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Presenting a Clinical Vignette: Deciding What to Present

If you are scheduled to make a presentation of a clinical vignette, reading this article will improve your performance. We describe a set of practical, proven steps that will guide your preparation of the presentation. The process of putting together a stellar presentation takes time and effort, and we assume that you will be willing to put forth the effort to make your presentation successful. This and subsequent articles will focus on planning, preparation, creating visual aids (slides), and presentation skills. The intent of this series of articles is to help you make a favorable impression and reap the rewards, personal and professional, of a job well done.

The process begins with the creation of an outline of the topics that might be presented at the meeting. Your outline should follow the typical format and sequence for this type of communication: history, physical examination, investigations, patient course, and discussion. This format is chosen because your audience understands it and uses it every day. If you have already prepared a paper for publication, it can be a rich source of content for the topic outline.

To get you started, we have prepared a generic outline to serve as an example. Look over the generic outline to get a sense of what might be addressed in your presentation. We realize that the generic outline will not precisely fit all of the types of cases; nevertheless, think about the larger principle and ask yourself, "How can I adapt this to my situation?" In order to help you visualize the type of content you might include in the outline, an example of a topic outline for a clinical vignette is presented.

Introduction

The main purpose of the introduction is to place the case in a clinical context and explain the importance or relevance of the case. Some case reports begin immediately with the description of the case, and this is perfectly acceptable.

1. Describing the clinical context and relevance

i. Ergotism is characterized by intense, generalized vasoconstriction of small and large blood vessels.
ii. Ergotism is rare and therefore difficult to diagnose.
iii. Failure to diagnose can lead to significant morbidity.

Case Presentation

The case report should be chronological and detail the history, physical findings, and investigations followed by the patient's course. At this point, you may wish to include more details than you might have time to present, prioritizing the content later.

1. History

i. A 34-year-old female smoker has chronic headaches, dyspnea, and burning leg pain.
ii. Clinical diagnosis of mitral valve stenosis is made.
iii. She returns in one week because of burning pain in the legs.
iv. One month after presentation, cardiac catheterization demonstrates severe mitral valve stenosis.
v. Elective mitral valve commisurotomy is scheduled, but the patient is admitted to hospital early because of increased burning pain in her feet and a painful right leg.

2. Physical Examination

i. Normal vital signs.
ii. No skin findings.
iii. Typical findings of mitral stenosis, no evidence of heart failure.
iv. Cool, pulseless right leg.
v. Normal neurological examination.

3. Investigations

i. Normal laboratory studies.
ii. ECG shows left atrial enlargement.
iii. Arteriogram of right femoral artery shows subtotal stenosis, collateral filling of the popliteal artery, and pseudoaneurysm formation.

4. Hospital Course

i. Mitral valve commisurotomy is performed, as well as femoral artery thombectomy, balloon dilation, and a patch graft repair.
ii. On the fifth postoperative day, the patient experienced a return of burning pain in the right leg. The leg was pale, cool, mottled, and pulseless.
iii. The arteriogram of femoral arteries showed smooth segmental narrowing and bilateral vasospasm suggesting large-vessel arteritis complicated by thrombosis.
iv. Treatment was initiated with corticosteroids, anticoagulants, antiplatelet drugs, and oral vasodilators.
v. The patient continued to deteriorate with both legs becoming cool and pulseless.
vi. Additional history revealed that the patient abused ergotamine preparations for years (headaches). She used 12 tables daily for the past year and continued to receive ergotamine in hospital on days 2, 6, and 7.
vii. Ergotamine preparations were stopped, intravenous nitroprusside was begun, and she showed clinical improvement within 2 hours. Nitroprusside was stopped after 24 hours, and the symptoms did not return.
viii. The remainder of hospitalization was uneventful.

Discussion

The main purpose of the discussion section is to articulate the lessons learned from the case. It should describe how a similar case should be approached in the future. It is sometimes appropriate to provide background information to understand the pathophysiological mechanisms associated with the patient's presentation, findings, investigations, course, or therapy.

1. Discussion

i. The most common cause of ergotism is chronic poisoning found in young females with chronic headaches.
ii. Manifestations can include neurological, gastrointestinal, and vascular (list each in a table).
iii. Ergotamine poisoning induces intense vasospasm, and venous thrombosis may occur from direct damage to the endothelium.
iv. Vasospasm is due primarily to the direct vasoconstrictor effects on the vascular smooth muscle.
v. Habitual use of ergotamine can lead to withdrawal headaches leading to a cycle of greater levels of ingestion.
vi. In addition to stopping ergotamine, a direct vasodilator is usually prescribed.
vii. Lesson 1: Physicians should be alert to the potential of ergotamine toxicity in young women with chronic headaches that present with neurological, gastrointestinal, or ischemic symptoms.
viii. Lesson 2: The value of a complete history and checking the medication list.

Creating a topic outline will provide a list of all the topics you might possibly present at the meeting. Since you will have only ten minutes, you will prioritize the topics to determine what to keep and what to cut.

How do you decide what to cut? First, identify the basic information in the three major categories that you simply must present. This represents the "must-say" category. If you have done your job well, the content you have retained will answer the following questions:

What happened to the patient?
What was the time course of these events?
Why did management follow the lines that it did?
What was learned?

After you have identified the "must-say" content, identify information that will help the audience better understand the case. Call this the "elaboration" category. Finally, identify the content that you think the audience would like to know, provided there is enough time, and identify this as the "nice-to-know" category.

Preparing a presentation is an iterative process. As you begin to "fit" your talk into the allotted time, certain content you originally thought of as "elaboration" may be dropped to the "nice-to-know" category due to time constraints. Use the following organizational scheme to efficiently prioritize your outline.

Prioritizing Topics in the Topic Outline

1. Use your completed topic outline.

2. Next to each entry in your outline, prioritize the importance of content.

3. Use the following code system to track your prioritization decisions:

A = Must-Say
B = Elaboration
C = Nice-to-Know

4. Remember, this is an iterative process; your decisions are not final.

5. Review the outline with your mentor or interested colleagues, and listen to their decisions.

Use the Preparing the Clinical Vignette Presentation Checklist to assist you in preparing the topic outline.

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