Tips to Master Your Medical Long Case

MSU.IMS, Internal Medicine Unit

19/05/2017
Dr. Salma Elagel
Presentation’s outlines

 History.
 Physical examination.
 Summary.
 Time management.
 Discussion
 Assessment.
 Do and Do not.
 Remember: clinical medicine can only be learnt at the patient’s
bedside! Only practice will make you a good clinician.
History components

 The case Bio data.

 Presenting complaint.
 HOPC
 Systemic review.
 PMH/PSH.
 Drug and allergy history.
 Family History
 Social History
 Interviewing the patient

 Greet the pt. and introduce yourself

 Be polite to the pt. and check whether the pt is comfortable.

 Tell the pt that u have exam and that u have limited time to gather all the
important information and do the examination. (this is an important exam
in my life. Your cooperation is very essential for me)

 Do not be upset if the pt does not understand your q.. Just repeat the q in
another form.
Interviewing the patient
 You can use different approaches of the history but u need to be
systematic .. (you can start with medication. Or you can start with
chronic illness first).

 You can ask the pt; do you know the name of the disease from which
you are suffering? What drugs are you taking? Can you mention if any
procedure has been performed? (this will give you a valuable info
regarding the Dx)

 At the end of your history part ask the pt: is there anything else you
would like to tell me even if I did not ask about it ?
 HISTORY

 Pt bio data: Age, gender, address, occupation, marital status, DOA.

 P.C: would you plz tell me why are you admitted in the hospital? What is you
presenting problem?

 BE PATIENT WHILE STARTING WITH THE PATIENT

 PC: Symptom + duration
HISTORY (HOPI)
 OD PARA2:
 Onset:
 Duration:
 Progression:
 Aggravating factors:
 Relieving factors:
 Anything else, Anything else??
 HOPI should include both the significant positive and negative symptoms
 (DO NOT MIX SYMPTOMS WITH SIGNS)
 Some symptoms will need more elaboration (sakit/sick/pain), tak sehat/not
well, pening la/ dizzy, sakit hati/ sakit mulut)….. # weird presenting
complaint..
 Ask about the working hospital diagnosis (pt may know). And what was
done to the pt in the hospital as well as the pt progress.
HISTORY (Systemic Review)
 Screen and screen but you only mention the significant positive
symptoms.
 Screen and screen but you only mention the significant negative
symptoms related to the pt medical background
 S/R: General/ CVS/ RESPI/ GIT/ GUS/NEURO/ENDOCRINE/MSK/SKIN
 For females: remember 3 P (Period, Pills, Pregnancy)
HISTORY (PMH/PSH)

 Put it in chronological order.

 Ask about the disease’s details: DFTA3CI (Do Full Tracing After 3 Chronic
Illness). DF TA 3CI
• D: Duration.
• F: Follow up.
• T: Treatment.
• A: Admissions due to this illness.
• C: Control/ Compliance/ Complications
• I: Implications
 Any H/O operations and procedures.
 HISTORY (PMH/PSH)
 Example: DM:
Pt was diagnosed with DM 20 years ago whereby he presented with polyuria and polydipsia. He is currently on
regular follow up at Klang hospital, he is currently on Insulin 4 times per day “Actrapid 12 units pre-meals TDS and
Insulatard 20units at bedtime. He has multiple admissions due to DM. He is non compliant to his
medications and his diabetes is poorly controlled with SMBG ranging between 9-15 moml/lit, he reported having
blurring of vision for what he underwent LASER therapy as well as having hands and feet numbness however he is
not aware about existence of any renal disease. He underwent left toe amputation 4 months ago)
DRUG HISTORY AND ALLERGY
 Inquire about the drugs used with their dosage (Ask the pt if he/she
brought the medications along to hospital or if he has prescription for his
medications.
 Do not try to describe the medications (round, oval, heart-shaped, blue,
purple, Turquoise color)…
 If can not get much details; you can try to mention the categories of
medications and if the pt is on tablets or injections (e.g: insulin Vs OHA).
 Any allergy to drugs or food; if allergy present ask about the details of
the allergy (what happened when you took this medicine? rash, swelling,
SOB)
 Traditional medication use.
 Any H/O blood transfusion
 Immunization.
Family History

