Obviously I am not the best person to be asking how to present a case to specialist and consultants. But since one of my juniors is asking, I would share what I can with my very limited experience. Presenting cases is quite difficult to perform, but with practice you can get it right. Even MOs are having difficulties to present cases up to consultant’s satisfaction.
Usually cases are presented starting with age/race/gender of the patient. Any known medical illness such as hypertension and diabetis? Any known allergies? Then why did he present to the ward? What are his main complains, what are the relevant histories & associations? What other symptoms does he have? And physical exam shows what (mention the relevants only, don’t have to mention cervical lymph nodes not palpable if the case is diabetic foot ulcer!)
Then you come to investigations, bloods n X-rays. If patient is already few days in the ward, update the progress on what have been done to the patient. I will give you a simple example patient with diabetic foot ulcer.
60 year old indian man, with known case of diabetis and hypertension on this and that medication under which clinic follow up. Presented to us with 5 days history of fever, pain and swelling in right foot. Initially patient hit a stone nearby his house, and noted pain and swelling at the right foot. Went to private clinic, given painkillers and antibiotic. Pain not resolved, wound becoming worse with foul smelling and pus discharge. Fever not resolving. Had some other symptoms of sepsis such as lethargy, loss of appetite, vomiting and occasional shortness of breath.
On further history, he had the same symptoms before, with left foot wound. History of admission in orthopedic ward 7 months ago. Given antibiotics, wound debridement done.
So proceed to physical exam. General condition of patient was alert at time of admission, febrile 38, appears lethargic but clinically pink. Bp is 130/78, sugar was 15.3. Hydration mildly dry. Then mention if there are any irregularities in heart and lungs, if no abnormalities dont need to mention. Then mention foot exam.
What is the ABSI (ankle brachial systolic index)? Compare left and right feet. Describe the wound (draw it), location, size, edges, smell, any bleeding, sloughs or necrotic patch or pus dischrge? Describe neurovascular exam like peripheral pulses (DPA/PTA), capillary refill time, sensation, power and tones and reflex.
Then mention the relevant investigations ordered, swab and blood culture and sensitivity, full blood picture, renal profile, foot Xray. Justify what antibiotic you give. Usually in our practice we give unasyn (ampicillin & sulbactam). Diabetic foot ulcer is polymicrobial. So culture and sensitivity are very important to detect what type of microbes and what sensitivity to antibiotic in that foot.
When patient is already in the ward for 5 days, on intravenous antibiotic, present to the consultant what was done since admission. When was the wound debridement done? Any complications? Any cultures and sensitivity came back? If came back, was it sensitive to the antibiotic given? Then describe the wound post debridement. Is it clean? Anymore pus discharge? What kind of dressing was done? Describe the sugar control in the ward. How’s the patient clinically, is he still septic? If all of this looks ok, you can suggest to consultant to discharge the patient with oral antibiotic and daily dressing at nearest clinic, then see us back at ortho clinic in 2 weeks.
Thats how u present la. Simplest case to present, but not many got it right, even me.
I hope this helps my juniors in having some ideas on how to present cases to specialists.