Case Presentations – Logical Flow and Speaking Naturally

INTRODUCTION

Make the presentation flow. Use prose.
Don’t give the spiel in monotone with no breaks and punctuation. Preface each new section with a brief pause and then a change in tone of voice.

OPENING

Give a bright 30 second opening that improveS the flow and context of the rest of your presentation e.g. ‘I saw Mr. Smith who initially presented with increasing abdominal distension in the setting of chronic alcohol abuse’. ‘It appears that he is somewhat of a diagnostic and/or management problem’.
If you feel that you already are confident of the likely diagnosis then say it now.
If you aren’t sure preface the presentation by saying he has a ‘perplexing’, ‘unusual’ or ‘atypical history’ of chest tightness and a chronic dry cough’ and continuing ‘His story began 2 weeks ago when….’
Preface the opening with a comment of any factors that may have affected the assessment e.g. Non-English speaking background, dysphasia, patient upset, patient had a seizure, drowsiness, vague or inconsistent historian.

MIDDLE

Don’t stop and start with headings, instead…..‘He gives a history of….’, ‘A review of system also elicited a a few other undefined issues….’, ‘Examination revealed…’
Find a balance between reporting the patient’s story verbatim and providing an appropriate medical commentary e.g. “the patient described a feeling of ‘dizziness’ which further questioning sounded like vertiginous symptoms”, “he mentioned he was a small blue pill for an irregular heart beta which I take to be possibly digoxin”.
If there are parts of the story which are vague, unsubstantiated or unknown then say what you would do to fill in the gaps. “The patient could not give me a reliable list of his medications and I would need to speak to his carer or GP to confirm this.”, “He was unable to recall the result of his endoscopy and I would like to obtain a copy of the report”, “I would need to confirm the active ingredient in durogesic patches”

If a diagnosis, test or treatment has been recently been performed this is rightly presented in the history not at the end. e.g.‘two months ago he presented with similar symptoms and had a exercise stress test that was negative and further investigation with coronary angiogram was not pursued. The cardiologist did not commence anti-angina therapy but did address a few lifestyle factors and commenced him on lipid-lowering agents.

Often the HPC is tied up with the PMHx e.g. SOB/asthma, chest pain/IHD, visual disturbance/MS e.g. Mrs Walcott presented with 4 days of worsening joint pain in the setting of long standing remitting rheumatoid arthritis. Mr Flint awoke with an episode chest pain with a known history of both ischaemic heart disease, reflux oesophagitis and recurrent pulmonary emboli. Mrs Doe was referred by her GP with severe anaemia on a background of chronic renal failure and previous bleeding peptic ulcers. Mr. Jackson was being investigated for recurrent DVT.
Mention only the parts of the PMHx which are relevant at the time. Place non-related PMHX later in the presentation
The same is for the Review of Systems – mention all relevant symptoms in the body of the presentation. Incidental symptoms can be provided just prior to the examination findings. Any new information found in the ROS should be elaborated on in the same way as any other primary complaint e.g. heartburn – intermittent lasts few minutes, several times a week, worse with spicy food or laying flat, relieved with Mylanta.

Indicate that some parts of the medical history may be incomplete or not fully defined. They have been only partially evaluated in the past. Some are based on weak evidence or only the patient’s interpretation of events.
Mention the current information to date and those yet obtained e.g. chronic diarrhoea – negative screen for coeliac, colonoscopy performed but results are pending
Even if a diagnosis has not been firmly established comment on how the symptoms affects the patient functionally (see below)

Ensure that all problems are described in terms of cause and severity. Not ‘history of angina’ but ‘infrequent angina and requiring GTN sublingual only with heavy exertion.’ Not ‘previously suffered anaemia’ but ‘had a period of anaemia complicating severe gastritis but now well controlled with PPI’.

After presenting the history next present the examination system most relevant to the case eg. knee pain> MSS/rheum/ortho exam, vertigo > neuro exam, dyspnea > cardio-respiratory exam. Follow with the rest of the exam in the typical order – CVS, Resp, GIT, Neuro, Endo/Haem, MSS.

Outline all the problems. In the list mention the problem, its severity and its cause if known eg. #1 unrelieved chest pain possibly cardiac in origin requiring investigation, #2 significant social issues that will need addressing #3 mild well controlled asthma #4 poorly managed diabetes with early evidence of end-organ damage.
Next, expand on the problem list and indicate your investigations strategy and follow-up plan
Investigative strategy – don’t just list a battery tests. Indicate what specific test you wish to perform, what you are looking for, how you would proceed based on the result you get e.g. ‘I would proceed to CTPA if the d-dimer was negative’NOT ‘I would consider performing a d-dimer, V/Q scan and CTPA.’