AN INTRODUCTION TO

CLINICAL LECTURE
DEMONSTRATIONS
Saroj Jayasinghe
Department of Clinical Medicine
Faculty of Medicine
University of Colombo
OUTLINE
Place of CLDs
How clinicians think (clinical reasoning)
 CLDs
Common and important presentations
Approach to a patient with particular
symptoms and/or physical signs and/or
abnormal test results (blood, X-rays, ECGs
etc)
Introduces how clinicians think through
selected clinical topics: Clinical Reasoning
CLINICAL REASONING

How do clinicians think? (NOT

how we present a case)
Example of a clinical problem

Tackle you own case

Summary
Mr A
36 years
Married
Kollupitiya
Pain in the right side of chest: 2 days
What structures can
give rise to pain in this
area?
What structures can
give rise to pain in this
area?
Skin
Muscle
Bone (periosteum)
Pleura (parietal pleura)
CHARACTERISTICS OF PAIN ARISING
FROM THESE STRUCTURES

Skin: usually a visible skin lesion

Muscle: pain with movement
Bone: dull, continuous pain over bone
Pleura: sharp pain with breathing
Mr A
36 years
Married

Pain in the right side of chest: 2 days

Pain was sharp
Increased with breathing
Mr A
36 years
Married

Pain in the right side of chest: 2 days

Pain was sharp
Increased with breathing
What could be the affected structure?
Mr A
36 years
Married
Pain in the right side of chest: 2 days
Pain was sharp
Increased with breathing
What could be the affected structure?
PLEURA
CAUSES OF PLEURAL PAIN
Inflammation
Trauma
Vascular
Neoplasm
CAUSES OF PLEURAL PAIN
Inflammation: fever, cough
Trauma: history of fall, assault
Vascular: sudden onset, SOB (e.g. pulm emb)
Neoplasm: persistent (e.g. mesothelioma)
Mr A
36 years
Married

Pain in the right side of chest: 2 days

Pain was sharp
Increased with breathing

PLEURAL PAIN

Had fever for the past 4 days

Cough with yellowish expectorant
Pain gradually increased over the past 2 days
Mr A
36 years
Married

Pain in the right side of chest: 2 days

Pain was sharp
Increased with breathing

PLEURAL PAIN

Had fever for the past 4 days

Cough initially reddish, later yellowish expectorant
Pain gradually increased over the past 2 days

PLEURAL INFLAMMATION
PLEURAL INFLAMMATION

Pleurisy
Pneumonia with pleural involvement
PLEURAL INFLAMMATION

Pleurisy: pain with little expectoration

Pneumonia with pleural involvement:
features of pneumonia
 OTHER FEATURES
Past history
Family history
Social history
PHYSICAL EXAMINATION
PHYSICAL EXAMINATION

Vital signs and general examination

Pulse 95 / min and regular
BP 130/80
JVP normal....

Differentiate cause of chest pain

Pleurisy vs Pneumonia with pleurisy

PHYSICAL EXAMINATION

Differentiate cause of chest pain

Skin: usually visible skin lesion (e.g. H.zoster)

Muscle: tender over muscle
Bone: tenderness over bone
Pleura: auscultation a scraping sound
(pleural rub)
PHYSICAL EXAMINATION

Differentiate pleurisy vs. pneumonia with

pleurisy
Pleurisy Pneumonia with
Pleurisy
Pleural rub Pleural rub and signs of
pneumonia
Vocal fremitus, bronchial
breath sounds, vocal resonance
LIKELY DIAGNOSIS

Pneumonia with pleural involvement

INVESTIGATIONS
Confirm likely diagnosis
Chest X-ray
INVESTIGATIONS
Confirm likely diagnosis
Chest X-ray
Confirm likely diagnosis
WBC
Sputum Gram stain and culture
Blood culture
Assess severity
CURB-65 (Confusion; Urea; RR>30; BP<90; >65 age)
 Clinical severity assessment in the community setting: the CRB-65 score.

Lim W S et al. Thorax 2003;58:377-382

Copyright BMJ Publishing Group Ltd & British Thoracic Society. All rights reserved.
INVESTIGATIONS
Confirm likely diagnosis
Chest X-ray
Confirm cause of infection
WBC (Total 23,000, N 18,500, L 4500)
Sputum Gram stain and culture
Blood culture
ESR, CRP
Urea or Cr, electrolytes
TREATMENT

General points: admit (based on CURB-65), rest

Symptomatic: analgesics (paracetamol)
physiotherapy
deep breathing to remove
secretions
Specific: appropriate antibiotics
Follow up: confirm complete resolution
Prevention:
ANTIBIOTICS

Community acquired pneumonia

Pyogenic
Co-amoxiclav 1.2 g IV >>> oral
Duration: at least 10 days
Monitor
symptoms, signs, chest-Xray, WBC, ESR, CRP
 Complications
Lung: collapse, abscess, empyema, effusion,
respiratory failure, ARDS, pneumothorax
Outside lung: septicaemia, pericarditis;
DVT
 SUMMARY
Clinical reasoning
Methods and structure to think through
 CLINICAL REASONING
Clinicians reason-out clinical diagnosis
Practice this method while you see patients
in the ward
You all can become expert clinicians and
with time you will recognize conditions and
gangsters immediately....
 History taking and physical examination is not
simply a check-list
Experts use short cuts (just like what you did
now!)
At the beginning you have to slog your way
through! With time the short cuts will become
automatic
CLDs WILL TEACH YOU HOW TO FISH......