How to Present a Case in the Emergency Department

In Education & Quality Improvement, Infographics, Mentorship by Sophie RamsdenLeave a Comment

Presenting a case in the ED is important for a number of reasons. Not only does better communication result in better patient care, but it’s also a great learning opportunity and your chance as a clerk to impress your attending. Presenting a case well conveys your level of knowledge and understanding to an attending, which allows them to accurately assess and teach to your weaknesses. It also illustrates that you can create a complete diagnostic and management plan for a patient, while prioritizing dangerous diagnoses and critical next steps. Even if you know everything there is to know about abdominal pain and asked all of the right questions, if you can’t present a case thoroughly but concisely, your attending won’t be able to appreciate that. 

Whether you’re brand new to the ED or a well-oiled emergency medicine machine, check out our essential resources for key tips on presenting a case. If you’re interested in a deeper dive into case presentations and some of the evidence supporting different teaching styles, scroll a little further. 

To find the resources for this post, referrals from key experts were used, as well as a search on foamsearch.net. It’s also a great idea to use your preceptor as a resource! Ask them at the start of the shift if they have a preference for how you present a case. Being flexible in your presentation style will allow you to accommodate their preferences accordingly. 

Essential Resources

  1. Listen to ClerkCast Episode 1: a podcast for clerks, by clerks. In their first episode, they give a broad overview of life in the ED for clerks, which is especially useful when you are just starting out in the emergency department. They include tips for developing your differential diagnosis, assessing sick patients, and the RAPID mnemonic for discussing next steps with your preceptor. It also goes into a bit more depth (with good and bad examples) on presenting a case. As they explain in the podcast, structuring your HPI around pertinent positives and negatives for dangerous diagnoses will make it easier for your listener to rule in or rule out those diagnoses, as well as neatly convey to them that you’re thinking like an EM doc and prioritizing threats to life and limb. 
  1. Watch these videos on The 3-Minute Emergency Medicine Presentation (see Going Further for more details). The first video takes you through how to think like an EM doc in generating your differentials and approaching the patient history, and goes through some examples. The second video covers the 3 minute case presentation in detail with an example. They’ve also included an attachment with key red flags for common presentations, which might be a useful resource to have with you on shift!
  1. Save our 3 Minute EM Presentation Infographic as a handy on-shift reference:

Going Further

The 3-Minute Emergency Medicine Medical Student Presentation: A Variation on a Theme

This paper is the key resource for mastering case presentations. It goes over the differences between emergency medicine and other specialties, and how these differences impact the best way to present a case. If you’re looking to get straight into the meat of how to present a case, read the appendix or check out our handy infographic (above), which summarizes the key points. The paper itself is also useful to understand the rationale for the sections included or omitted from the presentation, as well as some common medical student pitfalls.​1​ 

A caveat: case presentations are inherently subjective, and the authors acknowledge that the best presenters are flexible to match the needs of their audience. There are a few areas that I think require extra flexibility. First, the Review of Systems mainly exists as a placeholder for any additional complaints unrelated to the chief complaint, so don’t feel the need to include it if there are none. Second, the authors omit the formal headings of Past Medical History, Social History, etc. This does not mean these are not important – it just means that pertinent details from those headings should be folded into your HPI. If you’re unable to integrate them into your HPI when you’re just starting out, it’s better to go through them systematically than to forget them entirely. 

Finally, as they discuss in the paper, your Summary Statement may be combined with your Impression. It’s good to start getting in the habit of committing to a provisional diagnosis and plan even as a medical student. As long as you’re keeping in mind the whole differential and the key rule-out conditions, most preceptors will appreciate you clearly stating your working diagnosis. If you’re feeling confident, it may even be appropriate to start the presentation with it. Here’s an example: “This is a 32 year old female with a likely peritonsillar abscess. She presented with a sore throat…”.

SNAPPS Framework

S – Summarize the history and physical

N – Narrow the differential to 2-3 possibilities

A – Analyze the differential – give evidence for or against each possibility based on your H&P

P – Probe the preceptor on any points of confusion or uncertainty in the workup

P – Plan the management

S – Select a topic for self-directed learning. 

This framework may also be useful for practicing emergency physicians looking for a way to give feedback and structure teaching. To see the SNAPPS framework demonstrated, check out these two videos:

Part 1: https://www.youtube.com/watch?v=rywuzkm8nmY

Part 2: https://www.youtube.com/watch?v=BPNOdPKUFDE

The original paper on the SNAPPS framework, which discusses its evidence and development, can be found here.​2​

As a contrast to SNAPPS, some practitioners in a teaching role may favour the One Minute Preceptor model, which is demonstrated here: https://www.youtube.com/watch?v=P0XgABFzcgE

If you’re interested in the evidence around different case presentation styles or teaching strategies, check out this paper. The bottom-line is the SNAPPS framework was preferred over the One Minute Preceptor model by the study participants in the learner role:

Present Your Plan RAPID-ly:

As you get more experienced your case presentations should incorporate your initial plan, in addition to simply presenting the cases. To scaffold this approach, Dr Rob Woods (USask RCPSC program director) did a project to define the components of a good initial management plan a few years ago. Read his staff review below find out how to best present your plans to your attendings too!

This post was edited by Megan Chu and Julia Heighton.

  1. 1.
    Davenport C, Honigman B, Druck J. The 3-Minute Emergency Medicine Medical Student Presentation: A Variation on a Theme. Academic Emergency Medicine. Published online July 2008:683-687. doi:10.1111/j.1553-2712.2008.00145.x
  2. 2.
    Wolpaw TM, Wolpaw DR, Papp KK. SNAPPS. Academic Medicine. Published online September 2003:893-898. doi:10.1097/00001888-200309000-00010

Reviewing with the Staff

The 3 minute clinical presentation is a great tool to start out with. It really organizes the patient information, gets you to commit to a differential diagnosis and justify why. It really brings your thought processes out, forcing you to use the skill of elaboration, which is a key skill in learning. Once this becomes quite familiar, you can start to take on more complex patients. The RAPID approach was developed to have an overall assessment and management plan for more complex ED patients. It serves as a checklist for ensuring key management issues are not missed.

Resuscitation
Analgesia & Assessment
Patient Needs
Interventions (Diagnostic & Therapeutic)
Disposition

The RAPID approach makes you consider time sensitive illness in every case. Chest pain (MI, Dissection, PE), unilateral symptoms (CVA), Fever (Severe Sepsis) and Hypotension/shock can all be identified with a scan of the vitals and the chief complaint. Analgesia before assessment but after Resuscitation ensures patients in severe pain don’t provide their family history and social history before you get them some intravenous analgesia (like in renal colic, severe abdominal pain or a deformed limb). Addressing patient needs before interventions ensures you have considered patient values in the diagnostic and treatment plan, and that you look after their basic needs of comfort/warmth/hunger/thirst and social supports. Emergency Physicians are primary experts in DISPOSITION. Can your patient go home or not? Finding this out early in the encounter really helps your efficiency and decision making when you present a patient to your attending.

Rob Woods
Rob is an emergency physician and STARS Transport Doc located in Saskatoon, Saskatchewan. He founded the Royal College emergency medicine residency program at the University of Saskatchewan (USask) and currently serves as Program Director. He has also recently founded the Clinician Educator Diploma AFC program at USask.
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Sophie Ramsden

Sophie Ramsden

Sophie Ramsden is an emergency medicine resident at McMaster University. Her academic interests include medical education, wilderness medicine, and critical care.
Sophie Ramsden

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