Student BMJ: How to Present Clincal Cases

Education

How to present clinical cases

Presenting a patient is an essential skill that is rarely taught

• By: Ademola Olaitan, Oluwakemi Okunade, Jonathan Corne
• Published: 13 April 2010
• DOI: 10.1136/sbmj.c1539

Clinical presenting is the language that doctors use to communicate with each other every day of their working lives. Effective communication between doctors is crucial, considering the collaborative nature of medicine. As a medical student and later as a doctor you will be expected to present cases to peers and senior colleagues. This may be in the setting of handovers, referring a patient to another specialty, or requesting an opinion on a patient.

A well delivered case presentation will facilitate patient care, act a stimulus for timely intervention, and help identify individual and group learning needs.[1] Case presentations are also used as a tool for assessing clinical competencies at undergraduate and postgraduate level.

Medical students are taught how to take histories, examine, and communicate effectively with patients. However, we are expected to learn how to present effectively by observation, trial, and error.

Principles of presentation

Remember that the purpose of the case presentation is to convey your diagnostic reasoning to the listener. By the end of your presentation the examiner should have a clear view of the patient’s condition. Your presentation should include all the facts required to formulate a management plan.

There are no hard and fast rules for a perfect presentation, rather the content of each presentation should be determined by the case, the context, and the audience. For example, presenting a newly admitted patient with complex social issues on a medical ward round will be very different from presenting a patient with a perforated duodenal ulcer who is in need of an emergency laparotomy.

Whether you’re presenting on a busy ward round or during an objective structured clinical examination (OSCE), it is important that you are concise yet get across all the important points. Start by introducing patients with identifiers such as age, sex, and occupation, and move on to the complaint that they presented with or the reason that they are in hospital. The presenting complaint is an important signpost and should always be clearly stated at the start of the presentation.

Presenting a history

After you’ve introduced the patient and stated the presenting complaint, you can proceed in a chronological approach—for example, “Mr X came in yesterday with worsening shortness of breath, which he first noticed four days ago.” Alternatively you can discuss each of the problems, starting with the most pertinent and then going through each symptom in turn. This method is especially useful in patients who have several important comorbidities.

The rest of the history can then be presented in the standard format of presenting complaint, history of presenting complaint, medical history, drug history, family history, and social history. Strictly speaking there is no right or wrong place to insert any piece of information. However, in some instances it may be more appropriate to present some information as part of the history of presenting complaints rather than sticking rigidly to the standard format. For example, in a patient who presents with haemoptysis, a mention of relevant risk factors such as smoking or contacts with tuberculosis guides the listener down a specific diagnostic pathway.

Apart from deciding at what point to present particular pieces of information, it is also important to know what is relevant and should be included, and what is not. Although there is some variation in what your seniors might view as important features of the history, there are some aspects which are universally agreed to be essential. These include identifying the chief complaint, accurately describing the patient’s symptoms, a logical sequence of events, and an assessment of the most important problems. In addition, senior medical students will be expected to devise a management plan.[1]

The detail in the family and social history should be adapted to the situation. So, having 12 cats is irrelevant in a patient who presents with acute appendicitis but can be relevant in a patient who presents with an acute asthma attack. Discerning the irrelevant from the relevant is not always easy, but it comes with experience.[2] In the meantime, learning about the diseases and their associated features can help to guide you in the things you need to ask about in your history. Indeed, it is impossible to present a good clinical history if you haven’t taken a good history from the patient.

Presenting examination findings

When presenting examination findings remember that the aim is to paint a clear picture of the patient’s clinical status. Help the listener to decide firstly whether the patient is acutely unwell by describing basics such as whether the patient is comfortable at rest, respiratory rate, pulse, and blood pressure. Is the patient pyrexial? Is the patient in pain? Is the patient alert and orientated? These descriptions allow the listener to quickly form a mental picture of the patient’s clinical status. After giving an overall picture of the patient you can move on to present specific findings about the systems in question. It is important to include particular negative findings because they can influence the patient’s management. For example, in a patient with heart failure it is helpful to state whether the patient has a raised jugular venous pressure, or if someone has a large thyroid swelling it is useful to comment on whether the trachea is displaced. Initially, students may find it difficult to know which details are relevant to the case presentation; however, this skill becomes honed with increasing knowledge and clinical experience.

Presenting in an exam

Although the same principles as presenting in other situations also apply in an exam setting, the exam situation differs in the sense that its purpose is for you to show your clinical competence to the examiner.

It’s all about making a good impression. Walk into the room confidently and with a smile. After taking the history or examining the patient, turn to the examiner and look at him or her before starting to present your findings. Avoid looking back at the patient while presenting. A good way to avoid appearing fiddly is to hold your stethoscope behind your back. You can then wring to your heart’s content without the examiner sensing your imminent nervous breakdown.

