A Structured Template for Long Case Presentation in Clinical Examinations

Step 1:

Prepare a SUMMARY:

Comprehensive but concise.

Must contain patient’s name, gender, age, occupation, nationality ± racial/geographic origin, relevant PH/SH/FH Drug/Allergic Hx, symptoms + duration, relevant physical signs, ending with conclusive remarks using technical language e.g. breathlessness on lying flat summarize as orthopnea, lateral chest pain on coughing as pleurisy, sensitivity to light as photophobia, shifting dullness as ascites, neck stiffness as meningism, late fine bibasal creps as pulmonary edema (in a cardiac patient) etc.

Step 2:

Prepare a Management Plan:

a. Prepare a Problem list

Medical – acute

- chronic

Include: Social/Psychological/Occupational difficulties etc.

b. Prepare a narrative

Acute Problem- “I am going to investigate and provide immediate treatment: hand-in-hand.

Chronic problems – investigation and treatment at a later time.

Use headings to outline your management steps for both acute & chronic problems. A. For Acute Problem Include:

Medical treatment – Outline in Headings: 1. ABC plus 2S: Immediate Symptomatic e.g. pain relief, antiemetic etc. and

Supportive interventions e.g. IV fluids, oxygen, bicarbonate, calcium gluconate etc.

2. My Diagnosis is …………………..….or 3. My Differential Diagnoses are……………………………………. 4. I am going to confirm my diagnosis….. 5. I need to assess the severity by….. (Not applicable to all!).

6. I need to investigate for a cause by requesting …… 7. I need to deal with any complication or co-morbidities….. 8. Use the 3S: Site of Care, Specific Treatment, and Specialty Referral (Need

for referral – ICU, subspecialty, Surgery, Others: to outline specific disease management strategy.

9. Discharge Planning: Identification and management of risk factors/Patient Education Inclusive of DVT and Stress Ulcer prophylaxis PLUS Assessing Response to Treatment/Criteria for Discharge PLUS Social/occupational/dietary/educational input/needs {including lifestyle changes, exercise, identification bracelet, self-management plan, partnership agreement, Rehabs (Pulmonary, Stroke) etc.}

Note:

1. You should have prepared the above “in writing” before being called for case discussion. 2. Be prepared to provide an idea about prognosis if asked. 3. Follow-up arrangements:

Timing of outpatient visits Specific disease monitors: symptoms, signs, blood tests etc. Drug compliance monitors. Preventative aspects e.g. vaccination

An Example of a Long Case Presentation: Narrative Case Presentation for Clinical Examinations

Incorporating the BESD, APP D/D and 5S Schemes.

History & Physical: A 61-year-old Hispanic man presents to the emergency department complaining of a nonproductive cough that worsens at night as well as chest pain; both symptoms have persisted for 2 weeks. The chest pain is localized in the mid-sternum with radiation to the epigastrum. He describes the pain as sharp with a severity of 7 on a 1-10 scale. The patient states that the pain is constant with no exacerbating or relieving factors. He also has had fever, chills, nausea, and vomiting. One week prior, his primary care physician prescribed ampicillin for suspected pneumonia. He noticed no improvement in symptoms. He is single, a non-smoker, drinks alcohol socially and keeps no pets. There is no recent travel. Physical Exam: Vital signs: temperature 101.5° F (38.6 C), blood pressure 119/82 mm Hg, heart rate 132, respirations 18, oxygen saturation 89% on room air. General: lying in bed and in mild respiratory distress. Head, eyes, ears, nose, and throat: Sclera are non-icteric and without any pallor. Pupils are equal in size and reactive to light. The rest of the ears, nose, and throat exams were normal. Neck: supple, without any lymph node enlargement Cardiac: S1, S2 present with regular rate and rhythm and tachycardia Respiratory: bilateral rhonchi and basilar crackles Abdomen: soft, tenderness with palpation in the epigastrium without guarding or rigidity; normal bowel sounds and no organomegaly. Extremities: no cyanosis or pitting edema. Neuromuscular and skin exam: grossly within normal limits. So in SUMMARY: Note: important points to include in the Summary are highlighted. This is a…… “ name” 61 year old, Hispanic single, male presenting with a 2 weeks history of dry cough,

central non- pleuritic chest pains, fever, chills, nausea and vomiting non-responsive to

ampicillin.

