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pre·sen·ta·tion

• breech presentation
• brow presentation

cephalic presentation

Compound presentation, face presentation, footling presentation, funic presentation, longitudinal presentation, oblique presentation, pelvic presentation, placental presentation, shoulder presentation, transverse presentation, vertex presentation, patient discussion about presentation.

Q. What are the presenting signs of ALS? Are the upper or lower extremeties affected initialilly? A. The most common presenting sign of ALS is asymmetric limb weakness, usually starting with the hands (problems with pinching, writing, holding things etc.) shoulders (lifting arms above head etc.) or legs (problems walking). Other presenting signs may be problems with speaking or swallowing, although these are less common. You may read more here: www.nlm.nih.gov/medlineplus/amyotrophiclateralsclerosis.html

Q. Iam a bipolar and presently on tegretol medication.I found this to be the best way to get my doubt clarified. I am a bipolar and presently on tegretol medication. My doctor frequently changes the meds and he has tried variety of medicines before prescribing tegretol. He changes the meds every time when I visit him for routine check-up. I am bit confused and obviously cannot question my doctor as I repose faith and confidence in him. I found this to be the best way to get my doubt clarified. A. Are you being treated by your GP? I would suggest if you are having trouble finding the right combinations it might be a good time to ask to be referred to a Psychaitrist. GP's will do their best but like anything specialized they only have a certain amount of knowledge and a specialist in the field could be more help. I also think that other treatments along with The medications like theropy and group theropy, excercise, good diet, plenty of sleep etc helps a lot too... Try to be patient it is a process to get everything in place that will work the best for you... everyone is different and the .mmedications and treatments that work for one may not work for another...

• 21-hydroxylase deficiency
• abnormal presentation
• anterior presentation
• antigen presentation
• asynclitism
• atypical GERD
• bacterial meningitis
• Baudelocque method
• Baudelocque, Jean-Louis
• bimanual version
• bipolar version
• cardinal points
• case report
• prescribing
• prescribing cascade
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• prescription exemption certificate
• Prescription Medicines Code of Practice Authority
• prescription monitoring program
• prescription only medicine
• Prescription Pre-payment Certificate
• Prescription Pricing Authority
• Prescription Pricing Division
• prescriptive authority
• presence of mind
• presenile dementia
• presenile spontaneous gangrene
• presenilin gene
• presenility
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• presenting symptom
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• pressed juice
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• Present Worth
• Present Worth of Capital Expenditures
• present you as
• present you with
• present yourself
• Present, The
• present-day
• Present-Day English
• Present-Minded Individualism
• present-worth factor
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• Presentance Report
• Presentaneous
• Presentasi Pemikiran Kritis Mahasiswa
• Presentation Accept
• Presentation and Personalization Management
• Presentation Brothers College, Cork
• Presentation client
• Presentation Connect
• Presentation Connection Endpoint
• Presentation Connection Endpoint Identifier
• Presentation Context Definition List
• Presentation Context Identifier
• Presentation Controller Mediator Entity Foundation
• Presentation Convent Kodaikanal
• Presentation copy
• Presentation Data Value
• Presentation Department
• Presentation Departments
• Présentation des Normes Européennes
• presentation drawing
• Presentation du Systeme de Planification et de Gestion de Frequence
• Presentation Element Parser, YACC
• Presentation Environment for Multimedia Objects
• Presentation File
• Presentation Function
• Présentation Générale Lex Persona
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Overview and General Information about Oral Presentation

• Daily Presentations During Work Rounds
• The New Patient Presentation
• The Holdover Admission Presentation
• Outpatient Clinic Presentations
• The structure of presentations varies from service to service (e.g. medicine vs. surgery), amongst subspecialties, and between environments (inpatient vs. outpatient). Applying the correct style to the right setting requires that the presenter seek guidance from the listeners at the outset.
• Time available for presenting is rather short, which makes the experience more stressful.
• Individual supervisors (residents, faculty) often have their own (sometimes quirky) preferences regarding presentation styles, adding another layer of variability that the presenter has to manage.
• Students are evaluated/judged on the way in which they present, with faculty using this as one way of gauging a student’s clinical knowledge.
• Done well, presentations promote efficient, excellent care. Done poorly, they promote tedium, low morale, and inefficiency.