Start with an opening statement as you would in any other situation, before moving on to the main body of the presentation. When presenting the main body of your history or examination make sure that you show the examiner how your findings are linked to each other and how they come together to support your conclusion.

Finally, a good summary is just as important as a good introduction. Always end your presentation with two or three sentences that summarise the patient’s main problem. It can go something like this: “In summary, this is Mrs X, a lifelong smoker with a strong family history of cardiovascular disease, who has intermittent episodes of chest pain suggestive of stable angina.”

Improving your skills

The RIME model (reporter, interpreter, manager, and educator) gives the natural progression of the clinical skills of a medical student.[3] Early on in clinical practice students are simply reporters of information. As the student progresses and is able to link together symptoms, signs, and investigation results to come up with a differential diagnosis, he or she becomes an interpreter of information. With further development of clinical skills and increasing knowledge students are actively able to suggest management plans. Finally, managers progress to become educators. The development from reporter to manager is reflected in the student’s case presentations.

The key to improving presentation skills is to practise, practise, and then practise some more. So seize every opportunity to present to your colleagues and seniors, and reflect on the feedback you receive.[4] Additionally, by observing colleagues and doctors you can see how to and how not to present.

Top tips

• Remember the purpose of the presentation
• Be flexible; the context should dictate the content of the presentation
• Always include a presenting complaint
• Present your findings in a way that shows understanding
• Have a system
• Use appropriate terminology

Additional tips for exams

• Start with a clear introductory statement and close with a brief summary
• After your summary suggest a working diagnosis and a management plan
• Practise, practise, practise, and get feedback
• Present with confidence, and don’t be put off by an examiner’s poker face
• Be honest; do not make up signs to fit in with your diagnosis

Ademola Olaitan, medical student¹, Oluwakemi Okunade, final year medical student¹, Jonathan Corne, consultant physician<sup>2

1</sup>University of Nottingham, ²Nottingham University Hospitals

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.

See “Medical ward rounds” (Student BMJ 2009;17:98-9, http://archive.student.bmj.com/issues/09/03/life/98.php).

References

1. 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.
2. Lingard LA, Haber RJ. What do we mean by “relevance”? A clinical and rhetorical definition with implications for teaching and learning the case-presentation format. Acad Med 1999;74:S124-7.
3. Pangaro L. A new vocabulary and other innovations for improving descriptive in-training evaluations. Acad Med 1999;74:1203-7.
4. Haber RJ, Lingard LA. Learning oral presentation skills: a rhetorical analysis with pedagogical and professional implications. J Gen Intern Med 2001;16:308-14.

Cite this as: Student BMJ 2010;18:c1539

Thanks Joe for sharing the article!

Free OSCE Revision Videos

Click here to access OSCE revision lectures. They are by delivered by the guy who wrote the Pastest OSCE book. Apparently, they are easygoing and good for quick revision if you have spare time.

Thank you Noura for sharing the link and good luck with your exam!

Sex and its Problems... A Crash Course!! Part 2

Psychosomatic Sex Cycle (adapted from Bancroft (2009))

So we've briefly touched on the components of the sexual response. Let's explore now the problems and their prevalence in males and females.

1/ DISORDERS OF SEXUAL DESIRE

Impairment of sexual desire can occur in both men and women; however lack of desire most commonly affects females with 60-70% prevalence rate.

Sexual desire correlates with the testosterone:oestrogen ratio in both genders so that a higher ratio is associated with increased sexual desire. Inhibition or lack of interest is broadly either psychogenic or organic in origin. Psychological factors include early parental problems, society or past experiences eg rape/incest. Organic causes include hyperprolactinaemia due to a pituitary adenoma (if impaired sexual response co-exists with symptoms of headache and impairment of peripheral vision- think pituitary adenoma!!). Diminished testosterone:oestrogen ratio may lead to lack of desire.

Management includes assessment for an underlying organic problem. Psychological problems are far more common, and a good history taker would be able to identify how patient attitudes of past and current relationships, any guilt or indication of early childhood problems contribute to the problem. Relationship therapy and taught focus exercises might be of benefit.

2/ DISORDERS OF SEXUAL AROUSAL

This is represented by erectile difficulties in men and by lack of lubrication and of general sexual responsiveness in women.

IN MEN

About 85% of cases with erectile dysfunction are organic in origin. Risk factors include obesity, lack of exercise smoking, high cholesterol, hypertension and diabetes.

- organic causes;

VASCULAR= atherosclerotic change in penile blood vessels (accounts for half of cases)

NEUROLOGICAL= can be either central (eg in Parkinson's, MS, spinal cord syndrome) or peripheral in origin (eg peripheral neuropathy like diabetic neuropathy or GBS, alchoholism, uraemia).

