[C&P]
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 working as 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. Tell us the reason for admission first, not throw away the current diagnosis in your first sentence.
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. Don’t be surprise when the reason can be as simple as admitted by specialist/consultant because the patient is his/her friend!
Then for each admission, justify if it 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.
Find out why your patients deserve those hospital beds, or still need to be on it instead of going home. Solve this puzzle first and you are already half way there.
STEP 2: OPENING STATEMENT
“50-year-old Malay gentleman. No known medical illness.”
“62-year-old Chinese lady. Known case of hypertension and diabetes mellitus under polyclinic follow up.”
“25-year-old Iban lady, gravida 2 para 1 at 32 weeks POA/POG.”
“4-year-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.
If you are the first person clerking the patient, you have to sell your diagnosis and management plan. This usually happens for a new admission with no definite diagnosis yet. So you have to follow the “medical school” steps up there.
For example, “20-year-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 15,000 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.”
Another example would be, “20-year-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 15,000 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.”
The second situation, on the other hand, is rather easier and you encounter this daily during morning round. Most of the patients have been admitted for few days. Diagnosis has been made and management has been laid out by specialists and even consultants. You don’t have to crack your head selling the diagnosis. Just tell us the diagnosis and what has been done. That’s all!
The example would be, “20-year-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 15,000. Antibiotic was started and today is day 1 post laparoscopic appendicectomy. Intra op finding was inflammed appendix with healthy base. Currently patient well, ambulating, allowed orally and passing flatus. Abdomen is soft, not distended. Plan for discharge today.”
Or, “20-year-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 15,000. 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. 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 am not 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. 😀
So seeing HO now struggling to present and refer cases, to even communicate with others, of course I feel frustrated and sad at the same time. But then again, like I said, we all start somewhere. I will always be around to help and to guide. The question is, do you want to start?
Credit to : FB Aimir Ma’rof
Dr Zai’s Medical Notes 
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