SURVIVAL GUIDE TO THE HISTORY, EXAM, and ORAL PRESENTATION
Rob Naismith, M.D.
The Neurological History | The Neurological Exam | Write-Ups | Sample Write-Ups | Oral Presentations
Your job for a presentation is to clearly and concisely reconstruct the timeline from the beginning, giving details about their symptoms as you go along. There are 2 types of presentations. The first is the 5 minutes work-rounds variety, and the second is the 45 minutes teaching conference variety.
You should not read from your notes during the history. You could make a brief outline on a card with a list of the medicines with doses, the vitals, and the labs, but reading the history is directly from the H&P is bad. You need to be able to look people in the eye and grab their attention. Remember, everyone is going to be tired and thinking about the other 10 things they need to do at the moment. If you give a boring presentation, then no one will pay attention. I would always try to put the story in the proper context when relevant, even for the 5 minute presentation. For example, if someone went to the county fair and rode the roller coaster, and an hour later developed vertigo, slurred speech, and inability to walk, then this gives us the context in which a vertebral dissection might have occurred. It also makes the story unique and memorable. If someone developed a headache while having sex, then this might be relevant for subarachnoid hemorrhage. If someone was in church singing in the choir and they passed out, then this is relevant. If you were to just list the symptoms without the context, then it is more boring and the patients start to sound the same.
The 5-10 minute presentation will be what is used during Team Rounds. This is a bare-bones presentation, but it is very dense with relevant material. It is really the ‘tip of the iceberg’ in terms of what you know about the patient. You cannot tell us everything, so you have to decide on what you do tell us. It consists of a chief complaint and the history. You should state pertinent positives and negatives along the way depending upon the differential diagnosis. There is no review of systems in the 5 minute presentation. If the family history is not relevant, then don’t even bother to mention it. If the social history is relevant, then include it in the history. If a past medical problem is relevant, then include it in the identifying information For example, “This is a 67 y/o RH white man who presents with acute onset of slurred speech. His history is significant for atrial fibrillation, congestive heart failure, coronary artery disease, and a previous stroke in 2005 with residual mild left hemiparesis.” We do not care whether they had their gallbladder or tonsils out, or if they have seasonal allergies unless it is relevant. We do not care if they take Prilosec unless it is relevant. Bottom line is that the attending should have a very clear picture of what is going on with this person within a few moments. There are no guessing games or cards to be kept up ones sleeves. Just go ahead and say it like it is.
When presenting to the attending on rounds, put the chief complaint up front and in medical terms. Do not use the patient’s words unless they are particularly relevant or insightful. Consider the following example, “Mr. Jones is a 72 y/o RH black man with CAD, HTN, hypercholesterolemia, GERD, and arthritis who presents because his daughter insisted he come to the hospital.” You are now 15 seconds in the presentation and the attending has no clue. By giving the medical complaint up front, the attending can start to organize your presentation. Now consider the opening statement in the paragraph above. Right from the start, the attending knows the complaint (slurred speech), along with age and gender. Is it ALS? Is it a Bell’s palsy? Is it a stroke? These are going through the attending’s mind. Next s/he hears a list of cardiovascular risk factors, and immediately stroke goes to the top of all considerations. That is how the brief presentation should work. You should present the details, almost anticipating what needs to be heard at that given time.
The exam should be abbreviated to convey what is important. Also, remember to stay organized: 1) mental status, 2) language, 3) cranial nerves, 4) motor, 5) reflexes, 6) sensory, 7) coordination and gait. We are all going on the assumption that you did a complete general and neurological exam. It would be fine to list out the vitals and then say that the general medical exam is unremarkable if that is what you found. For a stroke, you might say mental status and language are intact. Cranial nerves are relevant for left lower facial droop and dysarthria, but no field cut. Motor is relevant for a left hemiparesis 3-4/5 in severity affecting the arm greater than the leg. Reflexes are brisk on the left with an upgoing toe. Coordination on the left was appropriate for that degree of weakness. He had diminished sensation on the left, but was able to reliably perceive touch. He had both visual and sensory neglect. He needed assistance to walk due to the hemiparesis. You generally don’t want to get bogged down in listing out all the cranial nerves, all the numbers for the muscle testing, and all the numbers for reflexes. You want to include pertinent negatives here based on your differential. This is how your attending will know you are smart. If bacterial endocarditis is on the differential, then you should specifically state in the general exam that there were no conjunctival or extremity lesions and no murmur.
Because the presentation is brief, you shouldn’t have to give a summary statement of what you just said. You should give a statement about the localization, and then the differential diagnosis. The differential should be ranked to include things that are common, things that are treatable, and things that are dangerous. Next you can state your plan for evaluating the differential and for helping the patient get better.
You will need to prepare for the 5 minute presentation. Don’t think you could do it otherwise. It takes practice to condense 1-2 hours of your work-up into 5 minutes. The attending realizes you spent a lot of time with your patient, but doesn’t want to hear every last detail. You will show the attending how smart you are by how well you are able to do this. Losing focus and going on a tangent with your presentation will not impress. Some of your grade will come from this interaction. Rehearse out loud in your call room, or find another student to help practice. Make an outline on a card. All these things will help keep you focused, because we all get nervous when speaking in front of a group.
Lastly, don’t forget that your attending will like to hear the neuro exam in order. This is
- Mental status,
- Cranial nerves,
- Coordination & gait.