshold for intubation and mechanical ventilation can improve mortality outcomes. [3] [5]

• Pearls of Wisdom
• Not every case of shortness of breath is COPD or congestive heart failure (CHF). While less likely, a history of hypothyroidism should raise suspicion of myxedema coma in a patient with any cognitive changes.
• Myxedema is the great imitator illness that impacts all organ systems. It can easily be mistaken for congestive heart failure, COPD exacerbation, pneumonia, renal injury or failure, or neurological insult.
• Initial steps in therapy include aggressive airway management, thyroid hormone replacement, glucocorticoid therapy, and supportive measures.
• These patients should be monitored in an intensive care environment with continuous telemetry. [6]
• Enhancing Healthcare Team Outcomes

This case demonstrates how all interprofessional healthcare team members need to be involved in arriving at a correct diagnosis, particularly in more challenging cases such as this one. Clinicians, specialists, nurses, pharmacists, laboratory technicians all bear responsibility for carrying out the duties pertaining to their particular discipline and sharing any findings with all team members. An incorrect diagnosis will almost inevitably lead to incorrect treatment, so coordinated activity, open communication, and empowerment to voice concerns are all part of the dynamic that needs to drive such cases so patients will attain the best possible outcomes.

• Review Questions
• Access free multiple choice questions on this topic.
• Comment on this article.

Case Study of 60 year old female presenting with Shortness of Breath Contributed by Sandeep Sharma, MD

Disclosure: Deepa Rawat declares no relevant financial relationships with ineligible companies.

Disclosure: Sandeep Sharma declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Rawat D, Sharma S. Case Study: 60-Year-Old Female Presenting With Shortness of Breath. [Updated 2023 Feb 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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• How to present patient...

How to present patient cases

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• Peer review
• Mary Ni Lochlainn , foundation year 2 doctor 1 ,
• Ibrahim Balogun , healthcare of older people/stroke medicine consultant 1
• 1 East Kent Foundation Trust, UK

A guide on how to structure a case presentation

This article contains...

-History of presenting problem

-Medical and surgical history

-Drugs, including allergies to drugs

-Family history

-Social history

-Review of systems

-Findings on examination, including vital signs and observations

-Differential diagnosis/impression

-Investigations

-Management

Presenting patient cases is a key part of everyday clinical practice. A well delivered presentation has the potential to facilitate patient care and improve efficiency on ward rounds, as well as a means of teaching and assessing clinical competence. 1

The purpose of a case presentation is to communicate your diagnostic reasoning to the listener, so that he or she has a clear picture of the patient’s condition and further management can be planned accordingly. 2 To give a high quality presentation you need to take a thorough history. Consultants make decisions about patient care based on information presented to them by junior members of the team, so the importance of accurately presenting your patient cannot be overemphasised.

As a medical student, you are likely to be asked to present in numerous settings. A formal case presentation may take place at a teaching session or even at a conference or scientific meeting. These presentations are usually thorough and have an accompanying PowerPoint presentation or poster. More often, case presentations take place on the wards or over the phone and tend to be brief, using only memory or short, handwritten notes as an aid.

Everyone has their own presenting style, and the context of the presentation will determine how much detail you need to put in. You should anticipate what information your senior colleagues will need to know about the patient’s history and the care he or she has received since admission, to enable them to make further management decisions. In this article, I use a fictitious case to show how you can structure case presentations, which can be adapted to different clinical and teaching settings (box 1).

Box 1: Structure for presenting patient cases

Presenting problem, history of presenting problem, medical and surgical history.

Drugs, including allergies to drugs

Family history

Social history, review of systems.

Findings on examination, including vital signs and observations

Differential diagnosis/impression

Investigations

Case: tom murphy.

You should start with a sentence that includes the patient’s name, sex (Mr/Ms), age, and presenting symptoms. In your presentation, you may want to include the patient’s main diagnosis if known—for example, “admitted with shortness of breath on a background of COPD [chronic obstructive pulmonary disease].” You should include any additional information that might give the presentation of symptoms further context, such as the patient’s profession, ethnic origin, recent travel, or chronic conditions.

“ Mr Tom Murphy is a 56 year old ex-smoker admitted with sudden onset central crushing chest pain that radiated down his left arm.”

In this section you should expand on the presenting problem. Use the SOCRATES mnemonic to help describe the pain (see box 2). If the patient has multiple problems, describe each in turn, covering one system at a time.

Box 2: SOCRATES—mnemonic for pain

Associations

Time course

Exacerbating/relieving factors

“ The pain started suddenly at 1 pm, when Mr Murphy was at his desk. The pain was dull in nature, and radiated down his left arm. He experienced shortness of breath and felt sweaty and clammy. His colleague phoned an ambulance. He rated the pain 9/10 in severity. In the ambulance he was given GTN [glyceryl trinitrate] spray under the tongue, which relieved the pain to 5/10. The pain lasted 30 minutes in total. No exacerbating factors were noted. Of note: Mr Murphy is an ex-smoker with a 20 pack year history”

Some patients have multiple comorbidities, and the most life threatening conditions should be mentioned first. They can also be categorised by organ system—for example, “has a long history of cardiovascular disease, having had a stroke, two TIAs [transient ischaemic attacks], and previous ACS [acute coronary syndrome].” For some conditions it can be worth stating whether a general practitioner or a specialist manages it, as this gives an indication of its severity.

In a surgical case, colleagues will be interested in exercise tolerance and any comorbidity that could affect the patient’s fitness for surgery and anaesthesia. If the patient has had any previous surgical procedures, mention whether there were any complications or reactions to anaesthesia.

“Mr Murphy has a history of type 2 diabetes, well controlled on metformin. He also has hypertension, managed with ramipril, and gout. Of note: he has no history of ischaemic heart disease (relevant negative) (see box 3).”

Box 3: Relevant negatives

Mention any relevant negatives that will help narrow down the differential diagnosis or could be important in the management of the patient, 3 such as any risk factors you know for the condition and any associations that you are aware of. For example, if the differential diagnosis includes a condition that you know can be hereditary, a relevant negative could be the lack of a family history. If the differential diagnosis includes cardiovascular disease, mention the cardiovascular risk factors such as body mass index, smoking, and high cholesterol.

Highlight any recent changes to the patient’s drugs because these could be a factor in the presenting problem. Mention any allergies to drugs or the patient’s non-compliance to a previously prescribed drug regimen.

To link the medical history and the drugs you might comment on them together, either here or in the medical history. “Mrs Walsh’s drugs include regular azathioprine for her rheumatoid arthritis.”Or, “His regular drugs are ramipril 5 mg once a day, metformin 1g three times a day, and allopurinol 200 mg once a day. He has no known drug allergies.”

If the family history is unrelated to the presenting problem, it is sufficient to say “no relevant family history noted.” For hereditary conditions more detail is needed.

“ Mr Murphy’s father experienced a fatal myocardial infarction aged 50.”

Social history should include the patient’s occupation; their smoking, alcohol, and illicit drug status; who they live with; their relationship status; and their sexual history, baseline mobility, and travel history. In an older patient, more detail is usually required, including whether or not they have carers, how often the carers help, and if they need to use walking aids.

“He works as an accountant and is an ex-smoker since five years ago with a 20 pack year history. He drinks about 14 units of alcohol a week. He denies any illicit drug use. He lives with his wife in a two storey house and is independent in all activities of daily living.”

Do not dwell on this section. If something comes up that is relevant to the presenting problem, it should be mentioned in the history of the presenting problem rather than here.

“Systems review showed long standing occasional lower back pain, responsive to paracetamol.”

Findings on examination

Initially, it can be useful to practise presenting the full examination to make sure you don’t leave anything out, but it is rare that you would need to present all the normal findings. Instead, focus on the most important main findings and any abnormalities.

“On examination the patient was comfortable at rest, heart sounds one and two were heard with no additional murmurs, heaves, or thrills. Jugular venous pressure was not raised. No peripheral oedema was noted and calves were soft and non-tender. Chest was clear on auscultation. Abdomen was soft and non-tender and normal bowel sounds were heard. GCS [Glasgow coma scale] was 15, pupils were equal and reactive to light [PEARL], cranial nerves 1-12 were intact, and he was moving all four limbs. Observations showed an early warning score of 1 for a tachycardia of 105 beats/ min. Blood pressure was 150/90 mm Hg, respiratory rate 18 breaths/min, saturations were 98% on room air, and he was apyrexial with a temperature of 36.8 ºC.”

