I came across this post a while ago and thinking this is
really beneficial to be shared with.
From his use of example, the generous doctor must be a surgeon,
but I believe this tips can be applied in any department. He also shared his
experience with his fellow HOs.
To those who always got scolded for presenting your cases
poorly to fellow colleagues, digest this and make sure it stuck in your brain,
not in your colon :p
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name: Aimir Ma’rof
I will say that 90% of a doctor’s job is to talk. We present
cases, do referral, talk to seniors, teach the juniors, asking help from
nurses/PPK, explain to patients. We talk all the time!
Communication is very pertinent in this line of work. The
management for any patients starts with a clerking and case presentation. This
is the most important part of being a doctor.
Honestly, almost every day is a headache for me listening to
my HO presenting cases in the ward. I’ve been meaning to write something about
it. I really want to help them so here it is. The step-by-step guide for a good
case presentation.
STEP 1: REASON FOR
ADMISSION
The most important puzzle that you need to solve for each
clerking is why do patients need the admission. You figure this out and trust
me, half of your presentation is already done.
The current diagnosis may not be the reason why patient is
being admitted. Patient may be treated as gastritis now, but the initial reason
for admission may be to rule out pancreatitis. It is weird to admit patient for
a disease that can be managed as outpatient. Similarly, when patient is
electively admitted for an imaging study, find out the reason why. Because why
do we have to waste a bed for a procedure that can be done as outpatient.
Find out if patient is admitted from Emergency department or
a referral from other hospital/clinic. Find out who receive the referral or who
admit the patient. Then justify if the admission is necessary. Don’t just
clerk, examine patient, write endlessly in the case note, and worse, inserting
branula and sending blood specimens for investigation when in the end, the
admission ends up being cancelled.
Similarly, if patient is not discharged when they are
supposed to, also find out why. When post appendicectomy patient being kept for
5 days, there must be a reason for it.
Solve this puzzle first and you are already half way there.
STEP 2: OPENING
STATEMENT
“50 years old, Malay gentleman. No known medical illness.”
“62 years old, Chinese lady. Known case of hypertension and
diabetes mellitus under polyclinic follow up.”
“25 years old, Iban lady, gravida 2 para 1 at 32 weeks
POA/POG.”
“4 years old boy with underlying acute lymphoblastic
leukemia.”
Every department has its expected opening statement. The
script is almost the same for all patients. Know the pattern and after a while,
it will become natural to you. Know which is important, what to say and what
not to say. You do not have to list all the known medical illnesses. Tally it
to the person you are talking to at that particular moment.
A surgeon may not be particularly interested about medical
history in details, so enough just by stating that patient has underlying
relevant medical illness and then go straight to the REASON FOR ADMISSION.
However, if patient is on anti-platelet or anti-coagulant, you may want to say
it briefly in your opening statement because a surgeon would want to hear that.
Similarly, a physician wouldn’t want to hear in details
about history of laparotomy 20 years ago when the reason you talk to him/her is
only for uncontrolled hypertension. A gynaecologist also will not be interested
to hear about history of gout when the reason for referral is prolonged menses.
Recognize who you are talking to! Anticipate their questions
and provide the answers before they even ask!
STEP 3: THE USUAL
STEPS
History, physical examination, investigations, diagnosis and
management. We have been taught about this since medical school. Follow this
and you will never go wrong. But….
There are two circumstances how this pans out.
- Example 1: “20 years old Malay guy, no known medical illness, admitted from ETD for acute appendicitis. He presented with 3-day history of RIF pain, associated with fever, loss of appetite and passing loose stool. There is no UTI symptom. Clinically, not septic, not dehydrated. Abdomen is soft, tenderness at RIF, no mass palpable. Hernia orifice is intact and both scrotum and testis are normal. TWC is 15000 and UFEME is negative for UTI. My clinical diagnosis is acute appendicitis. I’m keeping him nil by mouth with IV fluid. I plan to start antibiotic and post for appendicectomy.
