I certainly wish I had more time to write on these subjects, insya Allah will do more in future as I can see quite a number of people find these useful.

Mazlyn Mustapha

Tips for medical students presenting and discussing cases for internal medicine bedside teaching/teaching rounds.

Reflecting on yesterday’s long case session, here are a few tips that might help.

1) The history is not a mere regurgitation of facts. Leave out the unnecessary and irrelevant information that does not aid in the diagnosis. Always remember, the whole purpose of the history and physical exam is to arrive at a diagnosis or list of differentials, so chose to exclude information that does not change diagnosis, nor help in the management of the patient.

2) The presenting complaint is the part of the history which should be left ‘in the patient’s own words’. Everything else should be your interpretation of what the patient told you, not just a repetition of exactly what had happened.

Example: An elderly man was admitted complaining of hoarseness of voice for the past two months. It began two months ago when he went to the dentist to get his tooth extracted. (This was the story given).

(This is the interpretation): Poor dentition has no direct correlation with lung cancer (which was the working diagnosis in this case for the cause of the patient’s symptom/s) hence, it was merely a coincidence (the toothache and resultant tooth extraction) and not a means of presentation or complication of lung carcinoma.

So present it that way – as a coincidence, rather than going into detail as if the tooth extraction had any direct correlation with the progression of the patient’s lung cancer. There is no need to mention in detail how many teeth were extracted etc.

3) Another problem some students have asked about before: what if the presenting complaint is not the reason for admission? How do we present the case? Present it from your perspective, ie the perspective of the doctor. Example: patient presented with a laceration of the fifth left finger (hardly a reason to admit a patient) however had haematemesis and melaena upon further questioning or was found to have haemoglobin of 3.0g/L. Or you can say ‘patient was admitted with haematemesis and melaena for 2 days when he presenting to the GP initially with laceration of left fifth finger’.

Do not present it as a case of finger laceration and then, after a detailed history of presenting complaint of the laceration, suddenly offer a ‘twist in the plot’ of symptoms of upper GI bleed. That works in the cinema, not in internal medicine case presentations.

4) As you progress from being a reporter, to interpreter, to manager of information, and eventually educator, you can alter your report in such a way that you are arguing towards a particular diagnosis.

Example, in the case of the elderly man complaining of hoarseness for the past two months, he may have a background of diabetes and hypertension, and that certainly would be mentioned in the opening sentence if he presented with ACS or symptoms of a stroke/TIA, but since the current problem is most likely associated with his 5 decade history of smoking cigarettes, it’s better to mention that in the opening sentence, instead of the diabetes and hypertension, which can be left after the smoking (in the opening sentence) or even left to the past medical history part of the report.

Regurgitating or a mere repetition of facts as stated by the patient will score you marks enough to pass, but to go beyond passing, show that you understand how risk factors alter the differential diagnoses.

5) Uncertainty in the physical examination.

The only way of being absolutely certain a mass is due to an enlarged liver, is to have examined 100 abdomens including both normal and abnormal livers, plus imaging.

The more skillful and experienced a physician, the less likely they are to make mistakes in the physical exam, for example, identifying pallor as normal, or vice versa.

Part of being a good doctor is having good clinical skills and this can only be acquired through months and months and eventually years of practice. I hope you get my point that practice is needed in order to gain that confidence in your physical examination skills, so that you can identify the normal and also the abnormal.

In the exam, rarely are patients with less than obvious signs included. Often, if the patient had jaundice, it would be yellow discolouration that can be seen from the end of the room. Not the ‘slight’ yellow tinge that makes one wonder is it the lighting or the curtains giving off a yellow hue. So in the exams, and also during teaching rounds, if something is ‘slightly’ enlarged or ‘slightly’ resonant, more often than not, its actually normal or best said/left as normal.

Do not hinge your answers with words such as ‘slightly, a bit’ etc. We want to see you being confident in your findings.

However, as the case may be, yesterday being a good example, adjust accordingly. The student was not sure whether tactile vocal fremitus (TVF) was normal or reduced, but percussion was dull, auscultation revealed reduced breath sounds and the vocal resonance was reduced. In this case, to say that the TVF was normal would contradict the other findings, so its better to either leave it out or adjust it to fit the big picture. Do not contradict yourself.

6) Propose solutions.

Ok, so you think the liver is ‘slightly’ enlarged and since the patient is suspected to have lung cancer, its probably metastasis to the liver causing the ‘slight’ liver enlargement. If so, propose to do a test that will confirm or refute your findings. Certainly at some point (for the patient with suspected lung cancer) a staging CT scan would be done, or if there turned out to be no obvious primary, you could propose to do liver ultrasound to confirm your physical examination findings. This is how we manage similar problems in real life/clinical practice.

7) Read the notes. I continue to be shocked by students who take the history, examine the patient, propose diagnoses and management plans but do not review the patients notes. Look up and see whether the managing team came up with similar list of differentials and if not, why not? Did they plan for tests that you didn’t? Why? What were the results of the investigations?

These are vital information that you can choose to incorporate into your presentation, or leave for discussion.

It’s like math. After solving the problem, we need to check whether our answer is correct, thus we go through our previous calculations and see if there were any mistakes leading up to the answer, or even calculate using another path/formula to make sure that we arrive at the same answer.

8) It’s not the answer that is the most important thing. While getting the diagnosis or differentials correct is important, it is not the most important thing. We also look at the process by which one arrived at the diagnoses. In fact, the ‘calculations’ or reasoning behind each action and subsequent diagnoses/action plan is more important than just getting the diagnosis/answer right.

Hope this helps.