General Tips:

• Practice, Practice, Practice! Do this on your own, with colleagues, and/or with anyone who will listen (and offer helpful commentary) before you actually present in front of other clinicians. Speaking "on-the-fly" is difficult, as rapidly organizing and delivering information in a clear and concise fashion is not a naturally occurring skill.
• Immediately following your presentations, seek feedback from your listeners. Ask for specifics about what was done well and what could have been done better – always with an eye towards gaining information that you can apply to improve your performance the next time.
• Listen to presentations that are done well – ask yourself, “Why was it good?” Then try to incorporate those elements into your own presentations.
• Listen to presentations that go poorly – identify the specific things that made it ineffective and avoid those pitfalls when you present.
• Effective presentations require that you have thought through the case beforehand and understand the rationale for your conclusions and plan. This, in turn, requires that you have a good grasp of physiology, pathology, clinical reasoning and decision-making - pushing you to read, pay attention, and in general acquire more knowledge.
• Think about the clinical situation in which you are presenting so that you can provide a summary that is consistent with the expectations of your audience. Work rounds, for example, are clearly different from conferences and therefore mandate a different style of presentation.
• Presentations are the way in which we tell medical stories to one another. When you present, ask yourself if you’ve described the story in an accurate way. Will the listener be able to “see” the patient the same way that you do? Can they come to the correct conclusions? If not, re-calibrate.
• It's O.K. to use notes, though the oral presentation should not simply be reduced to reading the admission note – rather, it requires appropriate editing/shortening.
• In general, try to give your presentations on a particular service using the same order and style for each patient, every day. Following a specific format makes it easier for the listener to follow, as they know what’s coming and when they can expect to hear particular information. Additionally, following a standardized approach makes it easier for you to stay organized, develop a rhythm, and lessens the chance that you’ll omit elements.

Specific types of presentations

There are a number of common presentation-types, each with its own goals and formats. These include:

• Daily presentations during work rounds for patients known to a service.
• Newly admitted patients, where you were the clinician that performed the H&P.
• Newly admitted patients that were “handed off” to the team in the morning, such that the H&P was performed by others.
• Outpatient clinic presentations, covering several common situations.

Key elements of each presentation type are described below. Examples of how these would be applied to most situations are provided in italics. The formats are typical of presentations done for internal medicine services and clinics.

Note that there is an acceptable range of how oral presentations can be delivered. Ultimately, your goal is to tell the correct story, in a reasonable amount of time, so that the right care can be delivered. Nuances in the order of presentation, what to include, what to omit, etc. are relatively small points. Don’t let the pursuit of these elements distract you or create undue anxiety.

Daily presentations during work rounds of patients that you’re following:

• Organize the presenter (forces you to think things through)
• Inform the listener(s) of 24 hour events and plan moving forward
• Promote focused discussion amongst your listeners and supervisors
• Opportunity to reassess plan, adjust as indicated
• Demonstrate your knowledge and engagement in the care of the patient
• Rapid (5 min) presentation of the key facts

Key features of presentation:

• Opening one liner: Describe who the patient is, number of days in hospital, and their main clinical issue(s).
• 24-hour events: Highlighting changes in clinical status, procedures, consults, etc.
• Subjective sense from the patient about how they’re feeling, vital signs (ranges), and key physical exam findings (highlighting changes)
• Relevant labs (highlighting changes) and imaging
• Assessment and Plan : Presented by problem or organ systems(s), using as many or few as are relevant. Early on, it’s helpful to go through the main categories in your head as a way of making sure that you’re not missing any relevant areas. The broad organ system categories include (presented here head-to-toe): Neurological; Psychiatric; Cardiovascular; Pulmonary; Gastrointestinal; Renal/Genitourinary; Hematologic/Oncologic; Endocrine/Metabolic; Infectious; Tubes/lines/drains; Disposition.

Example of a daily presentation for a patient known to a team:

