CASE PRESENTATION FORMATdoctkhalil
A simple stepwise clinical case presentation format is described below. In clinical exams, a command would usually be given to examine a certain patient. After having examined the patient, the candidate would have to reproduce his findings in a structured manner which is often a tough task. This method will help in reducing some of the pain associated with such oral presentations.
- Thank you for allowing me to examine Mr. ABC, a 50 year old carpenter ,who presented to the emergency room with shortness of breath.
- On general inspection he has mild dyspnea at rest with no clinical clues around the bed suggestive of respiratory disease.
- The patient appears wasted and cachexic.
- No obvious scar or chest deformity was noted.
- The pulse was 80 beats per minute and regular. He was tachypneic at a respiratory rate of 26.
- BP was 120 / 80.
- JVP was not visible and there was no lymphadenopathy.
- Accessory respiratory muscle use was also not appreciated.
- Examination of the hands revealed no pallor, clubbing, tobacco staining or peripheral cyanosis. There was no Co2 retention flap.
- On closer inspection of the face there was no pallor or central cyanosis.
- The apex beat was not displaced and the trachea was central with decreased lung expansion to the left.
- There was dull percussion in the left lower zone with decreased tactile vocal fremitus in the left lower zone.
- Auscultation of the chest revealed a decreased air entry in the left lower zone.
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