I’m going to start a series all about looking at case reports from a medical perspective. The focus will be on explaining what a medical student (and by extension doctors) thinks about when looking at a case or discussing with a patient. In this first post (and continued in next weeks’ post) we will be working through the case of Till Death Do Us Part ((Sa MM, Relvas A, Leandro S. Till Death Do Us Part. Journal of Clinical Case Reports 2016;6(4):1-.)) from the Journal of Clinical Case Reports.

The Journal of Clinical Case Reports is an open-access journal (open to the public), so no subscription issues exist and the cases are available for you to look at for free. This particular case was published in volume 6, issue 4, in 2016, and can be accessed at this link: https://www.omicsonline.org/open-access/till-death-do-us-part-2165-7920-1000769.php?aid=73621. This whole journal article is only a page long including discussion, so I would recommend having a quick read over it before continuing to follow along better. Because it is so short it serves as a good introductory article and still has plenty to discuss.

How cases are presented

Cases can often be presented and worked through in many formats, depending on the intended purpose, with two being particularly common. Frequently, they are presented from a medical perspective of the major steps (which are described below) of the history, examination, and investigations. Alternatively, they can be presented chronologically, with each trigger being presented as if working in an office, emergency department, or hospital ward. This latter model is generally used in medical school when working through cases, and is the model used by this paper. Even chronologically, the progression from history to examination to investigations still naturally occurs, but is more open to reverting to prior stages.

From a basic point of view, medically we tend to assess and think of patients in regard to their history, the examination and investigations. The history allows you to develop a large list of potential diagnoses (the differential diagnosis list), start refining these down, and a thorough history is incredibly valuable. So valuable in fact that many times a diagnosis can often be determined or at least very highly suspected from purely the history. In the very first weeks of Medicine they taught us that over 80% of the diagnosis is made by history.

The examination allows us to refine and narrow down the diagnosis list. The examination includes all of the physical steps, beginning with the general examination where you consider things such as how the patient looks and any obvious signs. It then continues to checking vital signs, assessing for visible signs in the hands, head, chest, abdomen, down to the toes. Finally, it involves a systematic examination which involves steps such as palpation (touching and feeling), percussion (tapping to listen to resonance), and auscultation (listening with the stethoscope) of the lungs, heart and bowels.

The last step is the investigation phase. Investigation is sending away for lab results such as bloods and urine analysis, performing ECG’s, obtaining images, etc. This is the part that most people expect, and think is most important, but generally the diagnosis should be basically known or the diagnosis list very much refined before investigations occur. It is also the most costly portion and the part that can often be avoided with sufficient history taking. However, it can also be very important and valuable in order to exclude or confirm disease states, particularly if it will modify treatment and management.

How to analyse a case

Each piece of a case can create thought and discussion. In medical school, we break the case down into triggers, which are effectively short excerpts of a case designed to be discussed and considered, with each building on the base that the previous trigger and discussion have created. In order to analyse a trigger, we go through a systematic process: Identify the (relevant) cues, formulate hypotheses, consider mechanisms, and determine what we need to know at a given stage.

Identifying the cues can range from what seems the most basic of details and observations through to specifics and interplay between ideas and triggers. Even the simplest triggers contain cues: In this case, as discussed below, the trigger that is the first line (which states “M.C.S., 56 years old, married, with an only child of 24 years old.”) contains at least five cues that I have been able to identify so far. Our very first case in our very first week of case-based learning included the first trigger to the effect of “You are a GP working at the university GP clinic.” Despite how short of a trigger this is, there was plenty of discussion generated out of just this trigger. However, most triggers would be at least half a dozen lines up to around half a page, with many cues dispersed throughout, and requiring analysis of just the relevant cues.

After identifying the cues, the hypothesis list (differential diagnosis) is the next step, although sometimes it can be generated in tandem with the cue identification. Generating the hypothesis list is what many people see as Medicine, including many medical students. This is partially bred from shows such as House MD which focus on this aspect, and from shows and movies with the “save the day” last minute diagnosis like in Doctor Strange where he runs in and stops a surgery just as the surgeon was going to make the incision. However, the diagnosis is only one part (and in fact one of the lesser parts) of the multifactorial role of being a great doctor. That said, it is an important skill, and without a potential diagnosis list no further progress could be made.

As part of considering the differentials, consideration of the mechanisms of those disease states, and of the normal human physiology, is important. In medical school and training this is something that is frequently discussed and tested. However, even when practicing medicine and not openly discussing these aspects they are important to consider. For example, recently we observed a patient that was fluid overloaded. For various reasons consideration was being made to change their diuretic medication (medication designed to increase the urine output) to oral administration instead of IV. However, understanding and considering the mechanism and implications of fluid overloading is particularly relevant in this case. A patient that is fluid overloaded has decreased absorption from the gut. As such, most medication administered orally will have a decreased absorption rate and so a higher dose will be required to have the same effect.

