Presenting a Clinical Case

by Nina Hattiangadi Thomas, Ph.D., ABPP-CN

Many times in interview situations I have asked an intern or postdoctoral applicant to briefly describe an interesting case they have seen, and have been met either with stunned silence or with a disorganized series of statements that provide little or no insight into the case conceptualization.

The ability to present a case clearly and concisely is a core skill for a neuropsychologist, and one that will be called upon many times in both training and professional practice.  Whether it is a five-minute case description in response to an interview question or a fifty-minute seminar presentation, the guidelines for case presentation are the same.  With a little preparation and practice, being called upon to present a case may be your opportunity to impress.

1.  Include relevant information

Every case description should start out with basic relevant information.  “The patient was a six-year-old female with a history of spina bifida presenting for difficulties with early reading skills…”  Many times I’ve seen an individual launch into test results, and I’ll have to back them up and ask, “How old was the patient? What was his or her medical condition?”  The results are certainly interesting and I can understand the urge to jump right to them, but a brief concise description of demographic and medical information is necessary context.

This skill will also serve you well in your professional career.  In communicating with busy medical professionals, it is always helpful to start out with, “Dear Neurologist:  As you may remember, John Smith is a 10-year-old boy seen by you over the last year for management of treatment-resistant seizures…” as opposed to stating, “I am writing to you regarding John Smith…” and forcing the physician to refer back to the medical record for context.

2.  Don’t include irrelevant information

As important as including the relevant facts is excluding the irrelevant facts.  Often individuals seem to get mired in the details of a patient’s history.  It may be important to document in the report that the patient is allergic to strawberries and once broke his pinky finger, but unless it has direct relevance to the concerns at hand or your conceptualization, these facts are best omitted in a brief case presentation.  If the patient is a typically-developing teenager whose uncle is left-handed, this information can be omitted.  If, however, the patient is a toddler with unclear hand dominance and a strong family history of left-handedness being considered for right hemispherectomy — this fact is now important.

3.  Describe brain-behavior relationships

APA Division 40 defines clinical neuropsychology as a specialty “…dedicated to enhancing the understanding of brain-behavior relationships and the application of such knowledge to human problems.”

Developing an understanding of brain-behavior relationships is at the core of training in neuropsychology, and case presentations are perfect opportunities to demonstrate this understanding.  When conceptualizing your case, be sure not to just describe the pattern of neurocognitive strengths and weaknesses, but also to make clear statements about how these strengths and weaknesses correspond (or conflict) with known medical concerns.  For example, “the patient’s weaknesses in expressive language are highly consistent with the identified left frontotemporal seizure focus.  Weaknesses in attention may be related to seizure occurrence, side effects of antiepileptic medication, or the strong family history of attention problems.”  Not all individuals will have a significant medical history or localizing concern, but if not you should be prepared to answer questions about what brain regions may be involved based on the pattern of findings.

4.  Brush up on the medical condition at hand

No one expects you to become the world’s leading expert in a given medical condition overnight, but if you know you are presenting about a particular medical condition you should at least have a familiarity with important aspects of the condition, particularly factors relevant to neuropsychological outcome.  Presenting a case of spina bifida?  Know that level of lesion, presence of hydrocephalus, and number of shunt placements / failures / revisions are all important factors for cognitive outcome, and be prepared to provide that information for your case.

5.  Don’t hunt for zebras

“When you hear hoofbeats, think horses, not zebras.”  This medical aphorism encourages individuals to consider high base rate level conditions before rare ones.  Although rare cases are certainly interesting and memorable, don’t worry if you haven’t run across one of the ten individuals with Crisponi Syndrome, or a notable case of pure word deafness.  The point of a case presentation is to inform and to demonstrate your thinking, and you can be just as successful in providing a well-formulated description of a child with learning disability as you can one with maple syrup urine disease.

6.  Don’t get defensive

Once again, the purpose of a case presentation is to demonstrate how well you can “think through a case,” and part of that involves flexibility and being able to adapt your thinking to new information.  Not to mention that, as fellow neuropsychologists, cases are all very interesting to us and we may be not so much challenging your conceptualization as we are becoming drawn into the case and thinking it through ourselves.  Try not to consider any additional questions or alternate theories posed as a criticism of your abilities.  If you presented a case of slow recovery from concussion and are asked about the role depression might play in hindering recovery — even if it didn’t occur to you before, consider it now.  Even if you may not have the information at hand, you could say, “That’s a good point.  Her mood appeared positive and her family endorsed no concerns about mood, however we do routinely administer the BASC-2 questionnaire, and therefore it might be helpful to look back at that data.”

To sum up, there’s no need to feel “on the spot” when called upon to present a case.  A little preparation in advance, and you’ll be able to demonstrate your developing skills as a neuropsychologist in training as well as in your future professional career.

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