GUIDE TO CASE PRESENTATION

Summary report of the essential aspects contained in the dialogue

based on the following questions.

1-What’s the age and sex of the patient?

-My case is a--------year old man/ woman/ boy/ girl who-----------------
-I’m reporting the case of a----------------------who---------------
-I have a patient of----------years. It’s a man/ woman. --------------
-would like to report a case. It’s a man/ woman/ boy/ girl
aged------------who-------

2-Why did the patient come to hospital?

-He/She came to the hospital to see me because he/ she had/ was
feeling/ has—-----------------
-This patient told me that he/ she---------------------
-The reason this patient came was----------------------

3-What were the patient’s symptoms and signs?

-When I questioned him/ her I could see/ notice/ Know that he/ she
had--------
-The patient had the following symptoms-----------------

4-What diseases have the patient suffered from?

-This patient has suffered from-------------------for which he had a
treatment of------------------.
-He/ she has been healthy all his/ her life until------------------
-He/ she had --------------------when---------------------

5-What medication has the patient been prescribed for the diseases
he/ she suffered/ suffers from?
-He/ she took/ has taken/ takes/----------
-He/ she didn’t take/ hasn’t taken/ doesn’t take any medication.
-He/ she is allergic to------------------

6-What about his/ her family history?

-In his/ her family there is a history of--------------
-His/her mother/ father died of/ suffer from-------------------
-Family history isn’t remarkable

7-What are the patient’s habits?

-He/she usually / often/ sometimes/ never----------------
-He/she doesn’t-----------------
-He/she is a heavy drinker.
-He/ she has been----------------------for---------------

8-What aspects did you find on the physical examination?

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-When I examined him/ her I found/ noticed-----------
-On the physical exam I could see/ find-------------
-He/ she is well oriented to time place and person.
-He/ she seems/ appears to be very healthy
-The -------------- was----------------------

9-What tests did you indicate the patient for the present illness?
-I ordered----------------------because---------------------
-He/ she needs-----------------to----------------------

10-What’s your diagnosis?

-According to what I have presented/ stated-------------I think he/ she
should/ must have-------------
-My diagnosis is----------------------

11-What about your treatment?

-My treatment is------------------------
-I prescribed/ suggested/ indicated him / her to------------------

12-What’s his/ her prognosis?

-The chances to overcome/get over/ recover from the disease
are-------------if he/ she------------------ because---------------------
-The prognosis is good/ bad/ reserved/ grim

13-What complications could the patient have?

-In case he/she doesn’t follow the treatment he/ she may have some
complications such as-------------------
-There may be some complications like----------------------
-Complications are rare in this disease.
-----------------------, ---------------------- are the most common.

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USEFUL LANGUAGE HINTS

Identifying data

-A (25) year old ( Angolan female medical student)---------------

-A (Cuban male nurse) aged (40)--------------
-A (French male nurse) of (56)-----------
- This Caucasian man had persistent proteinuria at the age of 9 in
1959. He was----------

Main complaint (A)

--------presented to (his general practitioner/ family physician/ the
emergency room/ the casualty department----------------
--------was admitted to hospital because (he had fallen from a tree).
-----------was brought into the emergency room/ the casualty
department--------)
-----------attended the (surgical outpatient clinic/ orthopedic
clinic-----------)
-----------was sent/ referred to (me/ the eye doctor---------)
------------came to (me / the clinician/ the neurologist---------------)

Main complaint (B)

….with a complaint of (severe abdominal pain)
….complaining of (back pain).
….because (he/ she had fallen from a tree).
…..because of (increasing breathlessness).
…..after (having several episodes of hemoptysis).
……with a history of (continuous wheezing and breathlessness for two
days).
……with a (two week) history of (fever and arthralgia)
……with no history of (recent travel).
……with (shortness of breath).

History of the present illness

-On this occasion/ On arrival/ At the time of admission/ On admission/
On direct questioning/ On closer questioning/ On further questioning:
.he/ she was (in obvious distress/ pale/ in pain/ having fits)
.he/she said he/ she had had (frequent attacks of asthma since
childhood).
.he/ she admitted having experienced (a similar pain/ nausea and
vomiting).
.he/ she reported (a sore throat three weeks previously….)