- Example 2: “20 years old Malay guy, no known medical illness, admitted from ETD for acute appendicitis. He presented with 3-day history of RIF pain, associated with fever. However, patient also complained of UTI symptoms. Appetite remain good and bowel habit was normal. Clinically, not septic, not dehydrated. Abdomen is soft, very mild tenderness at RIF, no mass palpable but the right renal punch is positive. Hernia orifice is intact and both scrotum and testis are normal. TWC is 15000 and UFEME shows presence of leukocyte and nitrites. I don’t agree with ETD diagnosis of acute appendicitis. I think he has right pyelonephritis. I plan to allow him orally, send for urine C&S, start antibiotic and observe his symptoms. I am requesting a KUB x-ray to rule out renal calculi, KIV for USG.
- Example 1: “20 years old Malay guy, no known medical illness, admitted 2 days ago for acute appendicitis. He presented with 3-day history of RIF pain, associated with fever. Clinically, he was not septic on admission. Per abdomen tender at RIF. TWC was 15000. Antibiotic was started and today is day 1 post laparoscopic appendicectomy. Intra op finding was inflamed appendix with healthy base. Currently patient well, ambulating, allowed orally and passing flatus. Abdomen is soft, not distended. Plan for discharge today.”
- Example 2: “20 years old Malay guy, no known medical illness, admitted 2 days ago initially for acute appendicitis. He presented with 3-day history of RIF pain, associated with fever. However, we figured out that patient had UTI symptoms. Per abdomen only mild tenderness at RIF but right renal punch was positive. TWC was 15000. UFEME showed UTI picture. KUB x-ray and USG, no obvious stone seen. We treat him as acute pyelonephritis. Antibiotic was started. Urine C&S still pending. Clinically remain well and afebrile. Abdomen is soft, not distended. Plan for discharge today.”
Still I follow THE USUAL STEPS. History until management. You
can never go wrong. But unfortunately, my HO always like the word CURRENTLY.
The usual thing that I hear every day is “This patient is day 5 post laparotomy
+ adhesiolysis. CURRENTLY patient well, vital signs stable, urine output good,
bla, bla, bla.”
Ask what is the diagnosis, they vomit out the documented
post-operative diagnosis. Ask why laparotomy was decided, I get blank stare.
Ask can patient be discharged since all the CURRENTLY seems good, another blank
stare. Ask why patient is still in acute cubicle, continuous blank stare. The
fact that patient was in hypovolemic shock on admission and intubated in ICU,
no one knows.
Patient is not just managed for a day. Not only during the
day that you review the patient. Management starts from the first clerking
until you give the discharge plan. Understand those and trust me, you will be
surprised on how fluent you are telling the story of your patients.
Read again all my examples above and time yourself. See how
long do you take to present a case. Less than a minute!! It is not that
difficult. But if you still think it is, go to the next step!
STEP 4: REPEAT ALL
THE STEPS
It is about practice and practice. Do it again and again and
again. No one can miraculously get it right the first time. Not even your consultants
now. We all start somewhere. The question is, do you want to start? If you keep
quiet and hide behind others all the time, how do you expect to present well?
If you don’t force yourself to be brave, making mistake and take the occasional
scolding, you will never improve.
I started doing this, or rather being forced to do it,
during medical school. I remember as a 3rd year medical student in O&G
posting that I won’t even be allowed to sit for my end of posting exam and be
considered non-redeemable fail, if I do not perform a total of 10 case
presentations. I remember that as a group of 10 students in General Surgery, we
have to know ALL patients in the ward. God forbid, our lecturer picked a
patient in the ward for bedside teaching that no one clerked. Because that
means we will be chased out from the ward. By the time I was in final year, I
was so tired of presenting cases that I said to myself, just give me the
professional exam and be done with it. So I can start working and earn money
because I was doing a HO job anyway. Might as well be paid doing it. :D
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My 2 cents: It's a struggle, but practices make perfect!! \(^O^)/ It's better to make mistakes during housemanship, because you still have your fellow seniors of MOs and Specialists to guide and correct you. Learn from the mistakes and you will become a better doctor =)