Introduction to Clinical Medicine: Presenting a patient

As part of continuous assessment for this module, we have to prepare and present a case to the Module Head.

Due to my apparent silence in hospital rounds since everybody knows that I can actually speak in public, my wonderful clinical group (I do love them ) informed me that I would be presenting if we were selected.

We got selected, but then I kind of had an idea we would.

This is the gist of our patient. Bear in mind that it is not a particularly rare or strange case. This exercise served to teach us how to present a case, as we shall be doing so for the rest of our careers.

Mr J. P, 43 year-old male:

Presenting complaint:

Cough

• Any time of day but worse at night
• Productive, yellow
• No haemoptysis
• Severe drenching night sweats

Associated complaints:

Dyspnoea

• Grade III
• SOB after minimal exertion, rest alleviates

Paroxysmal Nocturnal Dyspnoea

Weight loss: 10kg since August 2010

Previous medical history:

1. Known hypertension
2. TB treatment – no reaction
3. “Pills” for suspected asthma
4. No allergies
5. Polio as a child

Environmental history:

1. No known family history of disease
2. Lives on a farm in a house
3. Three children and wife healthy
4. Worked on open coal mine for three months many years ago.
5. No exposure to gold or asbestos
6. Currently employed on fruit farm and works with pesticides

Social history:

1. Previous smoker: 5 pack years
2. Weekend use of alcohol – no abuse

Biopsychosocial perspective:

• Ideas: something on the farm caused his “asthma”
• Expectations: to alleviate his symptoms so that he can go home
• Fears: none

General appearance:

• Wasting
• Tired
• Respiratory distress – use of accessory muscles

General examination:

• Severely clubbed
• Peripheral oedema

Chest inspection:

• Median sternal scar from stab wound six years ago
• Rib retraction
• JVP not visible due to accessory muscle use
• Hyper-inflated, stiff chest

Chest palpation:

1. normal apex beat: 5^th intercostal space MCL
2. central trachea

Chest percussion:

1. normal lung percussion
2. normal heart percussion
3. liver displace but not enlarged: 6^th intercostal space

Auscultation:

• slight bilateral wheeze, lower lobes
• fine bilateral crackles
• normal S1 and S2, S2 slightly loud, no murmers

No significant findings on GIT examination.

Differential diagnosis (made by the real doctor:

1. occupational asthma
2. silicosis
3. Type II Respiratory failure

Treatment as prescribed by Mr J.P’s doctor:

1. HCTZ [diuretic for associated cardiac effects due to Respiratory Failure]
2. ACE inhibitors [for high blood pressure]
3. Theopylline [for asthma, COPD not suspected]
4. Cimetidine [for heart burn]
5. Heparin [anticoagulant, possibly for polycythaemia due to decreased oxygen]

So that is our patient. I didn’t feel that we did so well, but the lecturer gave us some of the best feedback she had given all day. Her reasons were that we presented in a very systematic manner and didn’t use any redundant facts or expressions.

That felt good. I got a lot of compliments since I did all the talking, but to be honest, I spoke well because the slide-show and write-up were so well done by the whole group. I enjoy this whole co-operation thing!

On a side note, we visited Mr J.P. yesterday and because I tend to daze off a bit I didn’t know that we were going back to a previous patient. I kept thinking, “This sounds so familiar.” Only when we checked for his pedal pulses and for pitting oedema and I saw his brown socks did the switch in my head click and I realises that I had seen him before. I felt terrible. I never want to be one of those doctors who can’t remember patients’ names.

There you have it. Not necessarily exciting but definitely a good learning experience (and an ego-booster). Unfortunately the life of a medical student can be rather mundane at times.

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