Internal Medicine

Problem Round

Presentation at Problem RoundsChoice of Case and Preparation

Your object is not to present the case, but the problem. You need to summarise the patient’s story into a brief, succinct presentation – just enough to allow people to understand the patient sufficiently to appreciate the problem and to contribute to an intelligent discussion of it.

Identify the Problem

The first step is to identify the problem or point of interest around which the discussion will take place. You need to be certain in your own mind why the patient merits presentation on the Problem Round, and you need to build the presentation around that. In most cases, you need to begin the presentation by telling the audience what the problem is which they are being asked to think about.

Example: A patient admitted with a history of recent-onset seizures has a very strange CT scan: your team is not certain whether it shows tuberculomata, tumour, congenital hamartoma etc.

You need to begin thus:

I am presenting a case of a 20 year-old man admitted with seizures who has a very unusual CT scan. We are hoping that some of our visitors will share their opinion of it with us. The patient is a…


Do not go into exhaustive detail. Present only that part of the history which is relevant to the problem.

Example: A patient is admitted with tuberculosis. He is placed on Rifafour. Two weeks later he develops renal failure.

For the purposes of Problem Round, the problem is the renal failure, not the tuberculosis. In presenting the history therefore, you need say nothing about his initial symptoms of tuberculosis. All you need say is:

This patient, with no history of renal disease, was admitted two weeks ago with pulmonary tuberculosis suspected on chest x ray and confirmed by direct sputum microscopy. He was placed on Rifafour. Yesterday we noticed that his urine had become very dark and we tested his renal function. On examination...


Present only those examination findings (positive and negative) which are relevant to the current problem. You must omit anything and everything which is not immediately relevant – after all, people can ask you if they require more information.

Example: A middle-aged woman is admitted with active rheumatoid arthritis, including all sorts of joint deformities. Subsequently she is noticed to be cyanosed, to have widespread crackles and to have a high JVP and gallop rhythm. The problem here is: Is this rheumatoid lung, or is it left heart failure?

For the purposes of Problem Round, the fact of the rheumatoid arthritis is a given, is not the problem per se and is not the focus of discussion. You will therefore not describe every joint and its examination in detail. You will summarise it thus:

Examination revealed a thin, middle-aged woman who is distressed and cyanosed. She has no finger-clubbing, but has rheumatoid nodules on the extensor surfaces of her elbows. She has active synovitis of her metacarpal joints and typical rheumatoid deformities involving many joints, both small and large. On examining her chest…


Presenting the investigations badly is actually worse than not presenting them at all.
You bore or confuse your audience, whereas the whole point of the presentation is to enlighten them. Present only investigations relevant to the problem, certainly not all the investigations done, and not even avery abnormal result, unless it is relevant. Present results slowly and clearly, pause, emphasise the abnormal results. Do not rattle everything off in one long speech. Your audience does not possess “photographic hearing”!

The Problem

End by informing or reminding the audience what the problem or question is for which you are seeking comment, and let the discussion flow from there.

In Summary

The value of a presentation lies in the discussion which arises from the case material, and not in the case itself. Remember that you should be presenting a problem or a subject rather than a person – the clinical details are only there to illustrate the message.

You can maximise the impact of your presentation by:

  • Bearing in mind the problem to be put to the audience.
  • Keeping the presentation short so as to maximise time for discussion.
  • Including only those clinical details essential to the problem.
  • Reporting only those investigation results relevant to the problem, and doing so in a way which makes it easy for the audience to remember them and to grasp their importance.

Adequate preparation makes all the difference. Choose which of the following preparatory steps are most likely to make your presentation an excellent one and follow them:

  • Thoughtful preparation of the case material.
  • Rearranging order of information so as to make comprehension easier for the audience.
  • Ruthlessly suppressing unnecessary data.
  • Bringing out the underlying problem .
  • Discussing the presentation in advance with a senior colleague.