 Ask about similar illness to the patient’s illness among the family
members.
 Ask about common diseases among family members; IHD, DM,HTN,
young age deaths and the cause, F/H/O malignancy.
 Ask about other diseases that is related to the presenting complaint.
Social History
 Marriage marital status + social support and living condition
 Children
 Smoking history
 Ethanol/alcohol history/drug use
 House/home
how she or he manages at home, and whether
the house has been modified to accommodate the patient’s needs.
 Driving
Ask whether the patient drives and, if not, how they get around.
 Pets
Whether the patient keeps any pets. This may be important in situations of socially isolated
patients and also in patients suspected of having zoonotic infections such as psittacosis.
 Travel history+ activity
 Nutrition and exercise
Obtain details about the main meals. A detailed dietary history may be necessary in
an obese or malnourished patient.
Physical Examination
components
 V/S
 Blood Pressure.
 Heart Rate.
 Temperature.
 Respiratory Rate.
Physical Examination
components
 The most relevant system
 Other systems including the signs related to the patient’s medical
background. (sensation is a must in Diabetic pt, meningeal signs in a pt
with fever)
 Again .. Do not forget the VITAL SIGNS
 Reporting the PE findings: DO NOT SAY:
 NAD
 DRNM
 S1+S2
 RR. PR
Summary

 you should be alert to the important clues with diagnostic, prognostic and
management implications.
 It should be comprehensive but concise.
 Contents of the summary (in the following sequence):
• Pt Bio data>> relevant PMS/Drug history/social history/allergy.
• PC with the duration and the most relevant positive symptoms.
• Relevant Physical signs.
• Conclusion remarks.
 Use medical language.
 Summary
 60 years old male with underlying medical background of uncontrolled DM for 15 years, HTN, IHD post CABG and
CKD. He is smoker and chronic Alcohol drinker with history of allergy to Cotrimoxazole Presented with history of
progressively worsening SOB, Orthopnea, PND and painless Bilateral leg swelling for 1 week prior to admission.
 His physical examination revealed high blood pressure of 170/100 mmHg with bilateral biting pedal and sacral
oedema, raised JVP and respiratory examination showed bilateral basal crepitation on both lower zones. He also
has midsternotomy scar with bilateral Harvest scars on both lower limbs as well as displaced Apex beat.Other
systemic examination were unremarkable
 My provisional diagnosis is……..
 Time Management
 The first 20 minutes of the hour with the patient should be spent on history taking.
 30 minutes on the rest of the history+ physical examination.
 10 minutes for summary+ PD+ D.D+ Inx+ Mx. (remember that you may need to
revisit some questions back)
TIPS
 You can start examining the pt while taking family and social history.
 It is easiest to begin by asking the patient about the medications that
he or she is currently taking.
 A strong bonding with the patient can be achieved from the outset by being very
courteous and polite>>> pt will be more cooperative to volunteer more info.
Discussion

 1. Provisional diagnosis. (with reasoning)

 2. Differential diagnosis. (with reasoning)
 3. Investigations with expected findings.
 4. management.
 PROVISIONAL AND DIFFERENTIAL DIAGNOSIS MAP
Patient’s background History/HOPI physical examination findings
Relevant Inx
up on
presentation
s
60 years SOB for 1 BP: 170/100
week
male Raised JVP

Uncontrolled DM Pedal oedema with bilateral scars

HTN Bilateral crepitation

CKD Sternotomy scar with displaced apex beat

IHD/POST CABG Others: neuro/skin

smoker and alcohol

drinker
Management

 1. Management of acute Medical condition:

A) symptomatic and supportive treatment.
B) specific treatment.
 2. Management of chronic Medical conditions and comorbidities.
 3. Management of psychosocial issues.
 3. prevention and rehabilitation (If needed)
Tips for answering the treatment
section
 Use headings to outline your management steps for both acute and
chronic problems. (do not give patchy answers)
 You can use the 4S approach : Symptomatic Rx
Specific Rx
Specialty referral (If needed)
Stop the progression and prevent the
Cx.
 Layout of the management plan

 MEDICAL
Problem D.D Inx Expected Rx
results of Inx
1.
2.
3.