Differential diagnoses

Mentioning one or two of the most likely diagnoses is sufficient. A useful phrase you can use is, “I would like to rule out,” especially when you suspect a more serious cause is in the differential diagnosis. “History and examination were in keeping with diverticular disease; however, I would like to rule out colorectal cancer in this patient.”

Remember common things are common, so try not to mention rare conditions first. Sometimes it is acceptable to report investigations you would do first, and then base your differential diagnosis on what the history and investigation findings tell you.

“My impression is acute coronary syndrome. The differential diagnosis includes other cardiovascular causes such as acute pericarditis, myocarditis, aortic stenosis, aortic dissection, and pulmonary embolism. Possible respiratory causes include pneumonia or pneumothorax. Gastrointestinal causes include oesophageal spasm, oesophagitis, gastro-oesophageal reflux disease, gastritis, cholecystitis, and acute pancreatitis. I would also consider a musculoskeletal cause for the pain.”

This section can include a summary of the investigations already performed and further investigations that you would like to request. “On the basis of these differentials, I would like to carry out the following investigations: 12 lead electrocardiography and blood tests, including full blood count, urea and electrolytes, clotting screen, troponin levels, lipid profile, and glycated haemoglobin levels. I would also book a chest radiograph and check the patient’s point of care blood glucose level.”

You should consider recommending investigations in a structured way, prioritising them by how long they take to perform and how easy it is to get them done and how long it takes for the results to come back. Put the quickest and easiest first: so bedside tests, electrocardiography, followed by blood tests, plain radiology, then special tests. You should always be able to explain why you would like to request a test. Mention the patient’s baseline test values if they are available, especially if the patient has a chronic condition—for example, give the patient’s creatinine levels if he or she has chronic kidney disease This shows the change over time and indicates the severity of the patient’s current condition.

“To further investigate these differentials, 12 lead electrocardiography was carried out, which showed ST segment depression in the anterior leads. Results of laboratory tests showed an initial troponin level of 85 µg/L, which increased to 1250 µg/L when repeated at six hours. Blood test results showed raised total cholesterol at 7.6 mmol /L and nil else. A chest radiograph showed clear lung fields. Blood glucose level was 6.3 mmol/L; a glycated haemoglobin test result is pending.”

Dependent on the case, you may need to describe the management plan so far or what further management you would recommend.“My management plan for this patient includes ACS [acute coronary syndrome] protocol, echocardiography, cardiology review, and treatment with high dose statins. If you are unsure what the management should be, you should say that you would discuss further with senior colleagues and the patient. At this point, check to see if there is a treatment escalation plan or a “do not attempt to resuscitate” order in place.

“Mr Murphy was given ACS protocol in the emergency department. An echocardiogram has been requested and he has been discussed with cardiology, who are going to come and see him. He has also been started on atorvastatin 80 mg nightly. Mr Murphy and his family are happy with this plan.”

The summary can be a concise recap of what you have presented beforehand or it can sometimes form a standalone presentation. Pick out salient points, such as positive findings—but also draw conclusions from what you highlight. Finish with a brief synopsis of the current situation (“currently pain free”) and next step (“awaiting cardiology review”). Do not trail off at the end, and state the diagnosis if you are confident you know what it is. If you are not sure what the diagnosis is then communicate this uncertainty and do not pretend to be more confident than you are. When possible, you should include the patient’s thoughts about the diagnosis, how they are feeling generally, and if they are happy with the management plan.

“In summary, Mr Murphy is a 56 year old man admitted with central crushing chest pain, radiating down his left arm, of 30 minutes’ duration. His cardiac risk factors include 20 pack year smoking history, positive family history, type 2 diabetes, and hypertension. Examination was normal other than tachycardia. However, 12 lead electrocardiography showed ST segment depression in the anterior leads and troponin rise from 85 to 250 µg/L. Acute coronary syndrome protocol was initiated and a diagnosis of NSTEMI [non-ST elevation myocardial infarction] was made. Mr Murphy is currently pain free and awaiting cardiology review.”

Originally published as: Student BMJ 2017;25:i4406

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed

• ↵ Green EH, Durning SJ, DeCherrie L, Fagan MJ, Sharpe B, Hershman W. Expectations for oral case presentations for clinical clerks: opinions of internal medicine clerkship directors. J Gen Intern Med 2009 ; 24 : 370 - 3 . doi:10.1007/s11606-008-0900-x   pmid:19139965 . OpenUrl CrossRef PubMed Web of Science
• ↵ Olaitan A, Okunade O, Corne J. How to present clinical cases. Student BMJ 2010;18:c1539.
• ↵ Gaillard F. The secret art of relevant negatives, Radiopedia 2016; http://radiopaedia.org/blog/the-secret-art-of-relevant-negatives .

How to Present a Nursing Case Study

What Is a Case Study in Nursing?

A nursing case study is an in-depth examination of a situation that a nurse encounters in her daily practice. The case study offers a safe way for the nurse to apply theoretical and actual knowledge to an actual or potential patient scenario. She can employ her decision-making skills, use critical thinking to analyze the situation, and develop cognitive reasoning abilities without harming a patient. Nursing case studies are commonly used in undergraduate nursing programs, graduate schools offering a master’s of science degree in nursing (MSN), and orientation programs for new graduate nurses. They may be presented in written form, online, or live in a classroom setting.

Choose a topic. According to Sigma Theta Tau International, the topic should be focused, based in reality, and relevant. It should demonstrate current best practices that are supported by nursing research. The nurse may choose to discuss a situation from his past experience, or delve into something in his current job.

Write objectives. There should be at least three learning objectives, or outcomes, that identify what the learner will gain from completing the case study. Learning objectives are written as clear, measurable behaviors, such as “Identify five risk factors for falls in older adults.”

Write an introduction. This should be a one- or two-paragraph overview that describes the patient, the situation, and circumstances relevant to that situation. The introduction can also include a little about the patient’s history leading up to the situation.

Integrate more history and background. The next 1 to 2 paragraphs provide the learner with in-depth information to analyze the situation, such as lab values, diagnostic study results, findings from the nurse’s assessment of the patient, and a more detailed patient history.

Formulate questions. Nursing case studies are interactive scenarios that stimulate analysis and critical thinking. The questions typically require the learner to use the nursing process (assessment, nursing diagnosis, planning, intervention, and evaluation) and to anticipate what will happen next in the situation.

Give feedback. According to Sigma Theta Tau, the nursing case study provides the learner with two types of feedback: informational and reinforcing. Informational feedback lets the learner know if she has answered questions correctly, and gives her an idea of how she is progressing through the patient scenario. Reinforcing feedback gives the learner additional information about her responses to the questions. If she answers the question correctly, she’ll be given the rationale behind her right answer. If she gives the wrong answer, reinforcing feedback lets her know why that answer is wrong.

Provide references. It’s important to point the learner toward additional learning opportunities in print or on the web.

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• Sigma Theta Tau International

Sandy Keefe, M.S.N., R.N., has been a freelance writer for over five years. Her articles have appeared in numerous health-related magazines, including "Advance for Nurses" and "Advance for Long-Term Care Management." She has written short stories in anthologies such as "A Cup of Comfort for Parents of Children with Special Needs."

