The technique of presenting a clinical case

The pedantry of exposing a clinical case implies the observance of certain rigors. These
refer to going through certain steps of exposition, a logic of the speech, as well as a rigorous time
framing, respectively 20 minutes. Nevertheless, we have to pay attention to the level of the
medical language used, that has to be a professional one, with the omission of verbal tics and
repetitions. It is allowed sometimes to quote the terms used by the patient to describe its pain,
fact that has to be enunciated in a manner by which the usage of quote marks is being implied.
Keeping a constant rhythm/sustained cadence of speech would be best in order to maintain the
attention of the auditory.
Any presentation of a clinical case begins with the general data of the patient, such as:
1. Name and surname – which for ethical reasons have to be mentioned only as initials.
2. Mentioning the sex is important, because there are certain specific diseases (such as
gynecopathies), and others more frequent (systemic erythematous lupus occurs
preferentially in women, urinary infections as well; the men are more prone to spondylitis
ankylopoetica, have COPD more frequently maybe also due to the habit of smoking, have
a delayed response/ not as receptive to hypotension treatment). However, if it is
formulated, “I have seen a female patient” becomes irrelevant to mention the initials and
sex.
3. The place of residence (the town/county) is useful to be mentioned because there are
pathologies more frequent in certain areas (thalassemia in the Mediterranean basin,
certain infectious diseases such as malaria that remains an important problem in the
tropical and under tropical areas, leishmaniosis for Mediterranean area and Middle East.
For our country can be taken into consideration the endemic Balkan nephropathy for the
south of the country, endemic gout for the Moldova area, and increased cardiovascular
pathology in the regions with increased consumption of salty fat meat and alcohol, the
way it happens predominantly in Ardeal, but also in the rest of the country).
4. The profession/occupation has a major importance if not under the context of
development of professional diseases, then in the light of diseases professionally
conditioned or of which have an evolution positively marked or on the contrary by
exposure to certain environments
5. The blood group has to be mentioned for the reason that it has pathologies correlated to it
(duodenal ulcer seems to be more frequently correlated with group OI, group AII is more
frequently correlated to gastric cancer).
6. The presence of atopic terrain/territory has to be taken into consideration because
represents the fact that the pathology evolves on a terrain with special reactivity.
Moreover, these patients won’t be able to benefit of drugs/products which they are
allergic to and neither other drugs that these are related to; these patients can develop
sensitivity in time to other substances too, and certain diseases can become chronic
easier, the way it happens in the case of chronic pyelonephritis
 It begins the presentation of the anamnesis, that has to be made in such a convincing manner,
that at the end of it the clinical diagnosis or at least part of it to be able to be introduced to the
auditory
Reasons of addressing to the medic have to be grouped in accusations meaning the signs
and symptoms of apparatus and systems, then general signs and symptoms (cephalalgia, weight
loss, physical and psychical asthenia, fever).
Following logically the presentation of disease history that has to be made in reportage
system and to take note of:
 The debut of the disease, with its fixation in the calendar;
 The type/way of debut, acute, insidious, caused by traumatic injury;
 Initial/ opening symptoms, their eventual correlation with certain triggering
causes;
 The evolution of these with and without treatment , or the addition of other signs
and symptoms;
 It is being mentioned the evolution in time of the subjective accusing symptoms
under the followed medication, if one has been followed;
 In the end it is pointed out the conjuncture in which the patient finds itself in that
led him to the present consult
If there is a predominant symptom, for example pain, there will be an emphasis on the
localisation, irradiation, intensity, frequency, conditions of occurrence and disappearance or
amelioration, duration, or other associated phenomena.
Moving on to mentioning the heredo-collateral history/antecedents that has to
comprise those affection of which predisposition can be transmitted (ulcerous disease, HTA,
DZ[diabetes mellitus], neoplasia), which are contagious (aerogenous, sexual), maladies with
genetic transmission (haemophilia, neurofibromatosis and other phacomatosis, colonic
polyposis). It will be considered the presence in the family of people with a physical or psychical
handicap/ invalidity and the ones, which induce a state of domestic tension.
Personal history/ antecedents consist of marking the physiological ones in women;
these comprise the age at which took place the first menarche, as well as the quality of it
(regularity, presence of meno- metrorrhagia, dysmenorrhea), and eventually the date for starting
the menopause or the date of the last menstruation; the number of pregnancies, births and type of
these. If the birth took place in natural ways, it will be mentioned if it caused perineum ruptures
and if those have been solved in a surgical way. If the birth was by C-section, to mention the
reason for which that option has been chosen. It has to be mentioned if there were any
macrosomic foetuses.
It is being mentioned what contraception ways have be used, because, especially the ones
with oral administration can have redoubtable adverse reactions (increase of arterial pressure
values, thrombosis especially in female smokers, dyslipidaemias, hepatic steatosis). Local birth
control options produce dismicrobism which can facilitate urinary infections.
 Personal pathological history/antecedents have to be listed chronologically, and if the
information was hard to be obtained from the patient, the patient will be asked specifically,
targeting groups of affections:
 Infectious maladies/childhood eruptive diseases;
 Respiratory affections;
 Cardio-vascular maladies;
 Diseases of the digestive apparatus and annex glands; even if it is not suspected a hepatic
affection it is good to ask the patient if he had and transfusions (especially before 1989),
dentistry interventions that involved bleeding, abortions in improper conditions, manicure
with unsterilized/not properly sterilised tools – these being sources of contamination with
viruses B, C, D and others;
 Affections of reno-urinary or genital apparatus;
 Endocrine and metabolism affections;
 Psychic diseases;
 Haematological affections;
 Traumas, loss of consciousness;
 Vaccinations, allergic affections;
 Dermatological diseases, diseases of the loco-motor apparatus, pre-neoplastic lesions