• Opening one liner: This is Mr. Smith, a 65 year old man, Hospital Day #3, being treated for right leg cellulitis
• MRI of the leg, negative for osteomyelitis
• Evaluation by Orthopedics, who I&D’d a superficial abscess in the calf, draining a moderate amount of pus
• Patient appears well, states leg is feeling better, less painful
• T Max 101 yesterday, T Current 98; Pulse range 60-80; BP 140s-160s/70-80s; O2 sat 98% Room Air
• Ins/Outs: 3L in (2 L NS, 1 L po)/Out 4L urine
• Right lower extremity redness now limited to calf, well within inked lines – improved compared with yesterday; bandage removed from the I&D site, and base had small amount of purulence; No evidence of fluctuance or undrained infection.
• Creatinine .8, down from 1.5 yesterday
• WBC 8.7, down from 14
• Blood cultures from admission still negative
• Gram stain of pus from yesterday’s I&D: + PMNS and GPCs; Culture pending
• MRI lower extremity as noted above – negative for osteomyelitis
• Continue Vancomycin for today
• Ortho to reassess I&D site, though looks good
• Follow-up on cultures: if MRSA, will transition to PO Doxycycline; if MSSA, will use PO Dicloxacillin
• Given AKI, will continue to hold ace-inhibitor; will likely wait until outpatient follow-up to restart
• Add back amlodipine 5mg/d today
• Hep lock IV as no need for more IVF
• Continue to hold ace-I as above
• Wound care teaching with RNs today – wife capable and willing to assist. She’ll be in this afternoon.
• Set up follow-up with PMD to reassess wound and cellulitis within 1 week

The Brand New Patient (admitted by you)