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Akhtar N, Lee L Utilization and complications of central venous access devices in oncology patients. Current Oncology.. 2021; 28:(1)367-377 https://doi.org/10.3390/curroncol28010039

BD ChloraPrep: summary of product characteristics.. 2021; https://www.bd.com/en-uk/products/infection-prevention/chloraprep-patient-preoperative-skin-preparation/chloraprep-smpc-pil-msds

Chloraprep 10.5ml applicator.. 2022a; https://www.bd.com/en-uk/products/infection-prevention/chloraprep-patient-preoperative-skin-preparation/chloraprep-patient-preoperative-skin-preparation-product-line/chloraprep-105-ml-applicator

Chloraprep 3ml applicator.. 2022b; https://www.bd.com/en-uk/products/infection-prevention/chloraprep-patient-preoperative-skin-preparation/chloraprep-patient-preoperative-skin-preparation-product-line/chloraprep-3-ml-applicator

Website.. 2021; https://www.cdc.gov/cancer/preventinfections/providers.htm

Ceylan G, Topal S, Turgut N, Ozdamar N, Oruc Y, Agin H, Devrim I Assessment of potential differences between pre-filled and manually prepared syringe use during vascular access device management in a pediatric intensive care unit. https://doi.org/10.1177/11297298211015500

Clare S, Rowley S Best practice skin antisepsis for insertion of peripheral catheters. Br J Nurs.. 2021; 30:(1)8-14 https://doi.org/10.12968/bjon.2021.30.1.8

Caguioa J, Pilpil F, Greensitt C, Carnan D HANDS: standardised intravascular practice based on evidence. Br J Nurs.. 2012; 21:(14)S4-S11 https://doi.org/10.12968/bjon.2012.21.Sup14.S4

Easterlow D, Hoddinott P, Harrison S Implementing and standardising the use of peripheral vascular access devices. J Clin Nurs.. 2010; 19:(5-6)721-727 https://doi.org/10.1111/j.1365-2702.2009.03098.x

Florman S, Nichols RL Current approaches for the prevention of surgical site infections. Am J Infect Dis.. 2007; 3:(1)51-61 https://doi.org/10.3844/ajidsp.2007.51.61

Gorski LA, Hadaway L, Hagle M Infusion therapy standards of practice. J Infus Nurs.. 2021; 44:(S1)S1-S224 https://doi.org/10.1097/NAN.0000000000000396

Guenezan J, Marjanovic N, Drugeon B Chlorhexidine plus alcohol versus povidone iodine plus alcohol, combined or not with innovative devices, for prevention of short-term peripheral venous catheter infection and failure (CLEAN 3 study): an investigator-initiated, openlabel, single centre, randomised-controlled, two-by-two factorial trial [published correction appears in Lancet Infect Dis. 2021 Apr 6]. Lancet Infect Dis.. 2021; 21:(7)1038-1048 https://doi.org/10.1016/S1473-3099(20)30738-6

Gunka V, Soltani P, Astrakianakis G, Martinez M, Albert A, Taylor J, Kavanagh T Determination of ChloraPrep® drying time before neuraxial anesthesia in elective cesarean delivery: a prospective observational study. Int J Obstet Anesth.. 2019; 38:19-24 https://doi.org/10.1016/j.ijoa.2018.10.012

Ishikawa K, Furukawa K Staphylococcus aureus bacteraemia due to central venous catheter infection: a clinical comparison of infections caused by methicillin-resistant and methicillin-susceptible strains. Cureus.. 2021; 13:(7) https://doi.org/10.7759/cureus.16607

Loveday HP, Wilson JA, Pratt RJ Epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. J Hosp Infect.. 2014; 86:(S1)S1-70 https://doi.org/10.1016/S0195-6701(13)60012-2

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Standards for infusion therapy. 4th edn.. 2016; https://www.rcn.org.uk/clinical-topics/Infection-prevention-and-control/Standards-for-infusion-therapy

Taxbro K, Chopra V Appropriate vascular access for patients with cancer. Lancet.. 2021; 398:(10298)367-368 https://doi.org/10.1016/S0140-6736(21)00920-X

Case Studies

Gema munoz-mozas.

Vascular Access Advanced Nurse Practitioner—Lead Vascular Access Nurse, The Royal Marsden NHS Foundation Trust

View articles · Email Gema

Colin Fairhurst

Vascular Access Advanced Clinical Practitioner, University Hospitals Plymouth NHS Trust

View articles

Simon Clare

Research and Practice Development Director, The Association for Safe Aseptic Practice

View articles · Email Simon

Intravenous (IV) access, both peripheral and central, is an integral part of the patient care pathways for diagnosing and treating cancer. Patients receiving systemic anticancer treatment (SACT) are at risk for developing infections, which may lead to hospitalisation, disruptions in treatment schedules and even death ( Centers for Disease Control and Prevention, 2021 ). However, infection rates can be reduced and general patient outcomes improved with the evidence-based standardisation of IV practice, and the adoption of the appropriate equipment, such as peripheral IV cannulas, flushing solutions and sterile IV dressings ( Easterlow et al, 2010 ).

Cancer treatment frequently involves the use of central venous catheters (CVCs)-also referred to as central venous access devices (CVADs)—which can represent a lifeline for patients when used to administer all kinds of IV medications, including chemotherapy, blood products and parenteral nutrition. They can also be used to obtain blood samples, which can improve the patient’s quality of life by reducing the need for peripheral stabs from regular venepunctures ( Taxbro and Chopra, 2021 ). CVCs are relatively easy to insert and care for; however, they are associated with potential complications throughout their insertion and maintenance.

One serious complication of CVC use is catheter-related bloodstream infections (CRBSIs), which can increase morbidity, leading to prolonged hospitalisation and critical use of hospital resources ( Akhtar and Lee, 2021 ). Early-onset CRBSIs are commonly caused by skin pathogens, and so a cornerstone of a CRBSI prevention is skin antisepsis at the time of CVC insertion. Appropriate antisepsis (decontamination/preparation) of the site for CVC insertion can prevent the transmission of such skin pathogens during insertion, while reducing the burden of bacteria on the CVC exit site ( Loveday et al, 2014 ).

Evidence-based practice for the prevention of a CRBSIs and other healthcare-associated infections recommends skin antisepsis prior to insertion of a vascular-access device (VAD) using a 2% chlorhexidine gluconate and 70% isopropyl alcohol solution. This is recommended in guidelines such as epic3 ( Loveday et al, 2014 ), the Standards for Infusion Therapy ( Royal College of Nursing, 2016 ) and the Infusion Therapy Standards of Practice ( Gorski et al, 2021 ). A strong evidenced-backed product such as BD ChloraPrep™ ( Figure 1 ) has a combination of 2% chlorhexidine gluconate in 70% isopropyl alcohol that provides broad-spectrum rapid-action antisepsis, while the applicators facilitate a sterile, single-use application that eliminates direct hand-to-patient contact, helping to reduce cross-contamination and maintaining sterile conditions ( BD, 2021 ). The BD ChloraPrep™ applicator’s circular head allows precise antisepsis of the required area, and the sponge head helps to apply gentle friction in back-and-forth motion to penetrate the skin layers ( BD, 2021 ). BD ChloraPrep’s rapidacting, persistent and broad-spectrum characteristics and proven applicator system ( Florman and Nichols, 2007 ) make it a vital part of the policy and protocol for insertion, care and maintenance of CVCs in specialist cancer centres such as the Royal Marsden. Meanwhile, the use of BD PosiFlush™ Prefilled Saline Syringe ( Figure 2 ), a prefilled normal saline (0.9% sodium choride) syringe, is established practice for the flushing regime of VADs in many NHS Trusts.

The following five case studies present examples from personal experience of clinical practice that illustrate how and why clinicians in oncology and other disciplines use BD ChloraPrep ™ and BD PosiFlush ™ Prefilled Saline Syringe in both adult and paediatric patients.

Case study 1 (Andy)

Andy was a 65-year-old man being treated for metastatic colorectal cancer at the Royal Marsden NHS Foundation Trust specialist cancer service, which provides state-of-the-art treatment to over 60 000 patients each year.

Andy had a peripherally inserted central catheter (PICC) placed at the onset of his chemotherapy treatment to facilitate IV treatment. While in situ, PICCs require regular maintenance to minimise associated risks. This consists of a weekly dressing change to minimise infection and a weekly flush to maintain patency, if not in constant use. For ambulatory patients, weekly PICC maintenance can be carried out either in the hospital outpatient department or at home by a district nurse or family member trained to do so. Patients, relatives, carers and less-experienced nurses involved in PICC care (flushing and dressing) can watch a video on the Royal Marsden website as an aide memoir.