 SOCIAL

Problem Management plan

1.
2.
Special situations

 Patient is admitted for exam purposes

 Talkative patient
 Female pt with male exam candidate
 Pt refused to be examined by you.

If you are irritated or angry ; never show this to the pt.

Patient admitted for exam

 PC/HOPI: Stretch your neurons/ show your knowledge

Mr. Cooperative. Is admitted for purpose of examination. Currently he has
no active medical compliant.
He has underlying: Thalassemia Major and DM….
Regarding his thalassemia : he was diagnosed at age of and he is on
regular follow-up and blood transfusion……. (Complete history about the
illness including Admissions, CX, Rx) etc.
Regarding his DM:
Add on the details of last admission
DO & DO NOT
DO and MUST DO
Practice the presentation with yourself then
with the person in the mirror then with friends
EIBB
DO (EXAM MODE ON)
 Have enough sleep and meals the night before exam (if possible)
 Get your parents' blessing again.
 Confirm regarding the exam’s place.
 Dress decently and be punctual.
 Prepare all the required instruments for exam before hand (Hammer)
 Greet your examiners and introduce yourself.
 Smile but do not lough.
 Prepare your name stickers before hand to hand it over to your
examiners.
DO (EXAM MODE ON)
 Listen to the q to understand it first not only to reply it.
 Keep eye contact with the examiners.
 Ask your seniors about their exam experience; But filter what
information you get.
 Be confident while presenting and answering q; But admit your
limitations too.
 Label your notes with numbers clearly..
 Study smart then study hard.
 Study group will help you (for presentation. Expected Questions)
DO Write clearly in your notes
DO NOT DO
Do not give this look to your
examiner
 Do not give background music for
your presentation
 Do not click the pen
 Do not crack your fingers’ knuckles.
 Do not waste time by Hmmmmmmmmm.
 Do not say wait.wait.wait.wait.wait.
 Do not fabricate new answers
DO NOT DO

 You do not need to tell the examiner that you do not know him/her.
 Do not use these words: may be . I guess. Not sure but. Some and some.
 Do not use the word (claim, claimed, claiming) excessively..
(Alternatives: pt reported that, pt experienced, pt stated that).
 Do not include unnecessary details in your history.
 Do not use abbreviations while presenting: (regarding my pt HOPI, my
D.D is AEBA/USA/CRBSI)
 Assessment:
 Attitude assessment:
• Self presentation (dressing, posture, vocalization).
• Addressing the pt and the examiners.
• Maintaining the patient’s welfare
 Skills assessment:
• Case history (completeness+ sequence+ contents)
• Physical examination (performing the complete examination including the vital signs+
main relevant system+ other systems).
 Knowledge assessment:
• understanding the symptoms and signs.
• Formulation of D/D with correlation and reasoning.
• Ability to choose the relevant investigations with their expected findings + outline the
appropriate management plan)
LIST OF (MUST KNOW LONG
CASES IN INTERNAL MEDICINE)
 CVS: IHD,ACS, HF,VHD, IE, HTN.
 RESPI: BA, COPD, BRONCHIACTASIS, PNEUMONIA, PLEURAL DISEASES, TB,
PULMONARY FIBROSIS.
 ABD: CLD, HEPATITIS, JAUNDICE, DIARRHEA, IBD.
 RENAL: AKI, CKD, NEPHROTIC/NEPHRITIC SYNDROME.
 NEURO: STROKE, PARAPARESIS, CNS INFECTIONS, CONVULSION.
 INFEC: PUO, FEVER, HIV
 ENDO: DM, THYROID, PITUITARY AND ADRENAL DISORDERS.
 RHEUMATO: SLE, RA,ARTHRITIS,CTD.
 HAEMATO: ANAEMIA, BLEEDING TENDENCY, LEUKEMIA,
LYPMHADENOPATHY.
 REMEMBER
 Remember: clinical medicine can only be learnt at the patient’s bedside!
Only practice will make you a good clinician.

 We may teach you many things but the patient will teach you everything.
 BST: BLOOD + SWEAT/ SOUL + TEARS

 BST: BRIGHT + STRONG + THOUGHTFUL

 BST: BENEFICENT + SAFE + TRUSTABLE

 BST: BEST STUDENT’S TIME.

ORGANIZING COMMITTEE.. THANK
YOU
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You