Finally, consideration needs to be made of what else we need to know. If the patient has presented and said “I have a severe headache” (as the below case will likely have), more questions are required. Things as simple as “When did this headache start?”, “How would you describe the pain?”, and “On a scale of 0 to 10, with 0 being no pain and 10 being the worst pain imaginable, how would you rate the pain?” all need to be considered. If a patient with stable angina (cardiac chest pain on exertion) presents with chest pain, the question of “Does this feel like the pain you are used to, or is it different?” or “Have you ever experienced pain like this before?” can strongly help with consideration of what is going on. And of course, considering what else we need to know guides the examination and investigation steps.

History

I will break down the history of this article as much can be considered in each line of this case. Most basically, the history, in this case, involves a 57-year-old female patient (note: sex, not gender, determined by the presence or lack of a Y chromosome). Even this simple statement includes many potential discussion points. Females have a higher prevalence of autoimmune conditions, around the order of 8 times as frequently. This is poorly understood but thought to be likely related to two factors: a protective role from testosterone in males, and the fact that many immunity genes are encoded on the X chromosomes (of which females have two (normally)). Most commonly these conditions occur around the 25-45 age range, but can realistically occur at any age. For example, when I worked at Nuclear Medicine at Sir Charles Gairdner Hospital, which includes the Endocrine clinic, many patients with Graves Disease (an autoimmune thyroid condition) would have been in their late 40’s and 50’s.

Further, with this patients age, she likely has already experienced menopause, but this phase can occur as late as a woman’s 60’s (or as early as their 30’s) and so must be considered. Additionally, if menopause has not occurred, pregnancy must always be considered as part of the differential in a sexually active female, which brings me to the next point.

M.C.S. is married. If M.C.S. has not been through menopause, there is the potential that another pregnancy could occur, and with her age, it would be common for complications to occur in this pregnancy. Further, the social considerations of giving birth to even a healthy child at her age (and the presumed roughly equal age of her partner) could be quite problematic.

Finally, as stated the assumption is that the partner is of roughly equal age: how does her situation change if the partner is in their 20’s? What about if her partner is in their 90’s? Is the partner healthy, or do they need constant care and support? Finally (for now), just because a patient has a partner or is even married does not mean that they are having sex or that they are only having sex with that one person, and so sexual history still needs to be elucidated.

M.C.S. had a child who is now 24-years-old. This generates further thought. Is the child completely independent? What happens with the child if the parents run into difficulty or pass away? Is the child local, or do they live on the other side of the world? Even if they are local, are they available, or do they never see their parents? What impact does this have on our patient and on her support network if she acquires a debilitating injury or disease?

A child of 24, with her age of 56, means that the child was delivered at the age of 32 years (or near enough to, excluding one birthday without the other having occurred). While not a major issue, the risks of pregnancy complications, birth defects and congenital abnormalities increase primarily with increasing maternal age (although paternal age is deterministic in some abnormalities). Was the child delivered without complications? Was (and is) the child healthy? If not, what impact does this have on our patient?

Furthermore, why was only one child delivered? This isn’t to say that there’s anything wrong with only having one child, but thinking that just because one child occurred means that that is the whole story is problematic. For example, assuming that the number of children is the same as the number of pregnancies is a mistake, so how many pregnancies has M.C.S. had? Medically, we consider what is known as gravida para abortus (GPA), meaning number of pregnancies (total), number of pregnancies reaching gestational age (including stillbirths), and abortus (covering induced abortions and miscarriages). This particular question is also useful because it can give indications or uncover further details.

For example, recently we were discussing a patient’s history with them, had completed about the presenting complaint and were asking the “routine bank” of questions. She advised that she had two sons and this patient had already been asked about surgical history (to which she’d responded that she had had none). However, when asked about if she had been pregnant any other times beyond these two deliveries, the patient advised that she had only been pregnant the two times, both had been complicated by excessive uterine bleeding during and post-delivery, and that a hysterectomy had been performed after the second birth. This despite having claimed no surgery having occurred previously. This shows how often you can discover additional details including medical and surgical history incidentally through other questions, as patients often cannot recall off the top of their head their full medical or surgical history on request.

Conclusion

Anyway, I feel like that is definitely enough for today. We’ve only even made it through the first line of the case! Please come back and take a look at the next blog post, where we will discuss and cover much quicker the rest of the case and its outcome. If you want to be notified when that post is published, you can subscribe to my blog (at the top of the right sidebar on desktop computers, or below the comments on tablet and mobile) to be notified immediately when I post.

I would love to hear any comments or queries that you have. What do you think would be good for me to discuss in more detail? Or was this discussion too long in the tooth already?!? Do you have any queries for me, or maybe a suggested case you think is interesting that you would like me to discuss in a future post? I always appreciate any input.

Until next time, be healthy and continue learning.

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