Often when medical students, residents or practicing physicians gather, they tell stories about patients. As a resident I remember another resident who would become almost apoplectic discussing a “great case”. (The use of the noun case rather than patient is a bit depersonalizing, but does represent standard usage amongst physicians.) Unfortunately, these “great cases” often described incurable conditions. At that time, I knew that these were not really great cases, but rather only interesting patients with bad disease.

As I have matured in my thinking, I have developed my own idiosyncracies and favorite phrases. One of my teams kept a record of Centor sayings! I use certain phrases and word recurrently: Stool is basic (explaining why diarrhea causes and acidosis); isosthenuria (amazingly enters the discussion in many morning reports); contrasting volume contraction with dehydration.

I have specific definitions now for great cases and interesting cases. For a patient to represent a great case, we (the physicians) must successfully detect an unusual diagnosis (or an ususual presentation of a common diagnosis) and making that diagnosis must lead to a treatment which resolves the problem An interesting case describes a patient with an usual presentation which stimulates us intellectually. However, when our intellectual stimulation does not result in being able to help the patient, the case is only interesting.

A couple of years ago I had a classic great case on my service. This 50 year old man present with low grade fever and fatigue. During his evaluation we did a bone marrow aspirate and to our surprise diagnosed 2 separate conditions – cryptococcal fungemia and hairy cell leukemia. 12 weeks of therapy cured his fungal infection, and then 6 days of chemotherapy cured the hairy cell leukemia (this is a very curable, rare cause of leukemia). This man fit the definition of a great case.

Recently I had a patient admitted with a Calcium level of 14.5 (normal is 8.5-10.5). He had a known squamous cell carcinoma. His hypercalcemia was intellectually stimulating. We discussed this issue on rounds for a long time. Unfortunately, hypercalcemia in a cancer patient usually portends death. He did die within a week (we did make certain that he received excellent palliation, and spent much time working with the family to prepare for his demise). This is not a great case, but rather an unfortunate, albeit interesting, complication of his cancer.

As an internist, I crave great cases. We do much “routine” work in medicine – another CHF exacerbation, another ulcer, another patient with pyelonephritis. Caring for our patients is generally satisfying and enjoyable. However, the adrenaline rush for the “great case” makes all our study and dedication even more worthwhile.

Related posts:

1. Great cases, interesting cases and sad cases
2. It should always be about the patient
3. More on great cases!
4. Perhaps my last post on “great cases”
5. Request for liver cases and electrolyte cases

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