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• Improved student patient presentation• Creates a student centered learning environment • SNAPPS helps students identify clinical uncertainties • Promotes the development of clinical re

ORAL CASE PRESENTATION:

THE SNAPPS METHOD

UNIT 6 – VOCABULARY & READING (2 hours)

ENGLISH IN MEDICINE 2 – GENERAL PRACTITIONER Y2

Editor: Nguyen Hoang Quynh Mai Email: nguyenhquynhmai@duytan.edu.vn

‘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

1 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 theteam in the morning, the H&P was performed by others

4/ Outpatient clinic presentations, covering several commonsituations

1 BRIEF OVERVIEW

Inpatient Bedside Teaching Rounds

1 BRIEF OVERVIEW

Outpatient Teaching Rounds

GOAL: to pass along the “right amount” of patient information to a specific audience in an efficient fashion

1 BRIEF OVERVIEW

• 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

THE CHALLENGES OF ORAL CASE PRESENTATION?

1 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

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

1 BRIEF OVERVIEW

Signpost method (good foundational approach):

https://www.youtube.com/watch?v=Mew2wzpuhTs

1 BRIEF OVERVIEW

One minute preceptor model (5-step approach):

https://www.youtube.com/watch?v=eRBdfXRj5N0

2 SNAPPS INTRODUCTION

SNAPPS introduction video

https://www.youtube.com/watch?v=cEZOjSyPhZ0

Watch the video twice & try to describe the SNAPPS method.

1/ What does it stand for?

2/ What does it mean by each step?

Summarize the case

Narrow the differential to 2-3 relevant possibilities

Analyze the differential by comparing and contrasting possibilities

Probe the preceptor: ask about uncertainties, difficulties, other

approaches

Plan for management

Select an issue for self-directed learning

A guide in patient presentation: S N A P

Help learners identify clinical uncertainties & learning need: P & S

Wolpaw, T.M., Wolpaw, D.R and Papp, K.K., 2003 SNAPPS: a learner-centered model for outpatient education Academic Medicine, 78(9), pp.893-898

• Improved student patient presentation

• Creates a student centered learning environment

• SNAPPS helps students identify clinical uncertainties

• Promotes the development of clinical reasoning

• Increases the number of differential diagnoses

WHY SNAPPS?

2 SNAPPS INTRODUCTION

3 SNAPPS MODEL EXAMPLE

VIDEO: https://www.youtube.com/watch?v=zWavIV7zPFY&t=119s

Case: a woman of childbearing potential age & she’s got lower rightquadrant (LRQ) pain

FOCUS ON HOW YOU SHOULD SAY

TO PRESENT THE CASE USING SNAPPS

What did you hear?

3 SNAPPS MODEL EXAMPLE

1/ -Summarize- Dr Smith, I’ve got this 29 year-old lady with rightlower quadrant pain of approximately a day’s duration I think it’spossible she might have appendicitis but I think we really have torule out an ectopic pregnancy

2/ -Narrow- Base upon her age, her symptoms, her physicalfindings I think that there are two main diagnoses that we got to

be worried about here: appendicitis and ectopic pregnancy

3 SNAPPS MODEL EXAMPLE

3/ -Analyze- So this all sort of started earlier today with a little bit ofright lower discomfort It grew during the day Interestingly shehasn’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 thingsaltogether kind of actually seem to argue a little bit againstappendicitis though appendicitis can present in slightly atypical ways.They don’t have to start with periumbilical pain and they don’talways have to be accompanied by anorexia but it does make methink that maybe is more likely to be an ectopic pregnancy [ ]

[ ] 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 anyspontaneous or therapeutic abortion and they’ve never hadany difficulties with fertility So given that they were trying toget pregnant, she doesn’t seem to have the absolutelyclassical presentation of appendicitis That’s really starting tomake me think that this could be ectopic pregnancy

3 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 do 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 [ ]

3 SNAPPS MODEL EXAMPLE

[ ] So actually while is waiting to see you, we did do a urinepregnancy test on her and in fact the betaHCG is positive So nowI’m thinking that in fact it’s almost definitely that this patient has

an ectopic pregnancy The clinical picture fits and she does have apositive 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’treally examine them, it’s kind of like you can’t check for a reboundtenderness Am I wrong there? Has that been your experience?

3 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 do 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 do have to start giving her lots of fluids, we’ve already got the IVs in place.

6/ -Selecting an

issue-Is 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?

4 PRACTICE SNAPPS

CASE 1 (1/2)

Cristina, 25-year-old woman, previously healthy

CC: abdominal pain day 3

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 6 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

4 PRACTICE SNAPPS

CASE 1 (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

4 PRACTICE SNAPPS

CASE 2 (1/2)

Martin, 13-year-old adolescent boy

CC: sore throat & fever day 2

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

4 PRACTICE SNAPPS

CASE 2 (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/ skills/oral-presentations-2/

https://clerkship.medicine.ufl.edu/portfolio/interpersonal-and-communicative-3/

https://osu-lp-preceptor.osu.edu/system/block_resource_items/resources/000/000/048/original/ Oral_Presentations_handout.pdf?1384793577

10 MCQS ON KAHOOT

QUESTIONS