Format: It is expected that your assignment will broadly follow case study writing principles and will conform to the following structure:
Introduction
Discussion of patient’s signs & symptoms in relation to pathophysiology
Explanation of physical examination findings/blood tests in relation to pathophysiology
Discussion of possible diagnoses in order of likelihood based on previous two points
Suggestion & justification of additional diagnostic tests to identify the final diagnosis/diagnoses (what should be ordered and why)
It is not expected that the students will reach the final diagnosis as that requires further diagnostic tests which have not yet been done. There is no ’correct list’ of possible patient’s conditions so different students can rightly suggest their own differential diagnosis list.
Case description:
Mr Lewis is a 63 years old person who has been suffering from hypertension and diabetes over the last 20 years. He is receiving treatments for both conditions (Minidiab and Tritace) but admits rather erratic compliance. He self-monitors his BP and BGL from time to time but not regularly. Today he presents in the office with shortness of breath which has been worsening over the past five weeks. He has, however, experienced episodes of shortness of breath during the past year, especially when exerting himself. He fatigues easily and has lost ’all his energy to do anything’. He is especially worried that even short walking now leads to marked weakness and shortness of breath forcing him to take a rest before continuing. On several occasions he awoke suddenly from sleep because ’he couldn’t catch his breath’ and developed a dry cough but with no audible wheezing. The breathing problem improved when he sat on the edge of his bed for an hour. He generally sleeps with two, sometimes three pillows, which seems to help him breathe better.
Few days ago he developed unusual weakness and numbness in his left arm and leg with dizziness, which went away in half an hour. During that time he was unable to get up from his armchair and had difficulties clearly articulating words. This never happened before. Often he has a feeling of heart racing and jumping, especially during physical activity. However, he has not experienced any chest pain or heaviness so far. He is also complaining about numbness, tingling and burning affecting his feet, interfering with his mobility and sleep.
He smokes around 15 cigarettes daily and drinks ’a beer or two a day’. He retired 2 years ago from his work as a truck driver.
Vital signs:
Temperature (ear): 37oC
Blood pressure: 150/95 mmHg
Pulse rate: 100 beats per minute, regular
Respirations: 20 breaths per minute
Pulse oximetry: 92%
Physical examination:
Weight: 79kg
Height: 168cm
On inspection his skin colour is pale and his lips/tongue are faintly bluish. Pulse on peripheral leg arteries is weak. There is moderate swelling around the ankles that pits on pressure. Coarse inspiratory crackles could be heard during chest auscultation over the lung bases. Heart activity is irregular and fast, S3 is heard at the apex.
Routine blood tests:
Hb 135 g/L
RCC 4.5 x 1012/L
Hct 43%
WCC 8 x 109/L
Platelets 280 x 109/L
ESR 12 mm/h
Urea 11 mmol/L
Creatinine 0.3 mmol/L
BGL (fasting) 8 mmol/L
Urinalysis (dipstick):
Blood neg
Proteins ++
Glucose +
Your task:
Explain the likely pathophysiology of presenting features
Interpret the vital signs and findings on physical examination
Interpret the significance of the blood tests
Develop the list of possible conditions the patient might have (differential diagnosis)
Suggest and give rationale for further diagnostic tests
Expanded marking criteria
Criteria
Mark
Introduction includes one or more paragraphs that informs the reader of the main idea and how it will be presented
/3
Pathophysiology of patient’s complaints is discussed
/20
Physical examination findings are explained and interpreted
/12
Laboratory tests are explained and interpreted
/10
The list of possible diagnoses is developed and justified
/12
Additional diagnostic tests are suggested and justified
/15
Arguments are well developed and built, paragraphs are logical and linked
/5
Text is legible and clear; spelling and punctuation are accurate; sentence structure is grammatically correct and reflects the writer’s intent
/2
Assignment is well structured and easy to read
/3
Referencing is clear, consistent and supports the argument
/3
Reference list includes at least 15 appropriate quality references; at least 60% of them primary sources (journal articles, conference proceedings)
/5
Assignment reveals clinical reasoning skills
/10
TOTAL
More information
Introduction (a paragraph or two briefly introducing the
patient/his complaints and stating what you intend to do in this assignment;
imagine that someone else and not me is reading your work; would it be clear
from the start what your intentions are?) •
Discussion of patient’s signs & symptoms in relation to
pathophysiology (eg. shortness of breath, productive cough, tiredness, blood in
sputum etc.). You should use subheadings for each of them. Every presenting
feature needs to be considered (after all it is the evidence in this mystery
case). Do not omit any complaint that the patient has mentioned.
• Explanation of
physical examination findings/blood tests in relation to pathophysiology. Focus
on abnormalities and their possible interpretation. What would they mean in
relation to this patient?
• Discussion of
possible diagnoses in order of probability based on previous two points
(develop a list of conditions in, as much as possible, the order of probability
and very briefly explain why such conditions were included, like what evidence
so far you have for their inclusion; here risk factors could be mentioned as
well; for some conditions which are less probable state why this is so eg. what
else would be expected in such condition and yet our patient does not have it,
or in a certain condition on the list you would not expect to find a
symptom/sign that our patient actually has
• Suggestion &
justification of additional diagnostic tests (investigations) to identify the
final diagnosis/diagnoses. What should be ordered and why? How can those tests
help you in narrowing down the list of conditions? What additional evidence
could be obtained in this way? Start with the simplest/cheapest test and go
from there. For example if we suspect a liver problem we will first do Liver
Function Tests in blood and then if there is evidence of liver disease we will
consider liver imaging.
/100