HORMONAL= Hypoganadism, Cushing's and thyroid diseases, hyperprolactinaemia

ANATOMICAL= Peyronie's disease

DRUGS = beta blockers, diuretics, Cu channel blockers, hormonal agents eg cyptotenone acetate,LH releasing analogues, H2 antagonists eg cimeetidine, ranitidine.

2/Psychogenic causes

- psychosexual factors (can be general due to a disorder of sexual intimacy and lack of arousability or situational due to partner or stress)

-Psychiatric illness ( Generalized anxiety disorder, depression, alcohol dependency)

Management - involves

- history taking ( ask about current/past sexual relationships, current emotional status, erectile symptoms eg onset and duration, arousal ejaculation and orgasmic difficulties). don't forget drug and social history. Latter is important to look for drinking problems, smoking, home situation, difficulties at work/marriage.

-Investigations - blood glucose, U&Es, urinarlysis, LFTs if indicated. If patient also has reduced sexual drive or abnormal sexual characterization, check testosterone levels, LH/FSH, prolactine (especially in young men).

Treatment - correct the underlying cause whether organic or psychological. First line symptomatic treatment is with phosphodiesterase inhibitors (sidenafil, tadafil, vardarefil) or vacuum devices eg external cylinder - one study reported that 23% asked for a prescription after a 2-week trial and 52% reported satisfaction (suitable for older patients).

IN WOMEN

Lack of arousal may be caused by inability to respond to sexual stimulation with dilatation of venous vaginal plexuses and lubrication to reach orgasm.

The causes are;

1/psychosexual;

- inhibitions from learned attitudes, past experiences or marriage difficulties.

- situational anxiety eg about a baby, in parental house

- inadequate stimulation from an inexperienced lover is often a cause of early difficulties

2/ organic

- Causes include drug side effects, neurological problems (MS), vascular disease (Diabetes), postmenopause (low oestrogen).

- Inadequate stimulation or lack of arousal may accompany dyspareunia, which is pain during a sexual intercourse. Fear of pain with intercourse causes anxiety with or without sexual reponse leading to vaginismus (contraction of pelvic muscles resulting in failure of penetrative sex) and more painful intercourse thus creating a vicious cycle.

For medical students reading this, dyspareunia is not an uncommon history station in your OSCE. You have to think of a differential. This depends on the site of the pain, which classifies dyspareunia into introital, midvaginal or deep.

Introital dyspareunia is caused by

-inadequate lubrication or vaginitis (eg due to STI)

-vaginismus

Midvaginal caused by

- urethritis, congenital vaginal abnormalities

Deep dyspareunia caused by

- endometriosis (ectopic bleeding uterine tissue outside uterus), adenomyosis (bleeding uterine tissue within uterine muscle layer), leiomyomata (benign uterine cancer), pelvic inflammatory disease, uterine retroversion or ovarian cyst.

Management

- Take a good history; if patient reports painful intercourse, ask about onset, duration and site of pain, and whether pain occurs with arousal or at penetration. Ask about associated symptoms eg rash, irritation, smell (local aetiology), vaginal discharge (STI), heavy periods and menstrual irregularities (endometriosis) and menopausal symptoms and any dragging sensation (prolapse).

- pelvic and speculum examination

-treatment; to correct the underlying cause. The cycle of fear must be broken in order to stop the pain if no evidence of organic aetiology and anxiety/vaginismus induced dyspareunia is suspected. A specialized Kegel exercise of the pelvic muscle is taught to the patient to learn how to relax pelvic muscles during an intercourse. Lubricants may be used in case of indequate lubrication.

3/ ORGASMIC DYSFUNCTION

5-10% of females report anorgasmia, which can either be primary (never been able to achieve orgasm under any circumstances) or secondary (diminished ability to active orgasm despite previous successful attempts). A study by Kinsey in 1953 found that 9% remain unable to experience orgasm throughout their lives.

Psychosexual factors include fear from momentary loss of control experienced during orgasm and unable to relax and let go. Vaginismus can cause orgasmic dysfunction as well as impaired arousal. Other physical factors include lack of normal bulbo-cavernous reflex which causes failure to reach orgasm.

I hope this brief post made a useful introduction into medical problems affecting sexuality, which is normally a big and complicated area. For further reading, please explore the references below.

Information was adapted from;

- www.patient.co.uk (highly recommended for non-medical readers)

- John Bancroft, human sexuality and its problems. 3rd edition. 2009

- David Goldberg, Linda Gask and Richard Morris. Psychiatry in medical practice. 3rd edition. 2008