The Art of the Medical Case Presentation in English

1. The Art of the Medical Case Presentation in English Peking Union Medical College May 18, 2010 dmd43@cornell.edu Dan Drzymalski (戴宇明) M.D. Candidate Harvard Medical School

2. Outline • How to prepare an effective presentation • Bad • Good • How to give an effective presentation • I will present • Audience will practice

3. Bad presentations • Problem: • NOT: lack presentation skills • ACTUALLY: lack of good preparation • Poorly prepared PPT • Poorly prepared presenter (“surprises” during presentation) • Reading PPT instead of presenting PPT

4. How to prepare a good presentation • Consider: • Audience • Purpose • Occasion (time limits, setting, circumstances) • Limit number of slides (1 slide / 2 minutes) • Limit words on the slides • Colors, fonts: • If you can’t see it, then don’t use it! • Practice, practice, practice!

5. BAD slide • The patient is a 78M non-smoker w/ h/o moderate COPD, last FEV1 of 1.41L (46.6% predicted) in May 2005, maintained on inhaled bronchodilators and steroids at home, no previous hospitalizations or intubations for COPD exacerbation, who presents with one month of worsening shortness of breath. At baseline, the patient can mildly exert himself throughout the morning and afternoon before needing to use his rescue inhalers, and has cough productive of whitish phlegm after each use of his inhaler. Over the past month, he has noted increasing need for rescue inhalers with only 3-4 hours of relief, inability to catch his breath at rest, and increased phlegm production. He otherwise denies orthopnea, PND, abdominal or pedal swelling, fever, chills, purulent sputum production, headache, pleuritic chest pain, hemoptysis, calf pain, asymmetric leg swelling, personal or family history of clots, recent travel or immobilization, palpitations, angina, diaphoresis, bloody stools, hematemesis, pale or yellow skin, history of panic attacks, anxiety, or psychiatric illness. Of note, the patient admits to decreased appetite and weight loss of 10-15lb over one month.

6. GOOD slide • 78M non-smoker • H/o moderate COPD • Last FEV1 of 1.41L (46.6% predicted), May 2005 • Worsening SOB x1 mo

7. How to give a good medical presentation (note acronyms)

9. CC Inappropriate • Content • Age, sex • Active ongoing medical problems (not full PMH) • Reason for presentation • Duration of symptoms

10. Practice CC • 42M, h/o DM (A1c=5.5) and  lipids, p/w intermittent CP x3 days • 59 y/o F, h/o CAD, HTN, MI 1 year ago (EF=50%), p/w CP x 1hr • 48M, h/o AS (valve area = 1.5 cm2), p/w 2 wks worsening DOE • 78M non-smoker w/ h/o moderate COPD, last FEV1 of 1.41L (46.6% predicted) in May 2005, p/w worsening SOB x1 mo • 46 y/o M, h/o HIV (C4=800, VL=18K), p/w SOB x 3d • 35F, h/o cholecystitis, s/p cholecystectomy 1 year ago, p/w abdominal pain x 1 day

11. HPI • Content • "Positive" signs/symptoms • Chronological • OPQRST • "Negative" signs/symptoms • Constitutional + relevant others • Prior episodes • Practice • 62M w/ CAD, DM, transfer from MGH w/ CP x3 wk • Pt was in his usual state of health until…(positive sx) • Otherwise, pt denies… (negative sx, essentially ROS) • Of note, pt has…

12. Cont hx • Relevant information • PMH • PSH • Meds • Allergies • SH (tobacco, etoh, drugs) • FH (i.e.: No FH of heart disease) • Example • His other problems include a 10 year h/o DM, without retinopathy, neuropathy or nephropathy. An A1c 6 months ago was 6.8. His current medications include NPH insulin, glyburide, aspirin, metoprolol, lisinopril, and simvastatin, and has no allergies. He does not smoke, drink, or use drugs, and no one in his family has DM

13. PE • Content • General description, VS • Abnormal findings • Only pertinent normal findings (i.e. in a CP pt., CVP = 5) • Note: • General: (1) Pt generally appears well… (2) Pt. clearly uncomfortable • VS: (1) VS are (say them)…; (2) Vital signs are stable • PE is significant for… (febrile, tachycardic, etc.) • Otherwise lungs, heart, and abdomen were unremarkable. • Don’t say “normal.”

14. Practice PE • Example 1 • Gen: elderly gentleman, no distress • VS: BP 150/90, HR 80, RR 18, T 98.4, O2sat 98% on 2L. • Resp: no crackles/wheezes • CV: RRR, no m/r/g • Abd: nt/nd, BS+ • Example 2: • Gen: lively young woman, NAD • VS: BP 120/80, HR 110, RR 18, T 101.4, O2sat 100% on RA • Resp: no crackles/wheezes • CV: RRR, no m/r/g • Abd: RLQ tenderness

15. Labs • Content • Presentation order: Chem7, CBC, coags, other chemistries, UA, cultures, etc. • Abnormal labs, (w/ previous value) • Only pertinent normal lab values (otherwise, WNL) • Example • On laboratory testing, his chem 7 is WNL except for Cr of 1.4 (his Cr 6 mo ago was 1.3). CBC was WNL. CPK and troponin at admission and 8 hours later are WNL. • Note: • Say “WNL,” not “normal” • Case specific (i.e. liver pt: emphasize LFTs)

16. Rads / Other tests • CXR • ECG • CT • MRI

17. Presenting a CXR • This is an AP and lateral chest x-ray of Mr. Jones taken today, in which the most significant finding is... • Otherwise, the soft tissues, vasculature, bones, etc. are normal.

18. Presenting a ECG • This is Mr. Smith’s ECG from today as compared to yesterday. He is in NSR at 80 bpm, with normal intervals, waveforms, etc., except for…

19. A/P • Example • In summary, this 75 y/o M with… whose presentation is most consistent with DISEASE X given the presence of…It is unlikely that he has DISEASE Y given the lack of… • Use medical vocabulary: leukocytosis, neutropenia

20. Summary of “Transition words” • CC: • Pt is a X y/o M/F w/ h/o Y who p/w… • HPI • Pt was in his usual state of health until… • Otherwise, pt denies… • Of note, pt has … • PE: • Pt is (general description). VS are... PE is significant for… Otherwise lungs, heart, and abdomen were unremarkable. • A/P: • In summary, this 75 y/o M with… whose presentation is most consistent with DISEASE X given the presence of…It is unlikely that he has DISEASE Y given the lack of…

21. Miscellaneous Tips • Posture, eye contact • Clear, energetic voice • Keep language precise • Stay organized

22. Two Key Points • Practice, practice, practice! • Do not read the presentation!

23. Distinguishing terms • Kidney vs Renal • Heart vs Cardiac • Liver vs Hepatic • Implies Anatomy vs Physiology • He has a kidney abnormality • He has a renal abnormality • Speaking with patients vs. medical professionals • Patients will NOT understand “renal”

24. REFERENCES • Steve McGee, M.D. Oral Case Presentation Guidelines. University of Washington. <http://depts.washington.edu/medclerk/student/presentation.html> • The Formal Patient Presentation. University of Medicine and Dentistry of New Jersey. <http://www.umdnj.edu/camlbweb/patient/presentation.html> • Jannette Collins, MD, MEd, FCCP. How to Give an Effective Presentation. University of Wisconsin Hospital and Clinics. <http://www.thoracicrad.org/assets/downloads/education/presentation.pdf>

25. Thank you!谢谢大家！