236 2021 u6 present a case SNAPPS VOC

UNIT – VOCABULARY & READING (2 hours) ENGLISH IN MEDICINE – GENERAL PRACTITIONER Y2 ORAL CASE PRESENTATION: THE SNAPPS METHOD Editor: Nguyen Hoang Quynh Mai Email: nguyenhquynhmai@duytan.edu.vn BRIEF OVERVIEW ‘He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all’ William Osler - the Father of Modern Medicine BRIEF OVERVIEW WHEN DO WE NEED TO PRESENT A CASE? Specific types of presentations: 1/ Daily presentations during ward rounds for patients known to a service 2/ Newly admitted patients, admitted by you 3/ Newly admitted patients that were “handed off” to the team in the morning, the H&P was performed by others 4/ Outpatient clinic presentations, covering several common situations BRIEF OVERVIEW Inpatient Bedside Teaching Rounds BRIEF OVERVIEW Outpatient Teaching Rounds BRIEF OVERVIEW GOAL: to pass along the “right amount” of patient information to a specific audience in an efficient fashion THE CHALLENGES OF ORAL CASE PRESENTATION? • Various structures: service to service, amongst subspecialties & btw environments • Time available is short  more stressful • Individual supervisors (residents, faculty) have different styles • A way to evaluate med student’s clinical knowledge & reasoning • Decide the quality of patient care BRIEF OVERVIEW BASIC STRUCTURE 1/ Identify information / chief complaint (ID/CC) 2/ History of present illness (HPI) / relevant review of systems (ROS) 3/ Other past medical & surgical history (PMH/PSH) 4/ Medications (Meds) / allergies / substance use 5/ Brief family & social history (FH/SH) 6/ Physical exam (PE) 7/ Key labs & imaging 8/ Brief summary 9/ Assessment and treatment plan BRIEF OVERVIEW COMMON MISTAKES - Slow rhythm - Too brief HPI - Failure to use parallel reference points (date & time) - Editorializing in the middle - Use of negative statements - Repetition - Disorganization - Physical findings presented without proper terminology - Diagnoses used in the PE Trigger video: https://www.youtube.com/watch?v=nOewqkejNXc BRIEF OVERVIEW Signpost method (good foundational approach): https://www.youtube.com/watch?v=Mew2wzpuhTs SNAPPS MODEL EXAMPLE VIDEO: https://www.youtube.com/watch?v=zWavIV7zPFY&t=119s Case: a woman of childbearing potential age & she’s got lower right quadrant (LRQ) pain FOCUS ON HOW YOU SHOULD SAY TO PRESENT THE CASE USING SNAPPS What did you hear? SNAPPS MODEL EXAMPLE 1/ -Summarize- Dr Smith, I’ve got this 29 year-old lady with right lower quadrant pain of approximately a day’s duration I think it’s possible she might have appendicitis but I think we really have to rule out an ectopic pregnancy 2/ -Narrow- Base upon her age, her symptoms, her physical findings I think that there are two main diagnoses that we got to be worried about here: appendicitis and ectopic pregnancy SNAPPS MODEL EXAMPLE 3/ -Analyze- So this all sort of started earlier today with a little bit of right lower discomfort It grew during the day Interestingly she hasn’t had any anorexia so she still actually got a bit of an appetite She’s had no vomiting, she’s had no fevers and chills Those things altogether kind of actually seem to argue a little bit against appendicitis though appendicitis can present in slightly atypical ways They don’t have to start with periumbilical pain and they don’t always have to be accompanied by anorexia but it does make me think that maybe is more likely to be an ectopic pregnancy [ ] SNAPPS MODEL EXAMPLE [ ] Now on that score, she and her partner had been trying to get pregnant again They actually had three other children She’s been pregnant three previous times, never had any spontaneous or therapeutic abortion and they’ve never had any difficulties with fertility So given that they were trying to get pregnant, she doesn’t seem to have the absolutely classical presentation of appendicitis That’s really starting to make me think that this could be ectopic pregnancy SNAPPS MODEL EXAMPLE [ ] On physical exam, she doesn’t have any upper abdominal tenderness but certainly at a right lower quadrant she does have tenderness, she’s guarding, she’s quite uncomfortable I’m not really the best at being able to say for sure if there’s rebound tenderness or not because she was in so much pain, I couldn’t really palpate deeply at all I did a chaperoned by manual exam and as I mentioned earlier, yes, she does have some right and axial tenderness, but no cervical motion tenderness So with all that together I think both are still possible but I’m actually thinking it’s most likely ectopic [ ] SNAPPS MODEL EXAMPLE [ ] So actually while is waiting to see you, we did a urine pregnancy test on her and in fact