Initially, Andy decided to have his weekly PICC maintenance at the hospital’s nurse-led clinic for the maintenance of CVCs. At the clinic, Andy’s PICC dressing change and catheter flushing procedures were performed by a nursing associate (NA), who, having completed the relevant competences and undergone supervised practise, could carry out weekly catheter maintenance and access PICC for blood sampling.

In line with hospital policy, the PICC dressing change was performed under aseptic non-touch technique (ANTT) using a dressing pack and sterile gloves. After removal of the old dressing, the skin around the entry site and the PICC was cleaned with a 3 ml BD ChloraPrep™ applicator, using back-andforth strokes for 30 seconds and allowing the area to air dry completely before applying the new dressing. As clarified in a recent article on skin antisepsis (Clare and Rowley, 2020), BD ChloraPrep™ applicator facilitated a sterile, single-use application that eliminates direct hand-to-patient contact, which help reduce cross-contamination and maintaining ANTT. Its circular head allowed precise antisepsis around the catheter, and the sponge head helped to apply gentle friction in back-and-forth strokes to penetrate the skin layers.

Once the new dressing was applied, the NA continued to clean the catheter hub and change the needle-free connector. Finally, the catheter lumen was flushed with 10 ml of normal saline (0.9% sodium chloride) with a pre-filled saline syringe (BD PosiFlush™ Prefilled Saline Syringe). This involved flushing 1 ml at a time, following a push-pause technique, with positive pressure disconnection to ensure catheter patency. The classification of these syringes as medical devices enables NAs and other nonregistered members of the clinical team to support nursing staff with the care and maintenance of PICCs and other CVCs, within local policies and procedures. Using pre-filled syringes can save time and minimise the risk of contamination of the solution ( Ceylan et al, 2021 ).

The use of pre-filled 0.9% sodium chloride syringes facilitates home maintenance of PICCs for patients. When Andy did not need to attend hospital, his PICC maintenance could be performed by a family member. Patients and relatives could access the necessary equipment and training from the day-case unit or outpatient department. Home PICC maintenance is extremely beneficial, not just to providers, but also to patients, who may avoid unnecessary hospital attendance and so benefit from more quality time at home and a reduced risk of hospital-acquired infections. Many patients and relatives have commented on the convenience of having their PICC maintenance at home and how easy they found using the ChloraPrep™ and BD PosiFlush™ Prefilled Saline Syringe ‘sticks’.

Case study 2 (Gail)

Gail was as a 48-year-old woman being treated for bladder cancer with folinic acid, fluorouracil and oxaliplatin (FOLOX). She was admitted for a replacement PICC, primarily for continuous cytotoxic intravenous medication via infusion pump in the homecare setting. Her first PICC developed a reaction thought to be related to a sutureless securement device (SSD) anchoring the PICC. The device was removed, but this resulted in displacement of the PICC and incorrect positioning in the vessel (superior vena cava). Now unsafe, the PICC was removed, awaiting replacement, which resulted in a delayed start for the chemotherapy.

A second PICC placement was attempted by a nurse-led CVC placement team, and a line attempt was made in Gail’s left arm. Skin antisepsis was undertaken using a 2% chlorhexidine gluconate and 70% isopropyl alcohol solution (ChloraPrep™). A BD ChloraPrep ™ 10 ml applicator was selected, using manufacturer’s recommendations, as per best practice guidance for CVC placement ( Loveday et al, 2014 ) and to comply with local policy for the use of ANTT. The BD ChloraPrep™ applicator allowed improved non-touch technique and helped facilitate good key-part and key-site protection, in line with ANTT ( Clare and Rowley, 2021 ).

The inserting clinician failed to successfully position the PICC in Gail’s left arm and moved to try on the right. On the second attempt, Gail noted the use of BD ChloraPrep™ and stated that she was allergic to the product, reporting a severe skin rash and local discomfort. The line placer informed the Gail that she had used BD ChloraPrep™ on the failed first attempt without issue, and she gave her consent to continue the procedure. No skin reaction was noted during or after insertion of the PICC.

BD ChloraPrep™ has a rapid-acting broad-spectrum antiseptic range and ability to keep fighting bacteria for at least 48 hours ( BD, 2021 ). These were tangible benefits during maintenance of the CVC insertion site, in the protection of key sites following dressing change and until subsequent dressing changes. There are reported observations of clinicians not allowing the skin to fully dry and applying a new dressing onto wet skin after removing old dressings and disinfecting the exit site with BD ChloraPrep™. This has been reported to cause skin irritation, which can be mistaken for an allergic reaction and lead the patient to think that they have an allergy to chlorhexidine. In our centre’s general experience, very few true allergic reactions have ever been reported by the insertion team. Improved surveillance might better differentiate between later reported reactions, possibly associated with a delayed response to exposure to BD ChloraPrep ™ at insertion, and local skin irritation caused by incorrect management at some later point during hospitalisation.

Staff training is an important consideration in the safe and correct use of BD ChloraPrep™ products and the correct use of adhesive dressings to avoid irritant contact dermatitis (ICD). It is worth noting that it can be difficult to differentiate between ICD and allergic contact dermatitis (ACD). Education and training should be multifaceted (such as with training videos and study days), allowing for different ways of learning, and monitored with audit. Local training in the benefits of using BD ChloraPrep™ correctly have been reinforced by adding simple instructions to ANTT procedure guidelines for CVC insertion and maintenance. Education on its own is often limited to a single episode of training, the benefit of using ANTT procedure guidelines is that they are embedded in a programme of audits and periodic competency reassessment. This makes sure that, as an integral part of good practice, skin antisepsis with BD ChloraPrep ™ is consistently and accurately retrained and assessed.

Gail’s case illustrates the importance of correct application of BD ChloraPrep ™ and how good documentation and surveillance are vital in monitoring skin health during the repeated use skindisinfection products. Care should be taken when recording ICD and ACD reactions, and staff should take steps to confirm true allergy versus temporary skin irritation.

Case study 3 (Beata)

Beata was a 13-year-old teenage girl being treated for acute myeloid leukaemia. Although Beata had a dual-lumen skin-tunnelled catheter in situ, a peripheral intravenous cannula (PIVC) was required for the administration of contrast media for computed tomography (CT) scanning. However, Beata had needlephobia, and so the lead vascular access nurse was contacted to insert the cannula, following ultrasound guidance and the ANTT. After Beata and her mother gave their consent to the procedure, the nurse gathered and prepared all the equipment, including a cannulation pack, single-use tourniquet, skin-antisepsis product, appropriate cannula, PIVC dressing, 0.9% sodium chloride BD PosiFlush ™ Prefilled Saline Syringe, sterile gel, sterile dressing to cover ultrasound probe and personal protective equipment.

Prior to PIVC insertion, a 4x5 cm area of skin underwent antisepsis with a 1.5 ml BD ChloraPrep ™ Frepp applicator, with back-and-forth strokes for 30 seconds, and was allowed to air-dry. The vascular access team prefer to use BD ChloraPrep ™ Frepp over single-use wipes, as the former is faster acting and provides the right volume to decontaminate the indicated area using ANTT ( Clare and Rowley, 2021 ).

Following insertion, the PIVC was flushed with a 10 ml BD PosiFlush ™ Prefilled Saline Syringe syringe, using a pushpause pulsatile technique, with positive pressure disconnection. Local policy recommends the use of pre-filled saline syringes, as they save time and minimise infection risk compared with manually drawn saline flushes ( Ceylan et al, 2021 ). The Trust also permits competent non-registered members of staff to perform PIVC insertion, which is more cost-effective than depending on registered nurses.

In Beata’s case, the team considered the use of BD ChloraPrep™ and BD PosiFlush™ Prefilled Saline Syringe to be essential for the prevention of VAD-associated infections, as well as increasing the quality of nursing care by saving time in the day-case and inpatient settings alike.

Case study 4 (Emma)

Emma, a 43-year-old woman diagnosed with acute lymphoblastic leukaemia, was scheduled for an allogenic stem-cell transplant and associated chemotherapy. To facilitate this, she attended the vascular access service at University Hospitals Plymouth NHS Trust for the insertion of a triple-lumen skin-tunnelled catheter. This was identified as the best VAD for her needs, because of its longevity, multiple points of access and decreased infection risk compared with other devices, such as PICCs.

