2 Cases for Medical Presentation using Digital Slides

2 Cases for Medical Presentation using Digital Slides

Posted on June 29, 2012

2 Cases for Medical Presentation using Digital Slides

 Instructions:

Given a text for medical presentation and a pool of picture slides, prepare a 6-minute presentation in consideration of the requirements for clear and clean digital slides.

You can use the gallery of picture slides that will be provided or you can surf the Internet for pictures you need (in case there is WIFI).

++++++++++++++++++++++++++++++++++++++++

Case 1:

Case Presentation on Patient with a Right Lower Quadrant Abdominal Pain

A 25-year-old female patient consulted a physician because of abdominal pain.  The pain started one day prior to consultation, initially, epigastric in location and after several hours, shifted to the right lower quadrant of the abdomen.  There were no associated gastrointestinal symptoms like diarrhea, constipation, vomiting and bloatedness.  There were also no symptoms of urinary disturbance, vaginal discharge and no febrile episode during this time.  She had been having menses at regular intervals of 28 days with the last one being two weeks ago.

Significant physical examination findings at the time of consultation consisted of a mild to moderate direct tenderness at the right lower quadrant of the abdomen. The other physical examination findings were essentially normal.

The initial primary and secondary clinical diagnoses were acute appendicitis and mittelschmerz (ovulation pain) respectively.

A paraclinical diagnostic procedure was considered because the certainty for the diagnosis of acute appendicitis has not reached 90% and the usual recommended treatments for the primary and secondary diagnoses were markedly different.  The usual recommended treatment for acute appendicitis is an operation to remove the appendix.  For mittelschmerz, the usual recommended treatment is administration of analgesics.

The following table of information on the options of paraclinical diagnostic procedures was presented to the patient and her relatives with the understanding that the primary objective in doing and selecting a procedure consisted of increasing the degree of certainty on the diagnosis of acute appendicitis:

Options

Benefit

Risk

Cost

Availability

Plain abdomen Detection of fecalith in the appendix as a clue for appendicitis – seen only in 10% of cases with acute appendicitis

Radiation

P200 Readily availablein the hospital and community
Ultrasound of the lower abdomen Detection of dilated appendix as a clue for appendicitis – seen only in 70% of cases with acute appendicitis Necrosis of tissue if there is malfunction of the machine P3000 Readily availablein the hospital and community
CT scan of the lower abdomen Detection of dilated appendix as a clue for appendicitis – seen in 90% of cases RadiationReaction to dye used as contrast medium P6000 Available in the in the hospital and community
Serial monitoring of the abdominal tenderness Persistence and increasing right lower abdominal pain as a clue of peritoneal irritation, with 95% of the time, usually due to acute appendicitis, after excluding other diseases Delay in treatment Professional Fee of MD- P1000 Readily available

The patient and her relatives decided to go for an ultrasound of the lower abdomen.  The result showed a dilated appendix.  There were no unusual findings on the uterus and its adnexal organs.

With persistence of the right lower quadrant abdominal tenderness, reinforced by the finding of dilated appendix on ultrasound, a pretreatment diagnosis of acute appendicitis was decided upon at this time.

The patient and her relative were informed of the pretreatment diagnosis and were appraised of the options for treatment.  The following tables of information on the options for treatment were given to them:

Between operative and non-operative treatment:

 Options

Benefit

Risk

Cost

Availability

Non-operative treatment  (relying on antibiotics) 63% success rate Side effects of antibiotics Cost of antibioticsP2000 Readily availablein the hospital and community
Operative treatment (removing the appendix) 99% success rate Side effects of anesthesia and operations Cost of operation (without professional fee)P15000 Readily availablein the hospital and community

Between open and laparoscopic appendectomy:

Options

Benefit

Risk

Cost

Availability

Open appendectomy 99% success rate; longer abdominal scars Complications of anesthesia and operationsuch as wound infection and bleeding; more painful P15000 Readily availablein the hospital and community
Laparoscopic appendectomy 95% success rate with conversion to open appendectomy in 5%;Shorter abdominal scars Complications of anesthesia and operationsuch as wound infection and bleeding; less painful P30000 Not readily available in the hospital and community

The patient and the relatives decided on an open appendectomy.

The patient was then prepared for the open appendectomy.  The following were done as part of the preparations:

  • Optimization of patient’s condition with screening for any condition that will interfere with treatment
  • Informed consent for operation
  • Psychosocial support
  • Prepare operating materials and needs
  • Preoperative antibiotics
  • Fasting for 6 hours
  • Intravenous fluid administration

The patient was operated 8 hours after, from the time of the consultation.

A spinal anesthesia was administered by an anesthesiologist.

A transverse right lower quadrant incision was made and carried down to the peritoneum. At the abdominal musculature layer, the external oblique, internal oblique and transversus abdominis were retracted in a gridiron fashion.

Intraoperative finding showed an appendix that is ileal in direction, dilated at the distal end, with thin strips of fibrin on its serosal surface.

The preoperative diagnosis of acute appendix was confirmed with the intraoperative findings.  An appendectomy was then done after mobilizing it and transecting the mesoappendix.  After the appendix was transected at the base near the cecum, the stump was ligated with two silk 2-0 sutures.   After a correct sponge, needle and instrument count, the abdominal incision was repaired and closed layer by layer.

Postoperatively, the patient was given analgesics to control the pain.  She resumed her regular diet.

A day after the operation, she was discharged with analgesics for home medication.  She was also advised on how to take care of her appendectomy wound.  She was asked to follow-up with the physician one week after.