Life conditions refer to the mention of the following aspects:

- Living in a salubrious environment, without dampness or condensation;
- The presence of pets or aquariums , their type of food;
These aspects are important because besides parasitic or microbial maladies which they
can transmit , animals can constitute allergens by saliva, hair, scales, dejections
- The existence of apartment plants is important also due to their allergen potential
Work conditions have to be mentioned under in all of their aspects:
- Exposure to an environment with irradiating-fibrosing mists and gases or with toxic
potential, which can determine complex pathologies related to the place of entrance in the
organism (respiratory, cutaneous) or complex systemic maladies such as the acute and
chronic intoxication ones
- Presence of unfavourable microclimate, vibrations, noise;
- Neuro sensorial and/or neuro psychical overload
- Other conditions present in the workplace which can lead to sickness or can prevent
healing of existing conditions that are under treatment
Habits refer to the chronic alcohol consumption, Tabaco, drugs or medications, except
the caffeine one on which will be recorded the excess consumption. It is made an approximate
estimation of the duration of consumption, its way, and if possible, quantity. For medications it is
followed the same procedure, adverse reactions being possible at variable moments from the
beginning of the treatment.
 Once finished the anamnesis, are being considered the data related to the clinical
examination of the patient. These will be structured as follows:
A. Data related to the general clinical exam
B. Data related to the exam on apparatuses and systems