This was Emma’s second advanced VAD insertion, having previously received an apheresis line due to poor peripheral venous access, to facilitate the prior stem-cell harvest. She was yet to receive any treatment, and, therefore, no immunodeficiency had been identified prior to the insertion procedure.

Trust policy for skin disinfection prior to the insertion or removal of PICC lines is a 2% chlorhexidine gluconate and 70% isopropyl alcohol solution, BD ChloraPrep™. There is an exception for patient history of allergy or sensitivity to BD ChloraPrep™, where 10% povidone iodine is used instead. Emma had received BD ChloraPrep™ before, with no sign allergy or sensitivity, and so the vascular access team decided to use this product again for insertion. BD Chloraprep™ was used, in preference of other skin antisepsis options, due to the applicator’s ability to effectively penetrate the layers of the epidermis, as well as the ability to eliminate direct hand-to-skin contact between the operator and patient ( Clare and Rowley, 2021 ).

Insertion of a skin-tunnelled catheter first requires disinfection of a large area, including the neck and upper chest. Following the manufacturer’s coverage recommendations, a 10.5 ml BD ChloraPrep™ applicator was selected as most suitable to cover an area of 25x30 cm ( BD, 2022 a).

The applicator was activated by pinching the wings to allow the antiseptic solution to properly load onto the sponge. To ensure proper release of the solution, the applicator was held on the skin against the anticipated site of insertion until the sponge pad became saturated. Then, a back-and-forth rubbing motion was undertaken for a minimum of 30 seconds, ensuring that the full area to be used was covered. The solution was then left to dry completely, prior to full-body draping, leaving the procedural area exposed for the procedure. Generally, drying time takes from 30 to 60 seconds, but local policy is not restrictive, as allowing the solution to fully dry is of paramount importance ( Gunka et al, 2019 ). BD Chloraprep™ is effective against a wide variety of microorganisms and has a rapid onset of action ( Florman and Nichols, 2007 ). Therefore, it was felt to be the best option for procedural and ongoing care skin asepsis in a patient anticipated to be immunocompromised during treatment.

It is the normal policy of the Trust’s vascular access service to flush VADs using BD PosiFlush™ Prefilled Saline Syringes with 0.9% sodium chloride. Likewise, BD PosiFlush™ Prefilled Saline Syringes Sterile Pathway (SP) are used to prime all VADs prior to insertion and to check for correct patency once inserted. BD PosiFlush ™ Prefilled Saline Syringe were used in preference of other options, such as vials or bags, due to the absence of requirement for a prescription in the local organisation. They are treated as a medical device and, therefore, can be used without prescription. The advantage of this is that flushes can be administered in a nurse-led clinic, where prescribers are not always available. Aside from the logistical advantages, the use of pre-filled syringes reduces the risk of microbial contamination through preparation error and administration error through correct labelling ( National Patient Safety Agency, 2007 ) In Emma’s case, three BD PosiFlush™ SP Prefilled Saline Syringes were used to check patency and/or ascertain venous location following the insertion of the skin-tunnelled catheter.

In this case, both BD ChloraPrep ™ and BD PosiFlush ™ Prefilled Saline Syringe proved simple to use and helped achieve a successful procedural outcome for the patient.

Case study 5 (Frank)

Frank was a 47-year-old man who had been diagnosed with infective endocarditis following a trans-oesophageal echo. A few days later, to facilitate his planned treatment of 6 weeks of intravenous antibiotics to be administered 4-hourly every day, he was referred to the vascular access service for insertion of longterm IV access. To facilitate this administration, the decision was made to place a PICC.

Frank’s referral included a history of illegal intravenous drug use and details of the consequent difficulty the ward-based team had in finding suitable veins to obtain vascular access. His medical history also included infected abscesses in the left groin and methicillin-resistant Staphylococcus aureus (MRSA) colonisation.

First, Frank was administered suppression therapy for MRSA decolonisation. Following this and prior to PICC insertion, the skin antisepsis procedure was undertaken using a 2% chlorhexidine gluconate and 70% isopropyl alcohol solution, BD ChloraPrep™, in adherence to Trust policy ( Loveday et al, 2014 ). Specifically, BD ChloraPrep™ applicators are selected for their single-use application. They have been demonstrated to reduce the risk of infectious complications (catheter colonisation and local infection) by 92% compared with 5% povidone iodine (PVI) 69% ethanol ( Guenezan et al, 2021 ). A 3 ml BD ChloraPrep™ applicator was considered suitable to decontaminate an area sufficient for the intended PICC insertion procedure, as recommended by the manufacturer ( BD, 2022 b). It was applied using a back-and-forth motion for a minimum of 30 seconds and left to fully dry ( Loveday et al, 2014 ). Staphylococcus aureus bacteraemia’s have a mortality rate of 20-40% and are predominantly caused by VAD insertion ( Ishikawa and Furukawa, 2021 ), and, therefore, the need to reduce this risk was of particular importance for this patient due to the history of MRSA colonisation.

In Frank’s case, the use of BD ChloraPrep™ during the insertion procedure and for each subsequent dressing change episode participated in an uneventful period of treatment. The clinical challenges posed by the patients’ presentation of MRSA colonisation meant the risk of infection was increased but, through correct antisepsis, no adverse events were noted, and the full course of treatment was successfully administered through the PICC.

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Summer Latif, Alexia Thorley, & Brianna Villeda

Rosy McBloom is an 81 year old female with a history of dementia. She lives in a skilled nursing facility and is visited by her daughter weekly. She was brought to the ER in acute respiratory distress. She was showing signs of sepsis including hypotension, tachycardia, and a temperature of 101.1 degrees F. Her lactic acid level and white blood cell (WBC) count came back elevated. She was admitted to the ICU with a diagnosis of severe sepsis secondary to pneumonia. She was put on vancomycin, ceftriaxone, Levophed, and morphine for pain.

Rosy had to be intubated on her second day while in the ICU and was put on propofol. During the afternoon of the second day, the nurse noticed hematuria, petechiae, and blood tinged secretions. A coagulation study was ordered and showed a positive d-dimer, prolonged PT and aPTT, and a platelet count of 75,000. Rosy was then diagnosed with disseminated intravascular coagulation (DIC) secondary to sepsis. One unit of fresh frozen plasma (FFP) was ordered and administered. Her fingers and toes were cold and pale upon assessment throughout the night shift and started turning purple. She has a foley catheter and her output during the 12 hour night shift was 175 mL. Her BUN and creatinine are also elevated.

Rosy’s morning labs came back for Day 3 showing lactic acid level 3.4, WBC 17,000 hemoglobin 6.8, hematocrit 25%, BUN 42, and creatinine 3.2. Her coagulation study came back with the results as follows: platelets 80,000, PT 31 seconds, aPTT 63 seconds, d-dimer >500 ng/dL, and fibrinogen 88. Her vital signs throughout the day were BP ranging from 80s to 100 systolic, 40s-50s diastolic, MAP range of 57 to 67, RR 20 breaths/min on mechanical ventilation with an FiO2 of 60%, HR from 90s to 120s, temperature of 100.0 degrees F, and SaO2 ranging from 90% to 98%. On assessment her lung sounds were coarse and blood tinged sputum was being suctioned. She also had blood oozing from her IV sites, bruising and petechiae on all extremities, and several purple toes. One unit of red blood cells (RBC) and FFP were ordered and administered. Afternoon labs showed only a slight improvement in her RBCs and coagulation values. Rosy’s daughter met with the physician and palliative nurse to go over Rosy’s status and further treatment. After the meeting, the daughter changed Rosy’s status from a full code to DNR, but made no decisions on whether to further treat her or not.

On the fourth day, Rosy remained hypotensive, septic, and in acute renal failure. Her hemoglobin and platelets remain low despite transfusions of RBCs and FFP. Antibiotic therapy and fluid resuscitation were continued to treat the sepsis with minimal improvement. The DIC has continued to worsen and Rosy now has 6 necrotic toes while her hands are also now turning purple. She also continued to have hematuria. The daughter came in on the morning of the fifth day and made the decision to have Rosy extubated and to sustain from any further treatment. Rosy was extubated at 0900 and comfort measures were implemented. Rosy passed away at 1648 from complications of DIC.

