One of the most helpful articles I’ve encountered on teaching oral clinical presentations in the ED is a paper from Academic EM in 2008.
When we talk to one another, or talk to consultants about cases it is crucial for us to be concise and include all salient points of the history and physical. Because what you say (or don't say) could compromise patient care, it is important to instruct the medical student how to do this. As the paper explains, students learn to perform oral clinical presentations in other services, which are quite different from presentations in the ED.
The article describes one acronym SNAPPS, developed for the outpatient setting:
- S: Brief summary of the patient’s history and physical
- N: Narrowing the differential to two or three etiologies
- A: Analyzing the information to determine the most likely cause of the chief complaint
- P: Probing the attending for knowledge by asking questions
- P: Planning the patient's management
- S: Selecting an issue related to the case for self-directed learning.
- Assume that every patient has a life or limb-threatening condition
- Juggle multiple patients simultaneously
- Prioritize patients according to level of concern
- Address patient loyalty, follow up issues, and consequences of incomplete medical records
Typically, novice students typically think to present the HPI of their case as below (in chronological order):
A better way to present should be in the order of importance (especially because the person listening likely will have waning attention span...):
After the chief complaint is stated, to save time the HPI should include all pertinent information from other sections of the history, which include PMHx, PSHx, SoHx, FmHx. These other sections are not mentioned again during the oral presentation. As students gain more knowledge, the review of systems gets smaller during the presentation. But there might be cases in which the symptoms of that section may be significant enough to be a second chief complaint as well. Medications and allergies should also be mentioned during the oral presentation.
The summary statement should contain two sentences.
- Chief complaint and the HPI
- Include important signs, symptoms, physical findings, and labs
The key principles in EM when getting a history is knowing the chief complaint, drawing a differential diagnosis BEFORE seeing the patient, acquiring pertinent data, analyzing it, narrowing the differential diagnosis, and presenting it in a succinct manner.
The article is worth a look and don't forget to look at the Supplement Material, where examples are given.
1. Teaching Residents from Other Services: EM-RAP Educators Edition
Rob Rogers (@EM_Educator) and Michelle Lin (@M_Lin)
2. Medical Student Presentation
Rob Rogers (@EM_Educator), George Willis, and Adam Friedlander
Steve Carroll (@embasic)