It has to be mentioned that the exposition of the clinical exam follows different steps than
the ones used in the actual consultation.
The steps followed for the general clinical exam consist of mentioning the following
aspects:
- General state, with mention of BMI and PA(aerial pressure/ Paco2 = partial pressure of
arterial carbon dioxide.);
- Facies and attitude;
- Teguments and mucosae;
- Limfo-ganglionary system;
- Osteo-articular and muscular system;
- Subcutaneous cellular tissue.
It will be taken into consideration that each one of these systems present an objective
component (highlighted by inspection, percussion, palpation and auscultation, insisting on
maneuvers that bring useful information) and a subjective component represented by the
accusation (signs & symptoms) of the patient. For example, in case of an urticarial, it will be
formulated as follows: at the objective exam of the teguments, has be highlighted an
erythematous pruritic maculopapular rash/skin eruption, with fugacious and migratory character.
If it only exists the subjective component, without the objective one, it will be stated: at the exam
of the teguments, they present as clean, normally coloured, with the absence of any kind of
lesions, but clinically subjective the patient is accusing integumentary pruritus.
The clinical exam on apparatuses and systems presents as well an objective component
(realised by inspection, percussion, palpation and auscultation) and a subjective one (the
patient’s accuses).
Usually the exposition begins with the respiratory apparatus for which we mention the
pathological elements met by inspection of the superior respiratory airways (the aspect of nasal
pyramid, algia at the points of sinus pressure, pain at the pression of the tragus), as well as for the
thorax, of the costal excursions. There will be presented elements distinguished at the palpation
of the transmission of the vocal vibrations, thoracic percussion and elements distinguished at
auscultation, and eventually measuring of the Hirtz index (the difference between chest
circumference at inhale and at exhale). If there were no pathological elements, it will be
formulated as follows (clinical objective exam within the normal limits); after presenting the
elements distinguished at the objective exam, there will be added the presence or absence of
subjective accusations (the olfactory quality, cough presence and expectoration, dyspnoea)
 The clinical exam of the cardio-vascular apparatus follow the same steps, which
present the data provided by inspection, palpation, percussion and auscultation of the cardio-
vascular apparatus. There will be mentioned the place and quality of the apex beat, of the heart
sounds and abnormal murmurs. There will be discussed the values of the arterial pressure in
decubitus and in orthostatic position, at both arms. There will be taken into consideration the
central pulse (ventricular allure) and peripheral pulse or radial. The subjective component, if it is
present, it will be considered as the presence of effort and/or at rest dyspnoea, cough, retrosternal
pains, palpitations.
The exposition of the digestive apparatus will begin with the aspect of buccal cavity
(teeth, gums, tongue aspect and jugal mucosa), as well as providing of data related to the
deglutition and mastication quality. References will be made on the aspect of the pharynx,
tonsils, if these details have not been mentioned at the limpho-ganglionary system. Next there is
the abdomen description (slim, depressible, that follows or not the respiratory movements,
spontaneously sensitive and at palpation or on the contrary), dimension and liver and spleen
consistency, data about the appendicular, duodenal, gallbladder/cholecystitis points, quality of
intestinal transit. If at the clinical exam all the data was within the normal limits, it would be
formulated that at the objective clinical exam no pathological elements were highlighted. From
the subjective exam point of view it will be discussed the presence of abdominal pains along
with their character, nausea, vomiting, appetence quality and taste.
The renal-urinary apparatus is being described in the same manner by exposing
pathological elements of the objective clinical exam and presence or not of subjective
accusations. This way, it will be discussed the inspection, percussion, palpation and auscultation
of renal cavity, sensibility of urethral points (of course only for the palpable ones, respectively
superior and middle), the types of micturition and urine aspect.
After considerations are being made about CNS and sensory organs, endocrine system,
the clinical exam on apparatuses finishes.
It is the moment for the staged clinical diagnosis to be enunciated, by summing the
anamnesis data with the clinical exam results. This diagnosis can be of a disease (for example
“Duodenal ulcer in active phase, possible with positive helicobacter pylori”) if there is enough
data, syndrome diagnosis (painful thoracic syndrome of unspecified nature) or of a symptom
(irritative cough of unspecified nature).
For the accuracy of the diagnosis paraclinical investigations are required in order for the
diagnosis to be confirmed or for a different diagnosis to be found positive. The reasons will need
to be mentioned for these investigations along with the informational benefits that those bring.
After discussing the paraclinical investigations received and eventually what other investigations
would have had been useful in the formulation of the diagnosis, then the final diagnosis is
enunciated, complete and complex.
It follows the argumentation of the positive diagnosis (anamnesis’ elements and the
clinical exam that suggested the diagnosis and paraclinical data that confirmed it); there will be
discussed the differential diagnosis that were suspected and the reason for their elimination.
 The diagnosis being given, it has to be mentioned the evolution, complications and
prognostic with and without treatment.
Treatment and patient recovery have to be personalised for the presented case and it
will not be made an exhaustive presentation of the patient’s disease medication. It will be
presented in the following manner:
- Following an igieno-dietetic diet/regimen, formulating actual data about the diet, with an
qualitative and quantitative aspect, following a meal schedule, resting regimen at home or
even staying in bed, cessation of Tabaco consumption, cessation or at least limitation of
alcohol and caffeine consumption, in one word, change of lifestyle. If it is useful, diuresis
cure, avoidance of physical and/or psychic effort, change of domestic microclimatic or
workplace environment, allergenic eviction.
- The medicinal treatment can be etiologic, pathogenic or symptomatic, or all at once; there
will be made remarks regarding the name of the pharmaceutic concoction, dose per day
and repartition way, duration in time;
- Recovery scheme also comprises kineto-therapeutic aspects, crenotherapy, balneo(-
climateric) or helio-marine therapy, complementary therapies if it’s the case.

In the end, there will be made recommendations for ambulatory monitoring of the case
(by the GP’s practice) and observation by speciality practices.
The particularization of the case ends any presentation and is in regards to mentioning
those anamnesis elements, clinical or paraclinical exam that make out of the presented patient a
unique one. The particularities that can be mentioned can be the ones related to the disease, as
well as the therapeutic conduct.