• What were the most significant clinical manifestations and lab values that led to DIC?
• When the doctor’s diagnosed Rosy with DIC, what was the main goal of treatment and what were the secondary treatments, and why?
• Rosy passed away on her 5th day of care due to complications of DIC. Based on the pathophysiology of DIC, what are fatal complications of the disease process?

Question 1: Hematuria which indicated clotting and renal failure; petechiae; cold and pale fingers and toes, and purple toes from necrosis; blood tinged secretions; bruising; and blood oozing from her IV sites. The most significant lab values were the decreased platelet count, the prolonged PT and aPTT, the low fibrinogen level, and the elevated d-dimer.

Question 2: Primary: Antibiotics. Because Rosy’s DIC is secondary to her sepsis, the main goal of treatment is to resolve the sepsis. If the sepsis is not resolved, the DIC will remain. Secondary: FFP’s, RBC’s, and Levophed. FFP’s were given to replace coagulation factors to decrease bleeding. RBC’s were given to replace blood volume lost from bleeding. Levophed is used to maintain a MAP >65.

Question 3: Stroke, renal failure, heart attack/cardiac arrest, shock, and pulmonary embolism.

Nursing Case Studies by and for Student Nurses Copyright © by jaimehannans is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

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How to make an oral case presentation to healthcare colleagues

The content and delivery of a patient case for education and evidence-based care discussions in clinical practice.

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A case presentation is a detailed narrative describing a specific problem experienced by one or more patients. Pharmacists usually focus on the medicines aspect , for example, where there is potential harm to a patient or proven benefit to the patient from medication, or where a medication error has occurred. Case presentations can be used as a pedagogical tool, as a method of appraising the presenter’s knowledge and as an opportunity for presenters to reflect on their clinical practice [1] .

The aim of an oral presentation is to disseminate information about a patient for the purpose of education, to update other members of the healthcare team on a patient’s progress, and to ensure the best, evidence-based care is being considered for their management.

Within a hospital, pharmacists are likely to present patients on a teaching or daily ward round or to a senior pharmacist or colleague for the purpose of asking advice on, for example, treatment options or complex drug-drug interactions, or for referral.

Content of a case presentation

As a general structure, an oral case presentation may be divided into three phases [2] :

• Reporting important patient information and clinical data;
• Analysing and synthesising identified issues (this is likely to include producing a list of these issues, generally termed a problem list);
• Managing the case by developing a therapeutic plan.

Specifically, the following information should be included [3] :

Patient and complaint details

Patient details: name, sex, age, ethnicity.

Presenting complaint: the reason the patient presented to the hospital (symptom/event).

History of presenting complaint: highlighting relevant events in chronological order, often presented as how many days ago they occurred. This should include prior admission to hospital for the same complaint.

Review of organ systems: listing positive or negative findings found from the doctor’s assessment that are relevant to the presenting complaint.

Past medical and surgical history

Social history: including occupation, exposures, smoking and alcohol history, and any recreational drug use.

Medication history, including any drug allergies: this should include any prescribed medicines, medicines purchased over-the-counter, any topical preparations used (including eye drops, nose drops, inhalers and nasal sprays) and any herbal or traditional remedies taken.

Sexual history: if this is relevant to the presenting complaint.

Details from a physical examination: this includes any relevant findings to the presenting complaint and should include relevant observations.

Laboratory investigation and imaging results: abnormal findings are presented.

Assessment: including differential diagnosis.

Plan: including any pharmaceutical care issues raised and how these should be resolved, ongoing management and discharge planning.

Any discrepancies between the current management of the patient’s conditions and evidence-based recommendations should be highlighted and reasons given for not adhering to evidence-based medicine ( see ‘Locating the evidence’ ).

Locating the evidence

The evidence base for the therapeutic options available should always be considered. There may be local guidance available within the hospital trust directing the management of the patient’s presenting condition. Pharmacists often contribute to the development of such guidelines, especially if medication is involved. If no local guidelines are available, the next step is to refer to national guidance. This is developed by a steering group of experts, for example, the British HIV Association or the National Institute for Health and Care Excellence . If the presenting condition is unusual or rare, for example, acute porphyria, and there are no local or national guidelines available, a literature search may help locate articles or case studies similar to the case.

Giving a case presentation

Currently, there are no available acknowledged guidelines or systematic descriptions of the structure, language and function of the oral case presentation [4] and therefore there is no standard on how the skills required to prepare or present a case are taught. Most individuals are introduced to this concept at undergraduate level and then build on their skills through practice-based learning.

A case presentation is a narrative of a patient’s care, so it is vital the presenter has familiarity with the patient, the case and its progression. The preparation for the presentation will depend on what information is to be included.

Generally, oral case presentations are brief and should be limited to 5–10 minutes. This may be extended if the case is being presented as part of an assessment compared with routine everyday working ( see ‘Case-based discussion’ ). The audience should be interested in what is being said so the presenter should maintain this engagement through eye contact, clear speech and enthusiasm for the case.

It is important to stick to the facts by presenting the case as a factual timeline and not describing how things should have happened instead. Importantly, the case should always be concluded and should include an outcome of the patient’s care [5] .

An example of an oral case presentation, given by a pharmacist to a doctor,  is available here .

A successful oral case presentation allows the audience to garner the right amount of patient information in the most efficient way, enabling a clinically appropriate plan to be developed. The challenge lies with the fact that the content and delivery of this will vary depending on the service, and clinical and audience setting [3] . A practitioner with less experience may find understanding the balance between sufficient information and efficiency of communication difficult, but regular use of the oral case presentation tool will improve this skill.

Tailoring case presentations to your audience

Most case presentations are not tailored to a specific audience because the same type of information will usually need to be conveyed in each case.

However, case presentations can be adapted to meet the identified learning needs of the target audience, if required for training purposes. This method involves varying the content of the presentation or choosing specific cases to present that will help achieve a set of objectives [6] . For example, if a requirement to learn about the management of acute myocardial infarction has been identified by the target audience, then the presenter may identify a case from the cardiology ward to present to the group, as opposed to presenting a patient reviewed by that person during their normal working practice.

Alternatively, a presenter could focus on a particular condition within a case, which will dictate what information is included. For example, if a case on asthma is being presented, the focus may be on recent use of bronchodilator therapy, respiratory function tests (including peak expiratory flow rate), symptoms related to exacerbation of airways disease, anxiety levels, ability to talk in full sentences, triggers to worsening of symptoms, and recent exposure to allergens. These may not be considered relevant if presenting the case on an unrelated condition that the same patient has, for example, if this patient was admitted with a hip fracture and their asthma was well controlled.

Case-based discussion

The oral case presentation may also act as the basis of workplace-based assessment in the form of a case-based discussion. In the UK, this forms part of many healthcare professional bodies’ assessment of clinical practice, for example, medical professional colleges.

For pharmacists, a case-based discussion forms part of the Royal Pharmaceutical Society (RPS) Foundation and Advanced Practice assessments . Mastery of the oral case presentation skill could provide useful preparation for this assessment process.

A case-based discussion would include a pharmaceutical needs assessment, which involves identifying and prioritising pharmaceutical problems for a particular patient. Evidence-based guidelines relevant to the specific medical condition should be used to make treatment recommendations, and a plan to monitor the patient once therapy has started should be developed. Professionalism is an important aspect of case-based discussion — issues must be prioritised appropriately and ethical and legal frameworks must be referred to [7] . A case-based discussion would include broadly similar content to the oral case presentation, but would involve further questioning of the presenter by the assessor to determine the extent of the presenter’s knowledge of the specific case, condition and therapeutic strategies. The criteria used for assessment would depend on the level of practice of the presenter but, for pharmacists, this may include assessment against the RPS  Foundation or Pharmacy Frameworks .

Acknowledgement

With thanks to Aamer Safdar for providing the script for the audio case presentation.

Reading this article counts towards your CPD

You can use the following forms to record your learning and action points from this article from Pharmaceutical Journal Publications.

Your CPD module results are stored against your account here at The Pharmaceutical Journal . You must be registered and logged into the site to do this. To review your module results, go to the ‘My Account’ tab and then ‘My CPD’.