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Past history
-Over the previous (three years/ months/ days/ hours….)
-One year/ week/ month before (him / her) had had (a nagging
cough….)
- (One year) before (his/ her) admission…..
-The only past history of note was (a lump in her left breath one week
before)
-On further questioning he/ she had been (in remarkably good health
all his/ her life).
- (The pain) had been present (for several months...)
For the past (couple of months/ days/ hours/ years…)
-He/she had (lost 8 kg in weight)
-He/she had complained of (left-sided abdominal pain).
-He had developed (renal failure two years before admission).
-He/she had had (several episodes of vomiting).

Family history
-His/her father/ mother was/ is diabetic.
-His/ her father/mother complains of…./complained of…./died of…/
had had…
-There was/ is no family history of (hypertension).
-Both of his/ her parents/ children are (healthy)
-Other family members were also diagnosed as having….

Social history
-He/ she has been on that job for years.
-He/ she has changed jobs many times in the last couple of years
-He/ she has never taken any physical exercise.
-He/ she has been happily married for (many years)
-His/ her wife/ husband passed away recently.
-He/ she comes from a poor/ wealthy/ well-to-do family.

Habits and medication

-He/ she admits drinking (several bottles of brandy weekly).
-He/ she smokes (30 cigarettes daily).
-He/ she occasionally smokes (cigars).
-He/ she has never drunk alcohol in excess.
-He/ she is allergic to (penicillin)
-He/ she has an allergy to (iodine)
-She’s been on (the pill) at present.
-He/ she’s taking (water pills) at present.
-He/ she often takes (sedatives/ painkillers/ antacids)
-He/ she used to smoke (20 cigarettes) daily but he quit (a few
months ago)

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Physical Examination
-There were no significant findings on examination.
-There was nothing remarkable/ significant on examination.
-There were (no abnormal signs in the lung fields/ no localized
neurological signs.
-There was (no evidence of heart failure/ no tenderness/ no ankle
edema).
-There was mild rebound tenderness.
-His/ her general condition was satisfactory/ poor.
-Hi/ her (B/P was 100/60 / pulse…)
-His/ her BP was controlled.
-His/ her (abdomen was not distended).
-His/ her liver was palpable to (three) finger-breadths.
-He/ she had (a BP of 100/60/ a pulse of 90/ minute/ a dry tongue).
-BP (i00/60)/ pulse…
-No (palpable masses) were felt.
- (Bowel sounds) were absent.
-(In the lungs) there were……
-Neither liver, kidneys nor spleen) were palpable.
-On examination he/ she was or was found to be/ shown to be/
observed to be (obese, pale, overweight, healthy, jaundiced, febrile)
-Examination of the chest showed evidence of (emphysema)
--Examination of the abdomen revealed (an enlarged liver)
-On rectal examination there were (no masses)
-On bimanual examination (the uterus felt bulky)
-On vaginal examination (her uterus was enlarged to 30 weeks size)
-On (pelvic) examination she had (an ill-defined mass in the right
adnexun)