the betaHCG is positive So now I’m thinking that in fact it’s almost definitely that this patient has an ectopic pregnancy The clinical picture fits and she does have a positive beta HCG 4/ -Probe- So I was wondering it’s like rebound tenderness If somebody’s in a lot of pain I was like preventing you and you can’t really examine them, it’s kind of like you can’t check for a rebound tenderness Am I wrong there? Has that been your experience? SNAPPS MODEL EXAMPLE 5/ -Plan- I was thinking in this scenario, we should consult gynecology immediately In the meantime let’s get start ultrasound, bedside ultrasound here or bring her over to the ultra unit urgently so that we can confirm if there is acutally an ectopic pregnancy on her right side But before we that, I want to start some large bore Ivs, her blood pressure has been stable but she might suddenly start bleeding so I want to get the Ivs ready to go so if we have to start giving her lots of fluids, we’ve already got the IVs in place 6/ -Selecting an issueIs there an area that you think I should read up more? What are some of the management options if people can’t come and operate on this lady right away? PRACTICE SNAPPS CASE (1/2) Cristina, 25-year-old woman, previously healthy CC: abdominal pain day HPI: the pain is constant, exacerbated by movements, associated with subjective fevers and chills ROS: no recent changes in bowel habits, urinary symptoms, or menses; last menstrual period was weeks ago PE: T 38.4°C, HR 110, BP 112/70, RR 18; non-icteric skin; unremarkable cardiopulmonary exam; mildly distended & tender abd in LLQ & RLQ; involuntary guarding & localized rebound tenderness in RLQ PRACTICE SNAPPS CASE (2/2) Labs: WBC 14,000 cells/mm3 (high), normal Hb & Hct Most likely diagnoses: complicated acute appendicitis, pelvic inflammatory disease (PID) Considerations: healthy young woman, acute pain in lower abdomen, location of pain > acute appendicitis & gynecological pathology are most likely Another possibility: ectopic pregnancy base on her age Management plan: confirmatory studies with pregnancy test and pelvic ultrasound (the initial study to identify or rule out in this case) Select an issue: ectopic pregnancy PRACTICE SNAPPS CASE (1/2) Martin, 13-year-old adolescent boy CC: sore throat & fever day FH: younger sister was ill last week with “the same thing” HPI: pain with swallowing, no change in voice, drooling, or neck stiffness; no recent history of cough, rash, nausea, vomiting, or diarrhea; no other medical problems, takes no medications, no allergies PE: T 38.5°C, HR 104, BP 118/64, RR 18, SpO2 99% on room air; posterior oropharynx reveals erythema with tonsillar exudates without significant tonsillar swelling; neck is supple without tenderness of anterior lymph nodes; unremarkable chest & cardiovascular exam; abdomen is soft and non-tender, normal bowel sounds, no hepatosplenomegaly; no skin rash PRACTICE SNAPPS CASE (2/2) Most likely diagnoses: streptococcal pharyngitis, viral pharyngitis Considerations: 13-year-old patient with sore throat & fever > pharyngitis; most common cause is viruses; age less than 15 years, fever, absence of cough, and the presence of tonsillar exudate > streptococcus is more likely Probe: how to approach the patient? (look for more severe signs & symptoms; ABC assessment Plan: rapid antigen testing, bacterial culture > confirm diagnosis; antibiotics & supportive care Select an issue: approach to sore throat SOURCES 1/ https://meded.ucsd.edu/clinicalmed/oral.htm?fbclid=IwAR0O1PhaGxkhsLsXrIDiKzyP ujFk4KfPS3C3vFQfF2f8XL1dL6ISsitFGl0 2/ https://clerkship.medicine.ufl.edu/portfolio/interpersonal-and-communicativeskills/oral-presentations-2/ 3/ https://osu-lppreceptor.osu.edu/system/block_resource_items/resources/000/000/048/original/ Oral_Presentations_handout.pdf?1384793577 WRITING PRACTICE When the doctors need to present a case? (3-5 sentences) What are some challenges of oral case presentation? (3-5 sentences) REVIEW 10 MCQS ON KAHOOT QUESTIONS & ANSWERS ... https://www.youtube.com/watch?v=zWavIV7zPFY&t=119s Case: a woman of childbearing potential age & she’s got lower right quadrant (LRQ) pain FOCUS ON HOW YOU SHOULD SAY TO PRESENT THE CASE USING SNAPPS What did you hear? SNAPPS. .. this lady right away? PRACTICE SNAPPS CASE (1/2) Cristina, 25-year-old woman, previously healthy CC: abdominal pain day HPI: the pain is constant, exacerbated by movements, associated with subjective... tenderness or not because she was in so much pain, I couldn’t really palpate deeply at all I did a chaperoned by manual exam and as I mentioned earlier, yes, she does have some right and axial tenderness,