Any training, learning or development activities that you undertake for CPD can also be recorded as evidence as part of your RPS Faculty practice-based portfolio when preparing for Faculty membership. To start your RPS Faculty journey today, access the portfolio and tools at www.rpharms.com/Faculty

If your learning was planned in advance, please click:

If your learning was spontaneous, please click:

[1] Onishi H. The role of case presentation for teaching and learning activities. Kaohsiung J Med Sci 2008;24:356–360. doi: 10.1016/s1607-551x(08)70132–3

[2] Edwards JC, Brannan JR, Burgess L et al . Case presentation format and clinical reasoning: a strategy for teaching medical students. Medical Teacher 1987;9:285–292. doi: 10.3109/01421598709034790

[3] Goldberg C. A practical guide to clinical medicine: overview and general information about oral presentation. 2009. University of California, San Diego. Available from: https://meded.ecsd.edu/clinicalmed.oral.htm (accessed 5 December 2015)

[4] Chan MY. The oral case presentation: toward a performance-based rhetorical model for teaching and learning. Medical Education Online 2015;20. doi: 10.3402/meo.v20.28565

[5] McGee S. Medicine student programs: oral presentation guidelines. Learning & Scholarly Technologies, University of Washington. Available from: https://catalyst.uw.edu/workspace/medsp/30311/202905 (accessed 7 December 2015)

[6] Hays R. Teaching and Learning in Clinical Settings. 2006;425. Oxford: Radcliffe Publishing Ltd.

[7] Royal Pharmaceutical Society. Tips for assessors for completing case-based discussions. 2015. Available from: http://www.rpharms.com/help/case_based_discussion.htm (accessed 30 December 2015)

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Home Blog Business How to Present a Case Study: Examples and Best Practices

How to Present a Case Study: Examples and Best Practices

Marketers, consultants, salespeople, and all other types of business managers often use case study analysis to highlight a success story, showing how an exciting problem can be or was addressed. But how do you create a compelling case study and then turn it into a memorable presentation? Get a lowdown from this post! 

Table of Content s

• Why Case Studies are a Popular Marketing Technique 

Popular Case Study Format Types

How to write a case study: a 4-step framework, how to do a case study presentation: 3 proven tips, how long should a case study be, final tip: use compelling presentation visuals, business case study examples, what is a case study .

Let’s start with this great case study definition by the University of South Caroline:

In the social sciences, the term case study refers to both a method of analysis and a specific research design for examining a problem, both of which can generalize findings across populations.

In simpler terms — a case study is investigative research into a problem aimed at presenting or highlighting solution(s) to the analyzed issues.

A standard business case study provides insights into:

• General business/market conditions 
• The main problem faced 
• Methods applied 
• The outcomes gained using a specific tool or approach

Case studies (also called case reports) are also used in clinical settings to analyze patient outcomes outside of the business realm. 

But this is a topic for another time. In this post, we’ll focus on teaching you how to write and present a business case, plus share several case study PowerPoint templates and design tips! 

Why Case Studies are a Popular Marketing Technique 

Besides presenting a solution to an internal issue, case studies are often used as a content marketing technique . According to a 2020 Content Marketing Institute report, 69% of B2B marketers use case studies as part of their marketing mix.

A case study informs the reader about a possible solution and soft-sells the results, which can be achieved with your help (e.g., by using your software or by partnering with your specialist). 

For the above purpose, case studies work like a charm. Per the same report: 

• For 9% of marketers, case studies are also the best method for nurturing leads. 
• 23% admit that case studies are beneficial for improving conversions. 

Moreover, case studies also help improve your brand’s credibility, especially in the current fake news landscape and dubious claims made without proper credit. 

Ultimately, case studies naturally help build up more compelling, relatable stories and showcase your product benefits through the prism of extra social proof, courtesy of the case study subject. 

Most case studies come either as a slide deck or as a downloadable PDF document. 

Typically, you have several options to distribute your case study for maximum reach:

• Case study presentations — in-person, virtual, or pre-recorded, there are many times when a case study presentation comes in handy. For example, during client workshops, sales pitches, networking events, conferences, trade shows, etc. 
• Dedicated website page — highlighting case study examples on your website is a great way to convert middle-on-the-funnel prospects. Google’s Think With Google case study section is a great example of a web case study design done right.

• Blog case studies — data-driven storytelling is a staunch way to stand apart from your competition by providing unique insights, no other brand can tell. 
• Video case studies — video is a great medium for showcasing more complex business cases and celebrating customer success stories.

Once you decide on your case study format, the next step is collecting data and then translating it into a storyline. There are different case study methods and research approaches you can use to procure data. 

But let’s say you already have all your facts straight and need to organize them in a clean copy for your presentation deck. Here’s how you should do it. 

1. Identify the Problem 

Every compelling case study research starts with a problem statement definition. While in business settings, there’s no need to explain your methodology in-depth; you should still open your presentation with a quick problem recap slide.

Be sure to mention: 

• What’s the purpose of the case study? What will the audience learn? 
• Set the scene. Explain the before, aka the problems someone was facing. 
• Advertise the main issues and findings without highlighting specific details.

The above information should nicely fit in several paragraphs or 2-3 case study template slides

2. Explain the Solution 

The bulk of your case study copy and presentation slides should focus on the provided solution(s). This is the time to speak at length about how the subject went from before to the glorious after. 

Here are some writing prompts to help you articulate this better:

• State the subject’s main objective and goals. What outcomes were they after?
• Explain the main solution(s) provided. What was done? Why this, but not that? 
• Mention if they tried any alternatives. Why did those work? Why were you better?

This part may take the longest to write. Don’t rush it and reiterate several times. Sprinkle in some powerful words and catchphrases to make your copy more compelling.

3. Collect Testimonials 

Persuasive case studies feature the voice of customer (VoC) data — first-party testimonials and assessments of how well the solution works. These provide extra social proof and credibility to all the claims you are making. 

So plan and schedule interviews with your subjects to collect their input and testimonials. Also, design your case study interview questions in a way that lets you obtain quantifiable results.

4. Package The Information in a Slide Deck

Once you have a rough first draft, try different business case templates and designs to see how these help structure all the available information. 

As a rule of thumb, try to keep one big idea per slide. If you are talking about a solution, first present the general bullet points. Then give each solution a separate slide where you’ll provide more context and perhaps share some quantifiable results.

For example, if you look at case study presentation examples from AWS like this one about Stripe , you’ll notice that the slide deck has few texts and really focuses on the big picture, while the speaker provides extra context.

Need some extra case study presentation design help? Download our Business Case Study PowerPoint template with 100% editable slides. 

Your spoken presentation (and public speaking skills ) are equally if not more important than the case study copy and slide deck. To make a strong business case, follow these quick techniques. 

Focus on Telling a Great Story

A case study is a story of overcoming a challenge, and achieving something grand. Your delivery should reflect that. Step away from the standard “features => benefits” sales formula. Instead, make your customer the hero of the study. Describe the road they went through and how you’ve helped them succeed. 

The premises of your story can be as simple as:

• Help with overcoming a hurdle
• Gaining major impact
• Reaching a new milestone
• Solving a persisting issue no one else code 

Based on the above, create a clear story arc. Show where your hero started. Then explain what type of journey they went through. Inject some emotions into the mix to make your narrative more relatable and memorable. 

Experiment with Copywriting Formulas 

Copywriting is the art and science of organizing words into compelling and persuasive combinations that help readers retain the right ideas. 

To ensure that the audience retains the right takeaways from your case study presentation, you can try using some of the classic copywriting formulas to structure your delivery. These include:

• AIDCA — short for A ttention, I nterest, D esire, C onviction, and A ction. First, grab the audience’s attention by addressing the major problem. Next, pique their interest with some teaser facts. Spark their desire by showing that you know the right way out. Then, show a conviction that you know how to solve the issue—finally, prompt follow-up action such as contacting you to learn more. 
• PADS — is short for Problem, Agitation, Discredit, or Solution. This is more of a sales approach to case study narration. Again, you start with a problem, agitate about its importance, discredit why other solutions won’t cut it, and then present your option. 
• 4Ps — short for P roblem, P romise, P roof, P roposal. This is a middle-ground option that prioritizes storytelling over hard pitches. Set the scene first with a problem. Then make a promise of how you can solve it. Show proof in the form of numbers, testimonials, and different scenarios. Round it up with a proposal for getting the same outcomes. 

