CASE PRESENTATION FORMAT

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.

So in summary this 50 year old gentleman presented to us in the ER with clinical chest findings suggestive of a left sided pleural effusion.

This can be secondary to carcinoma lung. I would like to perform sputum AFB , sputum culture , ABGs (arterial blood gases ) for oxygenation levels, clotting profile as a chest drain may need to be inserted ,chest x ray ,CT scan and get a Pulmonology opinion.

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