• Provide enough information so that the listeners can understand the presentation and generate an appropriate differential diagnosis.
• Present a thoughtful assessment
• Present diagnostic and therapeutic plans
• Provide opportunities for senior listeners to intervene and offer input
• Chief concern: Reason why patient presented to hospital (symptom/event and key past history in one sentence). It often includes a limited listing of their other medical conditions (e.g. diabetes, hypertension, etc.) if these elements might contribute to the reason for admission.
• The history is presented highlighting the relevant events in chronological order.
• 7 days ago, the patient began to notice vague shortness of breath.
• 5 days ago, the breathlessness worsened and they developed a cough productive of green sputum.
• 3 days ago his short of breath worsened to the point where he was winded after walking up a flight of stairs, accompanied by a vague right sided chest pain that was more pronounced with inspiration.
• Enough historical information has to be provided so that the listener can understand the reasons that lead to admission and be able to draw appropriate clinical conclusions.
• Past history that helps to shed light on the current presentation are included towards the end of the HPI and not presented later as “PMH.” This is because knowing this “past” history is actually critical to understanding the current complaint. For example, past cardiac catheterization findings and/or interventions should be presented during the HPI for a patient presenting with chest pain.
• Where relevant, the patient's baseline functional status is described, allowing the listener to understand the degree of impairment caused by the acute medical problem(s).
• It should be explicitly stated if a patient is a poor historian, confused or simply unaware of all the details related to their illness. Historical information obtained from family, friends, etc. should be described as such.
• Review of Systems (ROS): Pertinent positive and negative findings discovered during a review of systems are generally incorporated at the end of the HPI. The listener needs this information to help them put the story in appropriate perspective. Any positive responses to a more inclusive ROS that covers all of the other various organ systems are then noted. If the ROS is completely negative, it is generally acceptable to simply state, "ROS negative.”
• Other Past Medical and Surgical History (PMH/PSH): Past history that relates to the issues that lead to admission are typically mentioned in the HPI and do not have to be repeated here. That said, selective redundancy (i.e. if it’s really important) is OK. Other PMH/PSH are presented here if relevant to the current issues and/or likely to affect the patient’s hospitalization in some way. Unrelated PMH and PSH can be omitted (e.g. if the patient had their gall bladder removed 10y ago and this has no bearing on the admission, then it would be appropriate to leave it out). If the listener really wants to know peripheral details, they can read the admission note, ask the patient themselves, or inquire at the end of the presentation.
• Medications and Allergies: Typically all meds are described, as there’s high potential for adverse reactions or drug-drug interactions.
• Family History: Emphasis is placed on the identification of illnesses within the family (particularly among first degree relatives) that are known to be genetically based and therefore potentially heritable by the patient. This would include: coronary artery disease, diabetes, certain cancers and autoimmune disorders, etc. If the family history is non-contributory, it’s fine to say so.
• Social History, Habits, other → as relates to/informs the presentation or hospitalization. Includes education, work, exposures, hobbies, smoking, alcohol or other substance use/abuse.
• Sexual history if it relates to the active problems.
• Vital signs and relevant findings (or their absence) are provided. As your team develops trust in your ability to identify and report on key problems, it may become acceptable to say “Vital signs stable.”
• Note: Some listeners expect students (and other junior clinicians) to describe what they find in every organ system and will not allow the presenter to say “normal.” The only way to know what to include or omit is to ask beforehand.
• Key labs and imaging: Abnormal findings are highlighted as well as changes from baseline.
• Summary, assessment & plan(s) Presented by problem or organ systems(s), using as many or few as are relevant. Early on, it’s helpful to go through the main categories in your head as a way of making sure that you’re not missing any relevant areas. The broad organ system categories include (presented here head-to-toe): Neurological; Psychiatric; Cardiovascular; Pulmonary; Gastrointestinal; Renal/Genitourinary; Hematologic/Oncologic; Endocrine/Metabolic; Infectious; Tubes/lines/drains; Disposition.
• The assessment and plan typically concludes by mentioning appropriate prophylactic considerations (e.g. DVT prevention), code status and disposition.
• Chief Concern: Mr. H is a 50 year old male with AIDS, on HAART, with preserved CD4 count and undetectable viral load, who presents for the evaluation of fever, chills and a cough over the past 7 days.
• Until 1 week ago, he had been quite active, walking up to 2 miles a day without feeling short of breath.
• Approximately 1 week ago, he began to feel dyspneic with moderate activity.
• 3 days ago, he began to develop subjective fevers and chills along with a cough productive of red-green sputum.
• 1 day ago, he was breathless after walking up a single flight of stairs and spent most of the last 24 hours in bed.
• Diagnosed with HIV in 2000, done as a screening test when found to have gonococcal urethritis
• Was not treated with HAART at that time due to concomitant alcohol abuse and non-adherence.
• Diagnosed and treated for PJP pneumonia 2006
• Diagnosed and treated for CMV retinitis 2007
• Became sober in 2008, at which time interested in HAART. Started on Atripla, a combination pill containing: Efavirenz, Tonofovir, and Emtricitabine. He’s taken it ever since, with no adverse effects or issues with adherence. Receives care thru Dr. Smiley at the University HIV clinic.
• CD4 count 3 months ago was 400 and viral load was undetectable.
• He is homosexual though he is currently not sexually active. He has never used intravenous drugs.
• He has no history of asthma, COPD or chronic cardiac or pulmonary condition. No known liver disease. Hepatitis B and C negative. His current problem seems different to him then his past episode of PJP.
• Review of systems: negative for headache, photophobia, stiff neck, focal weakness, chest pain, abdominal pain, diarrhea, nausea, vomiting, urinary symptoms, leg swelling, or other complaints.
• Hypertension x 5 years, no other known vascular disease
• Gonorrhea as above
• Alcohol abuse above and now sober – no known liver disease
• No relevant surgeries
• Atripla, 1 po qd
• Omeprazole 20 mg, 1 PO, qd
• Lisinopril 20mg, qd
• Naprosyn 250 mg, 1-2, PO, BID PRN
• No allergies
• Both of the patient's parents are alive and well (his mother is 78 and father 80). He has 2 brothers, one 45 and the other 55, who are also healthy. There is no family history of heart disease or cancer.
• Patient works as an accountant for a large firm in San Diego. He lives alone in an apartment in the city.
• Smokes 1 pack of cigarettes per day and has done so for 20 years.
• No current alcohol use. Denies any drug use.
• Sexual History as noted above; has sex exclusively with men, last partner 6 months ago.
• Seated on a gurney in the ER, breathing through a face-mask oxygen delivery system. Breathing was labored and accessory muscles were in use. Able to speak in brief sentences, limited by shortness of breath
• Vital signs: Temp 102 F, Pulse 90, BP 150/90, Respiratory Rate 26, O2 Sat (on 40% Face Mask) 95%
• HEENT: No thrush, No adenopathy
• Lungs: Crackles and Bronchial breath sounds noted at right base. E to A changes present. No wheezing or other abnormal sounds noted over any other area of the lung. Dullness to percussion was also appreciated at the right base.
• Cardiac: JVP less than 5 cm; Rhythm was regular. Normal S1 and S2. No murmurs or extra heart sounds noted.
• Abdomen and Genital exams: normal
• Extremities: No clubbing, cyanosis or edema; distal pulses 2+ and equal bilaterally.
• Skin: no eruptions noted.
• Neurological exam: normal
• WBC 18 thousand with 10% bands;
• Normal Chem 7 and LFTs.
• Room air blood gas: pH of 7.47/ PO2 of 55/PCO2 of 30.
• Sputum gram stain remarkable for an abundance of polys along with gram positive diplococci.
• CXR remarkable for dense right lower lobe infiltrate without effusion.
• Monitored care unit, with vigilance for clinical deterioration.
• Hypertension: given significant pneumonia and unclear clinical direction, will hold lisinopril. If BP > 180 and or if clear not developing sepsis, will consider restarting.
• Low molecular weight heparin
• Code Status: Wishes to be full code full care, including intubation and ICU stay if necessary. Has good quality of life and hopes to return to that functional level. Wishes to reconsider if situation ever becomes hopeless. Older brother Tom is surrogate decision maker if the patient can’t speak for himself. Tom lives in San Diego and we have his contact info. He is aware that patient is in the hospital and plans on visiting later today or tomorrow.
• Expected duration of hospitalization unclear – will know more based on response to treatment over next 24 hours.

