Case Rounds

CASE ROUNDS (MANDATORY)

THURSDAYS at 11:00 am via Zoom

The Residency Training Committee and the Division of Infectious Diseases has previously agreed that a "usual" weekly round should include:

• A case from the UAH Adult ID service

• A case from the Pediatric ID service

• A case from the RAH Adult ID service

Approximately every 4-5 weeks will also have a time slot allotted for the Microbiology trainees to present a case (either in conjunction with UAH Adult ID or completely lab based). Thus, presentations should be up to 15-20 minutes long WITH discussion, i.e. a 10-15-minute case maximum. The coordinating SSR can introduce the planned agenda of each round to make sure that sufficient time is given, especially if there are more cases to present. Recognizing that appropriate cases from each group may not be possible every week, a divisional email will go out weekly. If one of the three core case-presenting groups are unable, they will email the coordinating SSR and anyone who has a case they would like to present is encouraged to email the SSR regarding the availability of their case.

PURPOSE

The purpose of these rounds is to provide an educational forum by presenting instructive cases of human microbial disease or, on occasion, cases which mimic human microbial disease followed by a discussion about the cases by the presenter and then by the audience.

AUDIENCE

The rounds are the prinicpal continuing professional education (CPE) activity of both the Adult and Pediatric Divisions of Infectious Diseases. The audience includes infectious disease clinicians (both adult and pediatric), medical and clinical microbiologists, public health practitioners and trainees (students, residents, and SSRs) in these disciplines. The rounds are open to all healthcare professionals. Pharmaceutical representatives are NOT permitted to attends, except by special invitiation. The principal site is the UAH, but the rounds are telecast to the other AHS sites.

FORMAT

The preferred format is multiple-case presentations. It is expected that at least one case will be presented each week from each of the UAH Adult service, the RAH Adult service, and the Pediatric ID service. The case presentations should be succinct with pertinent positive and negative features, but they are NOT intended to be exhaustive and should include a relevant, but not "complete", history and physical examination.

The standard format for all case presentations at ID rounds should include the following in a 10-minute (maximum) summary of the case:

• Do not use the patient's name or other information which could identify them

• Brief relevant history

• Physical exam at presentation if relevant

• Lab data at presentation if relevant

• Course in hospital, including lab results, complete microbiology results and imaging or other tests during the course in hospital

• If it involves an unusual organism or unusual diagnosis, notifying the relevant medical microbiologist staff or resident of the intended presentation at least the day before is encouraged. They can then offer current comments on microbiology results. The med micro resident or staff may also present some info on an unusual organism or test

• Succint presentations maintain the audience's attention and permit more cases to be presented. Cases may be presented by house staff or attending staff and may include both inpatients and outpatients

• When relevant, medical imaging, clinical photographs, gram stains, or tissue phhotomicrographs should be included. A "guess the pathogen" or "guess the diagnosis" format can be quite effective in selected cases

The presentation style should be determined in part by the presenter, since it is recognized that part of the educational value is derived from creating the presentation; however, students and rotating residents should be guided by SSRs and attending physicians regarding what is expected.

The rounds are coordinated by the UAH Adult service. The coordinator will be the SSR, when there is one on this service, and the attending physician when there is no SSR on service. The coordinator must ensure that the required AV equipment is present and should ensure that rounds begin on time and that appropriate time is allocated to each presenter and should terminate discussion when it ceases to be of educational value.

TYPES OF CASES

In general, common clinical conditions due to common pathogens should not be presented (e.g. methicillin-susceptible Staphylococcus aureus endocarditis of the native tricuspd valve in an injection drug user, pyelonephritis due to ampicillin-susceptible Escherichia coli). Cases should be presented because they are interesting, unusual, educational or part of an outbreak. 

Examples of appropriate cases include:

• Diseases that are relatively rare locally (e.g. tetenus, botulism, trichnosis)

• Diseases which are imported (e.g. babesiosis, endemic mycoses, many "tropical" infections other than uncomplicated malaris)

• Unusual complications of common infections (e.g. erythema multiforme with HSV infections, strokes with varicella, sterile inflammatory arthritis with invasive meningococcal disease)

• Unusual pathogens causing non-rare conditions (e.g. non-group A Streptococcus causing necrotizing fasciitis, anaerobes causing meningitis or endocarditis) - the "guess the pathogen" format works here

• Uncommon complications of antimicrobial therapy (e.g. agranulocytosis due to B-lactams, lactic acidosis from nucleoside analogs, SJS from sulfonamides)

• Diagnostic challenges with known diagnosis ("guess the diagnosis" format)

• Outbreaks, including pseudoinfection

• Infection control and/or occupational health issues may also be appropriate

On occasion, cases are presented in which the diagnosis or treatment is difficult and the opinion of other specialists is sought. Such cases are occasionally appropriate for these rounds but usually provide little educational value. These cases should only be presented when the patient has already had an extensive workup (these cases should not be "half-baked") and the presentation should be made by an attending ID specialist or ID SSR. In addition, a brief update should be presented at a subsequent round.

Infrequently, it is appropriate to present cases of nonmicrobial disease which mimic infections (e.g. relapsing polychondritis initially diagnosed and treated as recurrent cellulitis, Still's disease causing FUO, tumour fever, drug fever). In such cases, the discussion should focus on the mimicry and not a detailed review about the nonmicrobial disease.

DISCUSSION

The discussion section should be relevant to the case and usually takes 5-10 minutes. It should have some substance and relevance to ID practitioners and not be "pitched" at a basic level. In general, students and junior residents should not be expected to present a discussion section. The discussion should ideally be presented using presentation software with appropriate references cited. When appropriate, guests from other specialties may be invited to provide their expertise. Sometimes, no "formal" discussion needs to be presented, as audience participation is often the most valuable form of discussion.