Clinically febrile, in mild respiratory distress, hypoxemic and tachycardic with airway obstruction and basilar crackles. I am going to do the following:

1. I am going to assess his A(B)C and start Immediate Symptomatic e.g. pain relief, antiemetic, bronchodilator etc. and Supportive interventions e.g. IV fluids, oxygen etc.

2. My Diagnosis is CAP likely Atypical: Viral, Mycoplasma, Legionella, Chlamydia etc. 3. My Differential Diagnoses are…….

Aetio-pathological differential diagnosis

Other Infections: e.g. CMV, Influenza A, RSV, Resistant S. aureus MRSA, resistant pneumococci, Brucella, Tuberculosis, PJP etc.

Inflammatory e.g. collagenosis, allergic alveolitis

Vascular e.g. pulmonary embolism

Neoplastic e.g. Lymphoma,

Drug-induced pneumonitis etc.

Poisoning: e.g. Paraquat 4. I am going to confirm my diagnosis by requesting a CXR. 5. I need to assess the severity by using the CURB-65 SCORE so that I can decide on the Site

of Care. 6. I need to investigate for a cause as well as initiate Sepsis Bundle interventions by

requesting Sputum for Gram stain and culture, blood culture, Pro-calcitonin/CRP level, WBC Count and Differential, lactic acid and glucose levels proceeding to other tests if patient is not improving.

7. I shall look for serious complications such as acute renal dysfunction by checking patient’s electrolytes and DIC by checking his platelet count and coagulation screen.

8. I am going to start the patient on Specific treatment: Antibiotic e.g. IV Azithromycin plus Ceftriaxone or a Respiratory Quinolone etc.

9. I am going to consider referring to Specialty: Pulmonary, Infectious Diseases, Intensivist etc.

10. I shall at the same time initiate my Discharge Planning interventions: Inclusive of DVT and Stress Ulcer prophylaxis PLUS Assessing Response to Treatment/Criteria for Discharge PLUS Social/occupational/dietary/educational input/needs (including lifestyle changes, exercise, identification bracelet, self-management plan, partnership agreement, Rehabs (Pulmonary, Stroke) etc.)

Note: 2. You should have prepared the above in writing before being called for case discussion. 3. Be prepared to provide an idea about prognosis if asked. 4. Follow-up arrangements:

Timing of outpatient visits Specific disease monitors: symptoms, signs, blood tests etc. Drug compliance monitors. Preventative aspects e.g. vaccination

Table 1: The Expert Clinician’s Actions Map for a Patient Encounter and their Cognitive Schemes

Step Clinical Action Expert ‘s Scheme/Cognitive

Aid

Example

1 Gather Information (History & Physical)

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2 Summarize the Case using Technical Language: Highlight the important points whilst writing the H&P.

Comprehensive but Concise, Text-book-Like: Must contain patient’s name, gender, age, ±occupation, ±nationality ± racial/geographic origin, relevant Past History/Social History/Family History, Drug/Allergic History, Symptoms + duration –in technical terms, Relevant physical signs in technical conclusive terms.

A 61-year-old Hispanic man presents to the emergency department complaining of a nonproductive cough that worsens at night as well as chest pain; both symptoms have persisted for 2 weeks. The chest pain is localized in the mid-sternum with radiation to the epigastrum. He describes the pain as sharp with a severity of 7 on a 1-10 scale. The patient states that the pain is constant with no exacerbating or relieving factors. He also has had fever, chills, nausea, and vomiting. One week prior, his primary care physician prescribed ampicillin for suspected pneumonia. He noticed no improvement in symptoms Physical Exam Vital signs: temperature 101.5° F (38.6 C), blood pressure 119/82 mm Hg, heart rate 132, respirations 18, oxygen saturation 89% on room air. General: lying in bed and in mild respiratory distress. Head, eyes, ears, nose, and throat: Sclera are nonicteric and without any pallor. Pupils are equal in size and reactive to light. The rest of the ears, nose, and throat exams were normal. Neck: supple, without any lymph node enlargement Cardiac: S1, S2 present with regular rate and rhythm and tachycardia Respiratory: bilateral rhonchi and basilar crackles Abdomen: soft, tenderness with palpation in the epigastrium without guarding or rigidity; normal bowel sounds and no organomegaly Extremities: no cyanosis or pitting edema Neuromuscular and skin exam: grossly within normal limits. Chest X-ray Bilateral patchy infiltrates (read as bilateral

