Disclaimer: This article is primarily intended for my students. However, it is of a general nature and may benefit others as well.
Clinico-social case presentation is an essential part of practical examinations in Community Medicine. There is no nationally accepted Clinico-social case format- variations exist between universities and between institutions within universities. Therefore, this article will not attempt to provide a harmonized clinic-social format. Instead, I will highlight key points students must bear in mind with respect to clinic-social case discussion.
Students must be familiar with the format in use in their university/ institution.
Students must present both clinical and social (and environmental) findings in the case assigned.
Regardless of format used, from an examiner’s perspective, the objectives of conducting clinic-social discussion generally include:
- Assessing the ability of students to obtain a reasonable history and perform focused examination
- Assessing the ability of students to arrive at a reasonable diagnosis/differential diagnoses
- Determining students’ ability to identify issues/problems in the case
- Determining students’ ability to link/relate issues/problems with clinical/social/environmental factors
- Determining students’ ability to identify the levels of prevention that have failed in the case of specific issues/problems
- Determining students’ ability to offer a reasonable plan of management/solution for the major issues/problems
Of the above, #1, #2, and #6 are generic skills, while the others are more specific to Community Medicine. With respect to #6, the approach is different from that in other clinical specialties.
In the examination, students must provide evidence that they possess (most of) the abilities listed above.
I will discuss each of the above points in some more detail below.
Clinico-social case format
It is important that students are familiar with the Clinico-social case format used in their institution/university before the commencement of the practical examination. All examinations are conducted with a strict time limit. Therefore, it is important not to waste time trying to recollect the format during the examination. Often, students are expected to present the social findings before clinical findings (locate the clinical issues in a social context).
In the larger scheme of things, the format does not matter as long as it includes all important elements.
Students must collect all relevant information within 30 minutes or so, leaving time to write the case sheet. With respect to case findings, the following points must be borne in mind:
The order of collecting information does not matter- one could collect social and environmental history first to establish rapport, before proceeding to collect clinical history.
Students must seek verification of information to the extent possible- do not accept whatever is told at face value, and try to cross-check everything before writing it down. Similarly, one must seek confirmation of clinical information during physical examination- both should agree with each other.
Where one discovers a discrepancy (either during history or examination), the same should be clarified with the patient/bystander and resolved before writing in the case sheet.
It is preferable not to mechanically ask questions to the patient/bystander without regard for relevance to the case at hand- this will waste time and not benefit the candidate in any manner. Simultaneously, important information pertaining to the case should not be omitted.
In patients with a chronic Non-Communicable Disease (NCD) like diabetes mellitus, hypertension, COPD, etc. a conscious attempt must be made to determine the following details regarding the disease:
- How it was diagnosed- accidentally, or due to symptoms/signs? Was there a delay in diagnosis? If yes, why?
- Initial treatment- lifestyle modification/pharmacological therapy advised? For what duration? Was the patient compliant to treatment? If no, why?
- Subsequent treatment- was treatment changed? Why? Was the change indicated/justified?
- Current status- what is the current status of the disease/condition? Is it under control, and how do you know (evidence of the same)? Have complications developed?
The ultimate purpose of this activity is determining if there were deviations from the expected course (of disease/treatment). These deviations will form the focus of discussion, and must be actively searched for- the more deviations one identifies, the better. Failure to identify issues may result in the examiner deciding the direction and breadth of discussion with the student having no possibility of guiding the same.
Ensure that the history and examination are coherent- there should be no contradictions between the two. Similarly, if a problem is discovered during examination although it was not mentioned during history, revise complaints to include the physical finding(s).
Ensure that the diagnosis is aligned with the presenting complaint(s), history, and examination. The diagnosis should logically follow from the presenting complaints, and explain all complaints.
Tip 1. Once you have arrived at a diagnosis/ differential diagnosis, go back and review the presenting complaint(s). Try to identify possible differential diagnoses from the presenting complaints- the final diagnosis should be one of the differential diagnoses.
Tip 2. Only state a diagnosis you can defend based on your knowledge and case findings. Remember, it is not the diagnosis, but how you arrived at the diagnosis that is being assessed.
Prior to the discussion students are advised to do the following:
Identify key points in history and examination-these should lead to the final diagnosis
Prepare a summary of history and examination- sometimes there won’t be enough time to present the entire case
Anticipate potential questions that may be asked (based on diagnosis, issues/problems identified, etc.) and prepare responses for them. The following are frequently asked questions:
- Why do say the diagnosis is _______? (Here, you must provide the reasoning and justification for your diagnosis.)
- What are the levels of prevention that have failed? (Here, you must list each issue/problem and specify the level of prevention- primary/secondary/tertiary- that has failed, and why you say so.)
- What would you like to do for this patient/ How will you manage this patient? (Here, you must provide suggestions/solutions to address the main issues/problems mentioned above. It is desirable to respond by specifying suggestions/solutions at the individual level/family level/community level. Similarly, describe various levels of prevention as appropriate.)
I have not specified it here, but students are expected to present a clinicosocial diagnosis, not merely clinical diagnosis. Therefore, it is advisable to practice framing a clinicosocial diagnosis before the examination. I will discuss how to frame a clinicosocial diagnosis in another article.