Take an Emotion-Inducing Perspective

The key to building a strong rapport with an audience is showing that you are one of them and fully understand what they are going through. 

One of the ways to build this connection is by speaking from an emotion-inducing perspective. This is best illustrated with an example: 

• A business owner went to the bank
• A business owner came into a bank branch 

In the second case, the wording prompts listeners to paint a mental picture from the perspective of the bank employees — a role you’d like them to relate to. By placing your audience in the right visual perspective, you can make them more receptive to your pitches. 

One common question that arises when creating a case study is determining its length. The length of a case study can vary depending on the complexity of the problem and the level of detail you want to provide. Here are some general guidelines to help you decide how long your case study should be:

• Concise and Informative: A good case study should be concise and to the point. Avoid unnecessary fluff and filler content. Focus on providing valuable information and insights.
• Tailor to Your Audience: Consider your target audience when deciding the length. If you’re presenting to a technical audience, you might include more in-depth technical details. For a non-technical audience, keep it more high-level and accessible.
• Cover Key Points: Ensure that your case study covers the key points effectively. These include the problem statement, the solution, and the outcomes. Provide enough information for the reader to understand the context and the significance of your case.
• Visuals: Visual elements such as charts, graphs, images, and diagrams can help convey information more effectively. Use visuals to supplement your written content and make complex information easier to understand.
• Engagement: Keep your audience engaged. A case study that is too long may lose the reader’s interest. Make sure the content is engaging and holds the reader’s attention throughout.
• Consider the Format: Depending on the format you choose (e.g., written document, presentation, video), the ideal length may vary. For written case studies, aim for a length that can be easily read in one sitting.

In general, a written case study for business purposes often falls in the range of 1,000 to 2,000 words. However, this is not a strict rule, and the length can be shorter or longer based on the factors mentioned above.

Our brain is wired to process images much faster than text. So when you are presenting a case study, always look for an opportunity to tie in some illustrations such as: 

• A product demo/preview
• Processes chart 
• Call-out quotes or numbers
• Custom illustrations or graphics 
• Customer or team headshots 

Use icons to minimize the volume of text. Also, opt for readable fonts that can look good in a smaller size too.

To better understand how to create an effective business case study, let’s explore some examples of successful case studies:

Apple Inc.: Apple’s case study on the launch of the iPhone is a classic example. It covers the problem of a changing mobile phone market, the innovative solution (the iPhone), and the outstanding outcomes, such as market dominance and increased revenue.

Tesla, Inc.: Tesla’s case study on electric vehicles and sustainable transportation is another compelling example. It addresses the problem of environmental concerns and the need for sustainable transportation solutions. The case study highlights Tesla’s electric cars as the solution and showcases the positive impact on reducing carbon emissions.

Amazon.com: Amazon’s case study on customer-centricity is a great illustration of how the company transformed the e-commerce industry. It discusses the problem of customer dissatisfaction with traditional retail, Amazon’s customer-focused approach as the solution, and the remarkable outcomes in terms of customer loyalty and market growth.

Coca-Cola: Coca-Cola’s case study on brand evolution is a valuable example. It outlines the challenge of adapting to changing consumer preferences and demographics. The case study demonstrates how Coca-Cola continually reinvented its brand to stay relevant and succeed in the global market.

Airbnb: Airbnb’s case study on the sharing economy is an intriguing example. It addresses the problem of travelers seeking unique and affordable accommodations. The case study presents Airbnb’s platform as the solution and highlights its impact on the hospitality industry and the sharing economy.

These examples showcase the diversity of case studies in the business world and how they effectively communicate problems, solutions, and outcomes. When creating your own business case study, use these examples as inspiration and tailor your approach to your specific industry and target audience.

Finally, practice your case study presentation several times — solo and together with your team — to collect feedback and make last-minute refinements! 

1. Business Case Study PowerPoint Template

To efficiently create a Business Case Study it’s important to ask all the right questions and document everything necessary, therefore this PowerPoint Template will provide all the sections you need.

Use This Template

2. Medical Case Study PowerPoint Template

3. Medical Infographics PowerPoint Templates

4. Success Story PowerPoint Template

5. Detective Research PowerPoint Template

6. Animated Clinical Study PowerPoint Templates

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Gynecology Breakthrough Theme

Download the Gynecology Breakthrough Theme presentation for PowerPoint or Google Slides.Treating diseases involves a lot of prior research and clinical trials. But whenever there’s a new discovery, a revolutionary finding that opens the door to new treatments, vaccines or ways to prevent illnesses, it’s great news. Should there be a...

Clinical Case 06-2023

Slidesgo is back with a new free medical template, perfect for a presentation about a clinical case. The design is very appealing, so these slides are a nice tool to provide a lot of useful information for doctors and researchers.

Oral Cavity Diseases: Gingivitis

Download the Oral Cavity Diseases: Gingivitis presentation for PowerPoint or Google Slides. Taking care of yourself and of those around you is key! By learning about various illnesses and how they are spread, people can get a better understanding of them and make informed decisions about eating, exercise, and seeking...

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Pastel Palette Doctor Theme

Presentations on health and medical topics can be challenging to create, but this Google Slides & PowerPoint template is here to rescue you! This multi-purpose layout is designed with blue pastel tones, providing a professional and calm environment to showcase your medical expertise to colleagues, students, or patients. The template...

National Library of Medicine

How many books about medicine can there be? And medical centers? We can't give you an exact number, but what we can offer you is a template for Google Slides and PowerPoint to present your medical center. In a simple, but direct style, you can talk about your center, where...

Clinical Case 04-2023

When trying to prevent diseases, information is key, and if it’s reliable, all the better. With this new free medical template, you can show the results of a clinical case, including the symptoms, the patient monitoring, the treatment and all the important data. Its design will help you grab your...

Patients and Nurses Medical Theme

As the backbone of every healthcare system, nurses play an integral role in providing top-notch patient care. Whether it's administering medication, monitoring vital signs, or simply holding a hand, these dedicated professionals are the ones keeping our loved ones safe and comfortable during their time of need. But let's not...

Anatomy & Physiology

Download the Anatomy & Physiology presentation for PowerPoint or Google Slides. Healthcare goes beyond curing patients and combating illnesses. Raising awareness about diseases, informing people about prevention methods, discussing some good practices, or even talking about a balanced diet—there are many topics related to medicine that you could be sharing...

Pregnancy Breakthrough

Giving birth to a baby is a beautiful occasion, a manifestation of love between two people. Obstetrics are key during pregnancy, so how about giving a presentation about the latest breakthrough in this field? Our free medical template will come in handy.

Uterine Hemorrhage Case Report

Download the Uterine Hemorrhage Case Report presentation for PowerPoint or Google Slides. A clinical case is more than just a set of symptoms and a diagnosis. It is a unique story of a patient, their experiences, and their journey towards healing. Each case is an opportunity for healthcare professionals to...

Alcoholism Treatment Drugs Breakthrough

Drug addictions are a difficult condition to treat, but thanks to the investigations and studies conducted by health professionals, new breakthroughs are appearing to help people who suffer them. Speak about it with this visual design for breakthrough news and share the treatment you have discovered with the medical community!...

Opioid Addiction Rehab Center

Download the Opioid Addiction Rehab Center presentation for PowerPoint or Google Slides. Hospitals, private clinics, specific wards, you know where to go when in need of medical attention. Perhaps there’s a clinic specialized in treating certain issues, or a hospital in your area that is well-known for its state-of-the-art technology....

Psychogenic Cough Breakthrough

Download the Psychogenic Cough Breakthrough presentation for PowerPoint or Google Slides.Treating diseases involves a lot of prior research and clinical trials. But whenever there’s a new discovery, a revolutionary finding that opens the door to new treatments, vaccines or ways to prevent illnesses, it’s great news. Should there be a...

Clinical Case 01-2023

Present your clinical case to the medical community with this dynamic and engaging presentation by Slidesgo. Who said science can’t be creative and fun?

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