Systematic Review of a Case Report
The article is authored by two authors, Tanyi John Tanyi and Julius Atashilli. Both authors contributed to the development and publication of the article. Tanyi John Tanyi managed and followed-up the patient and wrote the original manuscript. Julius Atashilli critically reviewed the manuscript. Both authors read and approved the final manuscript. Therefore, both authors merit inclusion in the authors list (International Committee of Medical Journal Editors, 2006). The authors do not provide information on whether they received any funding for the article but they declare no conflicts of interest.
On the overall presentation of the case report, it is short and focused with a limited number of references. It is appropriately structured into the following sections, abstract, introduction, description of the case, and discussion. The title of the article describes the case in question accurately and succinctly and names the setting of the case report. It also arouses the interest of the reader. The abstract section is unstructured and concise which is appropriate for a case report. It additionally accurately summarizes the information contained in the case report. It includes the issue of concern, history taking and physical examination, and the rationale why it is important, it leads to the making of a correct diagnosis 90% of the time. It also incorporates a brief summary of the case and take-home lessons from the case. The introduction section introduces the reader to the issue of concern, physical examination. The authors posit that physical examination and history taking are useful approaches to the diagnosis and consequently management of any condition. They cite four references (Knox, 2014; Verghese, Charlton, Cotter, & Kugler, 2011; Max, 2009; Beattiee, 2004) that contend that the advent of modern technological tools that aid diagnosis has led doctors to drift or shorten this time-honored approach to diagnosis. The introduction section thus justifies the need for publication of the case report.
The description of the case being reported is systematic and chronological. The section comprises of a clinical history, physical examination findings, differential diagnosis, results of investigations, working diagnosis, management, and follow-up (The Joanna Briggs Institute, 2016). The demographic characteristics of the patient reported are age and gender that is a 30-year old man. The patient’s history is clearly described as a timeline. The presenting symptoms are also described objectively. The patient had a one year and six months history of sporadic high grade fever as well as non-radiating abdominal pain in the right lower quadrant. He also had complains of non-productive cough, loss of appetite, nausea not associated with vomiting or altered bowel habit, and intermittent night sweat. He had a history of appendectomy 10 months earlier when he had presented with similar complaints. He also had a positive history of contact with a patient with pulmonary tuberculosis two years earlier. The patient had been managed at five different health facilities since he started experiencing the symptoms with no favorable outcome. The findings of the physical examination are clearly reported. The patient was febrile, sick-looking, and had experienced 10% loss in body weight over the preceding six months. He also had neck lymphadenopathy and mild tenderness over the right lower abdominal quadrant. The diagnostic tests conducted are mentioned and their findings reported. They included full blood count, chest x-ray, abdominal ultrasound, and lymph node biopsy/ histopathology. They revealed microcytic hypochromic anemia (Hb=11g/dl), lymphocytosis, parahila nodes, and granulomas that contained giant Langham cells as well as central cessation. The treatment protocol used on the patient is clearly described as six months anti-TB regimen under Direct Observational therapy. The post-intervention clinical condition of the patient is well described. Two weeks after commencement of treatment, the patient had no fevers and had started regaining his appetite. By the end of three months, the patient had no palpable axillary and submental lymph nodes, there was marked reduction in the size of the his cervical lymph nodes, and he had gained 4kg in body weight. Importantly, the authors have maintained confidentiality of the patient’s information as no personal identifying information about the patient is included in the case report.
The discussion section explains, clarifies, and interprets the key findings of the article. It is brief and to-the-point. It describes the concept of physical examination defining it as the process of objectively evaluating anatomic findings via the use of the following; observation, palpation, percussion, and auscultation. The section additionally provides an overview of typical management contextualizing history taking and physical examination within the process of patient assessment. It also provides a commentary that maps physical examination and history taking in the diagnostic process. Citing Gillis (2006), the authors of the article contend that physical examination should follow history taking and the history provided by the patient is important and should be incorporated into the physical examination. The authors trace the origin of physical examination to 1761 when percussion was discovered by Leopold Auenbrugger. The authors also discuss their hypothesis in this section. They posit that thorough history taking followed by a complete physical examination greatly contribute to a correct diagnosis and also minimizes the number of laboratory tests needed in resource limited settings. The authors cite two references (Hutchinson & Rainy, 1918; Kelder et al., 2011) that support their hypothesis on laboratory tests as far as correct diagnosis and differential diagnoses are concerned. In summary, the discussion contains the most important conclusions of the case report as well as an explanation of their relevance and importance. The take-home point emphasized by the authors is that history taking followed by a complete physical examination is essential to the making of a correct diagnosis and ordering of the most relevant laboratory tests especially in resource-constrained settings. Notably, however, the discussion section fails to discuss the strengths and limitations of the case report.
On the educational value and validity of the case report, five elements will be assessed that are documentation, uniqueness, educational value, objectivity, and interpretation. The case is well documented as complete, accurate, and appropriate information about the case is provided. The information on the history, clinical examination findings, diagnostic tests findings, and appropriate citation of references demonstrate that the case is what the authors contend it to be. The uniqueness of the issue discussed cannot be ascertained as the authors do not dwell on the issue hence it is unclear whether there are other authors who have addressed the issue. The article has educational value as it provides an educational resource on an already known entity. The article is objective as data provided is complete and there is no evidence of subjectivity in emphasis or presentation of data. The authors have also reported no potential conflicts of interest. On the issue of interpretation, the conclusions and recommendations made by the authors are appropriate and in line with the evidence presented in the article. The authors accomplished their objective of demonstrating the utility of history taking and physical examination in the making of medical diagnosis. Therefore, the case report is valid and has potential value as an educational resource. It is applicable to my practice as a registered nurse as it emphasizes the importance of taking an accurate history and complementing the history with a complete physical examination when assessing patients. The patient reviewed was diagnosed one year and six months after presentation with lymph node TB. Therefore, there was a delay in correctly diagnosing the condition of the patient which may have been due to inadequacies in history taking and physical examination.
In summary, this paper has reviewed a case report by Tanyi and Atashilli (2015) that emphasizes the importance of accurate and complete history taking and physical examination in diagnosing medical conditions. The case report meets the main requirements of a case report with regards to main elements, documentation, authors, objectivity, educational value, and interpretation. Although it reports on an already known entity, the case report clearly has implications for nursing practice as it reinforces the importance of thorough history taking and physical examination in arriving at a diagnosis.
References
Durbin, C. G. & Schwenzer, K. J. (2004). The spectrum of respiratory care research: Prospective clinical research. Respir Care., 49, 1165–1170.
Gopikrishna, V. (2010). A report on case reports. Journal of Conservative Dentistry, 13(4), 265- 271.
Hess, D. R. (2004). What is evidence-based medicine and why should I care? Respir Care., 49, 730–741.
International Committee of Medical Journal Editors (ICMJE) (2006). Uniform requirements for manuscripts submitted to biomedical journals: writing and editing for biomedical publication. Philadelphia: ICMJE; International Committee of Medical Journal Editors (ICMJE).
Tanyi, J. T. & Atashilli, J. (2015). Delayed diagnosis of lymph node tuberculosis: Time-honored importance of a through clinical examination, Cameroon. Pan African Medical Journal, 21, 38.
The Joanna Briggs Institute (2016). JBI critical appraisal checklist for case reports. Retrieved from http://joannabriggs.org/assets/docs/critical-appraisal-tools/JBI_Critical_Appraisal- Checklist_for_Case_Reports.pdf.