Lab tests. Diagnostic procedures and investigations

-Chest X-ray showed (pleural effusion/ a mass)
-(Abdominal x-ray) suggested the presence of (intraperitoneal fluid)
-(Ultra sonogram) revealed…
-(Endoscopy) showed--------------
-Haemoglobin (Hg) rose initially to (11g/dl)/ decreased to 8g/dl)
-A follow-up 8electrocardiography) revealed (resolution of the
pericardial effusion)
-(The findings on examination) reveal (a significant rise in the
systemic venous pressure)
-His/her erythrocyte sedimentation rate (ESR) was elevated at (62)
-His total protein was just normal at (60)
-His calcium was low at (1.96) with a (normal) phosphatase and
normal magnesium.
-(ESR) was considerably elevated.
-(Plasma valine) decreased from (1500umol/l to 721umol/l)
-Cultures of blood, bone marrow, urine and cerebrospinal fluid(CSF)
were (negative).
-(Cerebral magnetic imaging (MRI) showed--------------
-(Nephocalcinosis) was seen on plain radiographs.
-Laboratory results are shown in the table---------------------
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Differential diagnosis: Discussion
-A variety of illnesses may mimic (myocardial infarction), the most
common conditions are (acute pericarditis, myocarditis)
-Although no history of (trauma or seizures) were reported------------
-The possibility of (splenic rupture) should not be excluded.
-(This disease) may present with (severe neurological
manifestations)----------
-It may be that (the gastroenteritis) contributed to the crisis in this
patient--
-(Vitamin B 12) deficiency was found to be the cause ----------------------
-(Splenomegaly) found in our patient is also a manifestation
of------------
-In this case, patients may present with (heart failure)-------------------
-This illness responds well to (antibiotic treatment).
-(Tungsten) may cause (lung fibrosis or dermatitis) in----------------
-Our patient did not develop (renal failure).
-In this patient (clinical, haematological and histological) features
were initially suggestive of----------------.
-The lack of a clinical response (with steroids) prompted us to think
again.
-His/her symptoms could be produced by (many different disease
processes)
-A striking feature of the history is (The absence of dyspnoea).
-(Blood loss from piles) may certainly be sufficient t cause anaemia.
-It is difficult to evaluate (the left chest pain)
-(A number of points) must be considered in his personal history.
-He/she is a (heavy smoker) which predisposes him to--------------
-His/her (alcohol intake) is sufficient to cause significant tissue
damage.
- (Duodenal ulceration) has a tendency to recur.
-His/her (anaemia) may be due to (the bleeding from the duodenum
rather than the piles)
-It is impossible to exclude (this possibility) (without further barium
studies)
-- (The firmness and lack of tenderness of the liver) suggest
that------------
- (Many of the features of congestive heart failure) are present.
-There is no history/ evidence of (chronic pulmonary disease)
-The sings (in the chest) are of those of pleural effusion)
- (This) would not account for his/her (recent deterioration)
-A diagnosis of (myocardial infarction) does not fit in with (the pattern
of his previous illness)
- (Pericardial tamponade) is a very likely diagnosis/ highly probable.
- (Hyperproteinemia) might cause-------------
- (A chest x-ray) may show/ reveal/ showed/ revealed-------------
- (Endoscopy) confirmed the presence of----------------
-It is probable that (the precipitation of the left ventricular failure in
this woman) was the result of (the intravenous infusion of salbutamol)

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- (A number of factors) were undoubtedly contributory to (the onset of
pulmonary oedema)
- (Dietary and alcoholic excesses) can also cause (an acute gastritis)
- (Acute pancreatitis) can cause (pain of similar severity and
radiation) but/ however--------------
- (A peptic ulcer) is a possible but unlikely diagnosis due to (the
absence of…..)
- (Absence of fever and lower abdominal pain) make (appendicitis)
very unlikely

Diagnosis. Prognosis.
- Features such as a (preference to be alone, a short attention
span-------------) should alert the clinician to the diagnosis
of---------------------
- All the features of the history and examination are consistent with a
diagnosis of (pain due to gall stones)
- The history of------------- points to the diagnosis of--------------------
- This was confirmed (by histology) as being (an adenocarcinoma)
- If the presumptive diagnosis of (sarcoidosis) was made.
- He/she was diagnosed (as having) (hepatitis).
- No diagnosis was made.
- The prognosis is good/ poor/ guarded/ bad/ reserved/ grim.

Management
- He/she was given (two units of packed red blood cells).
- He was started on (prednisolone).
- He/she was prescribed (oral ampicillin)
- He/she was treated with (a course of antibiotics)
-He was commenced on (tipple therapy with (---------)
- He/she was transfused because of the (anaemia)
- He/she was sent home (on oral iron)
- He/she was sent (to a reference centre)
-The patient was (hemodialized)
- He/she developed (acute pulmonary oedema)
- The patient’s (fever) persisted.
- (Hydrolazine) was added to the treatment.
- The drug/ medication was changed to------------------
- (Cephalexin) was continued.
- Treatment with (oral sodium bicarbonate) was started.
- Vitamin B12 was started.
- (A digital examination) should be/ should have been made and
(sigmoidoscopy) should be/ should have been/ performed as a
routine.
- (An ultrasound examination) is essential in the assessment
of-----------
- There is no evidence of (peritonitis or------------)
- (Urine) should be tested for(bile pigments)
- (An ultrasound of gallbladder) will show both (the presence of
gallstones) and may reveal (additional information if inflammation
and thickening of the gallbladder wall are seen.)
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Other useful phrases
- His/ her symptoms subsided.
- He/ she relapsed with identical symptoms.
- He/ she had new/ different complaints/ signs/ symptoms.
- He/she was symptom free.
- He was readmitted-----------
- He was discharged on-----------
- At outpatient review-------------------
- At follow-up he continued to (lose weight)
- His/ her general condition (deteriorated).
- He/ she(improved) very quickly.

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