On follow-up one week after the operation, the initial complaint of right lower quadrant abdominal pain was already completely gone.  The appendectomy wound was healing well.  There were no signs of inflammation and infection such as erythema and purulent discharge.  The patient was satisfied with the result of the physician’s management.

The final diagnosis was acute suppurative appendicitis.

The following general goals in the patient management were achieved: resolution of the health problem in such as a way that the patient does not end up dead; does not have unwarranted disability and complication; is satisfied; and there are no medicolegal issues.

Mission accomplished.

 

Gallery of pictureslides to choose from:

https://sites.google.com/site/digitalmedicalpresentation/case-of-abdominal-pain-for-medical-presentation-using-digital-slides

 

++++++++++++++++++++++++++++++++++++
++++++++++++++++++++++++++++++++++++
++++++++++++++++++++++++++++++++++++

Case 2:

Case Presentation on Patient with a Jaundice

A 61-year-old female consulted a physician for jaundice.  Four months prior to consult (PTC) , patient developed epigastric pain with accompanying fever then jaundice, a month after.  One month PTC, she noted bipedal edema.  One week PTC, she developed generalized body weakness, which worsened over the course of the week, prompting her to consult the physician.

 

Pertinent physical examination findings showed jaundice; enlarged globular abdomen with fluid wave; palpable and firm non-tender liver, 2cm below the rib cage; splenomegaly; and bipedal edema.

The primary clinical diagnosis was portal hypertension secondary to liver cirrhosis.  The secondary clinical diagnosis, portal hypertension secondary to a hepatic tumor.

Using pattern recognition, patient had portal hypertension because of the presence of splenomegaly, bipeal edema, and ascites in the abdomen.  As to the cause of the portal hypertension, the main consideration was a pathology in the liver as the patient manifested jaundice and had enlarged liver.   The liver pathology might be due to a liver cirrhosis or a liver tumor, most likely cancer.  In the absence of reliable clues from the signs and symptoms and history of the patients, liver cirrhosis was chosen as the primary clinical diagnosis using prevalence process as liver cirrhosis is more common than liver tumor in the community.

A paraclinical diagnostic procedure is needed as the degree of certainty on the primary clinical diagnosis was only 80% and treatment for the two diagnostic considerations were markedly different, i.e, supportive treatment for cirrhosis and anticancer treatment, for liver malignancy.

The table below shows the comparative degrees of certainty for the differential diagnoses and their usual treatment.

Certainty

Treatment Modality

Por. Hyp. (Cirrhosis)

80%

Non-operative (supportive)

Por. Hyp. (Tumor)

20%

Anticancer

In the selection of a paraclinical procedure, the following table was drawn up to facilitate problem-solving-decision-making and securing informed consent: (the objective is to elevate the degree of certainty of the clinical diagnosis to a pretreatment diagnosis level)

 

  Benefit Risk Cost Availability
Liver Enzymes (alkaline phosphatase and gamma-glutamyl transferase) If elevated, just point to cholestatic liver disease.Cannot specify whether due to cirrhosis or cancer. Pain and hematoma associated with blood extraction P400 Readily available
Ultrasound Accuracy of 80% Necrosis if machine malfunctions P2000 Readily available
CT Scan Accuracy of 90% Radiation P 6000 Not readily available
Biopsy Accuracy of 95% Pain and bleeding P 10000 Not readily available

Among these possible paraclinical procedures, ultrasound was chosen as the initial paraclinical diagnostic procedure by the patient and her relative.  CT scan and biopsy would be considered again after the ultrasound.

Ultrasound of the liver showed fibrotic nodules and scarring on the liver highly suggestive of cirrhosis.

At this point, a hepatitis profile was done which showed elevated values suggestive of chronic hepatitis.

Thus, the pretreatment diagnosis was portal hypertension secondary to cirrhosis secondary to chronic hepatitis.

The patient and her relatives agreed to the following goals of treatment for the primary diagnosis: control the progress of the liver cirrhosis and control the ascites and bipedal edema.

The following tables show options for treatment for the two treatment goals:

Control of the progression of liver cirrhosis:

 

The patient was given anti-hepatitis drugs.

She was also advised against intake of substances and foods that could aggravate her liver cirrhosis.

 

Control of the ascites and edema:

 

Benefit

Risk Cost Availability
Support (Working against gravity by avoiding prolonged time on feet and elevating feet whenever possible) Can decrease severity of bipedal edema as its accompanying discomfort None 0 (None) Available
Support with Drugs (Diuretics) Can slightly aid in controlling edema, but not much different from support alone. Side Effects P100 / day Available

It was decided that diuretic drugs would be given only when necessary.

Prevention and Health Promotion:

The final diagnosis was portal hypertension secondary to liver cirrhosis secondary to chronic hepatitis.

Patient and relatives were advised on the diagnosis and prognosis and they understood and accepted the explanations and advices on supportive care.

At the end of the day, the following general goals in the patient management were achieved: resolution of the health problem (through acceptance of the incurable disease accompanied by comfort-supportive measures) in such as a way that the patient does not end up dead; does not have unwarranted disability and complication; is satisfied; and there are no medicolegal issues.

Mission accomplished.

Gallery of picture slides to choose from:

https://sites.google.com/site/digitalmedicalpresentation/case-of-jaundice-for-medical-presentation-using-digital-slides

Advertisements
This entry was posted in Asian Medical Students Conference - 2012, Powerful Presentation. Bookmark the permalink.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s