pneumonia) Laboratory Analyses Complete blood count: hemoglobin 11.3; hematocrit 32.5; white blood cell count 7.4 (N 42%, L 43%, M 5%, E 2%); platelets 421,000 Electrolyte panel: sodium 133 mEg/L; potassium 4.4 mEq/L; chloride 103 mEq/L; bicarbonate 16 mEq/L; blood urea nitrogen 16 mg/dL; creatinine 1.0 mg/dL; glucose 90 mg/dL; calcium 9.3 Additional studies: aspartate transaminase (AST) 90; alanine aminotransferase (ALT) 34; alkaline phosphatase (ALP) 102; albumin 3.4; creatine kinase (CK) 53; pro-brain natriuretic peptide (Pro-BNP) 437. Summary: 61 year old, Hispanic male presenting with a 2 weeks history of dry cough, central non- pleuritic chest pains, fever, chills, nausea and vomiting non-responsive to ampicillin. Clinically febrile, in mild respiratory distress, hypoxemic and tachycardic with airway obstruction and basilar crackles. Investigations showed bilateral patchy infiltrates, hyponatremia, mild metabolic acidosis and significantly raised pro-brain natriuretic peptide (Pro-BNP) 437.

3 Propose a Diagnosis Pattern-recognition PR, Hypothetico-deductive Strategies HD (from H&P) and Smart Heuristics (Rules-of-Thumb), Rule-Out worst Scenario ROWS, Red Flags (symptoms or signs of more serious pathology) etc. The 3Rs!

Use the BES-DIAGNOSTIC (BESD) Scheme: Bed-side Diagnosis: CAP likely Atypical Plus: ? SIADH ? Lactic Acidosis ?LVF Etiology: Viral, Mycoplasma, Legionella, Chlamydia etc. Severity: CURB-65= 0

4 Differential Diagnosis

Differential Diagnosis Cognitive Aids Anatomical: for Swellings, Pain etc Physiological: for Shock, Thrombosis, Hyponatremia Pathological: A:Acquired: 1. Traumatic, 2.

Infective, 3. Inflammatory/auto-immune, 4. Vascular/ degenerative, 5. Neoplastic/para-neoplastic, 6. Metabolic/endocrine, 7. Drug-induced/ poisoning, 8. Deficiency diseases, 9. Psychogenic and 10. Idiopathic/ cryptogenic.

B:Congenital/Hereditary (the APP Scheme)

Pathological: Aetio-pathological differential diagnosis Other Infections: e.g. Viral: CMV, Influenza A, RSV, Bacterial: Resistant S. aureus MRSA, resistant pneumococci, Brucella, Tuberculosis, Fungal/opportunistic: PJP, Cryptococci etc. Inflammatory e.g. collagenosis, allergic alveolitis Vascular e.g. pulmonary embolism Neoplastic e.g. Lymphoma Drug-induced pneumonitis etc. Poisoning: Paraquat This is what guides you in taking more focused history and for requesting the appropriate tests. “An important and well-recognized cause of diagnostic errors is failing to consider alternative diagnoses”

5 Therapeutic Interventions

Contextual, Patient-centered Therapeutic Cognitive Aid: Site of Care, Symptomatic, Supportive, Specific and Specialty Referral (the 5S Scheme).

Site of Care: Ward. ? ICU Symptomatic: Analgesia, Anti-emetic, Anti-pyretic, Bronchodilator etc. Supportive: Oxygen, IV fluids etc. Specific: Antibiotic e.g. IV Azithromycin plus Ceftriaxone or a Respiratory Quinolone etc. Specialty Referral: Pulmonary, Infectious Diseases, Intensivist etc.

6 Prepare for Discharge

Assess Response to Treatment (Subjective & Objective), Criteria for Discharge,

Assess Response to Treatment : Subjective & Objective Criteria for Discharge: Clinical, Laboratory, Radiologic, Social etc. Timing of Follow-up : Clinic Appointment for

Timing of Follow-up ( the ACT Scheme)

disease and drug monitoring