medical case study

medical case study

The Importance of Early Diagnosis in Medical Case Studies

1. Introduction

The importance of early diagnosis has long been a concern in the practice of medicine. It is a maxim in British medicine that expert and experienced physicians are those who possess accurate diagnostic skill. Unfortunately, diagnosis has not been emphasized as a skill in its own right for many decades, having become submerged beneath the emphasis on therapeutic technique and technology. There is now a growing concern that today’s student physicians are not acquiring an adequate diagnostic competence. In recent years, improved therapeutics have too often become equated with successful treatment, and a number of medical educators have called for a refocus on diagnosis. This is long overdue in many respects. The desire to help patients by identifying and understanding their illness is still the heart and soul of medical practice. Early diagnosis is an essential first step towards alleviating patients’ suffering and improving outcomes. It prevents further damage from developing pathology, provides a better chance for cure whether by treatment or avoiding triggers of disease, reduces suffering of patients and their family due to prolonged illness. Failure to reach a correct diagnosis is a common cause of medical error, often leading to inappropriate and sometimes dangerous management. And in this era of evidence-based medicine, it will allow physicians to apply recent advances in the management of a specific disease. Often, there are too many options whose efficacy is unclear.

The selected conditions are to reflect a spectrum of disease severity, ranging from self-limiting illnesses to those that progress quickly with significant morbidity or mortality if not diagnosed early. The cases include benign acute childhood illnesses – pharyngitis and otitis media, uncomplicated and complicated lower urinary tract infection in women by review of previous study – and serious potentially life-threatening diseases – heart failure and cancer.

This paper aims to provide an evidence-based overview of the current situations to early diagnosis with emphasis on medical history taking and physical examination, its importance in the era of recent advancement, and its barriers among medical practitioners in primary care. The concepts are illustrated with case studies selectively chosen from the author’s collection spanning among the common and serious conditions.

2. Case Presentation

A 50-year-old Caucasian woman with a family history of breast cancer presented to the hospital with symptoms that raised the suspicion of an underlying breast cancer. Seven months ago, the patient began showering complaints of the “skin pulling” over her right breast. This was followed shortly by a lump in the upper outer quadrant of the right breast. The patient ignored this, attributing it to fatty tissue. Over the next several months, she noted a yellowish watery discharge from the nipple. At this point, she consulted with her sister, and an appointment with a general surgeon was made. Physical examination revealed a 2cm x 2cm fixed, non-tender mass in the upper outer quadrant of the right breast. Expression of the right nipple resulted in the discharge of a yellowish fluid from a single duct. There was no axillary adenopathy. Mammography showed a 2cm ill-defined mass in the same location as the lump noted by the patient. Right upper outer quadrant duct excision was then performed. A frozen section done in the operating room revealed infiltrating ductal carcinoma.

3. Diagnosis and Treatment

The connection between clinical problems and their underlying scientific principles is essential to early diagnosis. The early recognition of a specific disease ensures timely and appropriate treatment. However, diagnosis is a complex process, often involving the synthesis of clinical impression with a variety of further tests and examinations. This may be particularly difficult in elderly patients who may have several pathological processes occurring simultaneously. The relation between diagnosis and successful treatment is best illustrated by an example. High blood pressure (hypertension) is a common problem in elderly individuals and is due to a variety of causes. Frequently it is not diagnosed because the symptoms are often vague and there is a reluctance to measure blood pressure. Early diagnosis can only be made by measuring the blood pressure, and this is often only done after an elderly patient has become unwell due to an unrelated illness. If hypertension is diagnosed then treatment can be given and if the high blood pressure is the cause of the illness then treatment will result in improvement of the illness. This example illustrates the need for early diagnosis, the sequence from diagnosis to treatment, and the potential improvement in patient outcome.

4. Discussion and Analysis

An attempt to bring together the basic knowledge and clinical problem-solving skills with the use of more advanced investigative tools is evident throughout the cases. This is primarily to show the clinical student that, with an integration of their knowledge, coupled with the use of tests available, the diagnosis and management of many clinical conditions becomes clearer. At times it may seem to the student that the use of further tests contradicts the original diagnosis first thought of from the history and examination. However, many tests provide the only definitive diagnosis, and this is the key to understanding the patient’s condition, which is integral in planning the correct management. While the importance of more advanced tests is highlighted, the cases have kept within the examination of MRCP at Part 2, and it is hoped that this combination of basic and clinical knowledge will be of benefit to the student.

The case studies were chosen to illustrate various points of understanding and managing medical cases in the context of an integrated medical education. The areas covered in the case studies range from the importance of initial findings, the decisions and actions taken when managing the patient, right through to clinical problem solving and understanding. The cases cover a wide range of common and important clinical conditions.

4.1 Introduction

5. Conclusion

This essay also uncovers how difficult it may be to determine a specific diagnosis. With general practitioners being the front line in healthcare, it is said that a diagnosis in 80% of cases can be made from the history alone. This may be true, but patients with rare or unusual conditions can present in a manner that confuses the most learned of physicians. This may result in a GP trying to manage a condition that is out of his depth and skill level. Knowledge of when to refer a patient to a specialist is paramount, and the sharing of case reports between physicians from different levels can further enhance their diagnostic skills.

From this essay, it is clear that the benefits that may be accrued from early diagnosis are numerous and significant, whether they are economic, therapeutic, or emotional. This again underlines the importance of an early and correct diagnosis. Early case reports by various specialties can serve as a rich resource for the young and those still in training, as it provides an avenue for understanding the natural history of diseases and seeing firsthand how the patient responded to various diagnostic and treatment modalities. It is hoped that from this essay, it is evident the part case reports have to play in early diagnosis. The various diagnostic and treatment modalities may not appear so in black and white when reading from a textbook or attending a lecture. By seeing how a patient responds to a certain mode of treatment can in some way influence the decision of what the most appropriate form of treatment for the patient is. This would ideally minimize morbidity and increase the chances of a cure.