The holdover admission (presenting data that was generated by other physicians)

• Handoff admissions are very common and present unique challenges
• Understand the reasons why the patient was admitted
• Review key history, exam, imaging and labs to assure that they support the working diagnostic and therapeutic plans
• Does the data support the working diagnosis?
• Do the planned tests and consults make sense?
• What else should be considered (both diagnostically and therapeutically)?
• This process requires that the accepting team thoughtfully review their colleagues efforts with a critical eye – which is not disrespectful but rather constitutes one of the main jobs of the accepting team and is a cornerstone of good care *Note: At some point during the day (likely not during rounds), the team will need to verify all of the data directly with the patient.
• 8-10 minutes
• Chief concern: Reason for admission (symptom and/or event)
• Temporally presented bullets of events leading up to the admission
• Review of systems
• Relevant PMH/PSH – historical information that might affect the patient during their hospitalization.
• Meds and Allergies
• Family and Social History – focusing on information that helps to inform the current presentation.
• Habits and exposures
• Physical exam, imaging and labs that were obtained in the Emergency Department
• Assessment and plan that were generated in the Emergency Department.
• Overnight events (i.e. what happened in the Emergency Dept. and after the patient went to their hospital room)? Responses to treatments, changes in symptoms?
• How does the patient feel this morning? Key exam findings this morning (if seen)? Morning labs (if available)?
• Assessment and Plan , with attention as to whether there needs to be any changes in the working differential or treatment plan. The broad organ system categories include (presented here head-to-toe): Neurological; Psychiatric; Cardiovascular; Pulmonary; Gastrointestinal; Renal/Genitourinary; Hematologic/Oncologic; Endocrine/Metabolic; Infectious; Tubes/lines/drains; Disposition.
• Chief concern: 70 yo male who presented with 10 days of progressive shoulder pain, followed by confusion. He was brought in by his daughter, who felt that her father was no longer able to safely take care for himself.
• 10 days ago, Mr. X developed left shoulder pain, first noted a few days after lifting heavy boxes. He denies falls or direct injury to the shoulder.
• 1 week ago, presented to outside hospital ER for evaluation of left shoulder pain. Records from there were notable for his being afebrile with stable vitals. Exam notable for focal pain anteriorly on palpation, but no obvious deformity. Right shoulder had normal range of motion. Left shoulder reported as diminished range of motion but not otherwise quantified. X-ray negative. Labs remarkable for wbc 8, creat 2.2 (stable). Impression was that the pain was of musculoskeletal origin. Patient was provided with Percocet and told to see PMD in f/u
• Brought to our ER last night by his daughter. Pain in shoulder worse. Also noted to be confused and unable to care for self. Lives alone in the country, home in disarray, no food.
• ROS: negative for falls, prior joint or musculoskeletal problems, fevers, chills, cough, sob, chest pain, head ache, abdominal pain, urinary or bowel symptoms, substance abuse
• Hypertension
• Coronary artery disease, s/p LAD stent for angina 3 y ago, no symptoms since. Normal EF by echo 2 y ago
• Chronic kidney disease stage 3 with creatinine 1.8; felt to be secondary to atherosclerosis and hypertension
• aspirin 81mg qd, atorvastatin 80mg po qd, amlodipine 10 po qd, Prozac 20
• Allergies: none
• Family and Social: lives alone in a rural area of the county, in contact with children every month or so. Retired several years ago from work as truck driver. Otherwise non-contributory.
• Habits: denies alcohol or other drug use.
• Temp 98 Pulse 110 BP 100/70
• Drowsy though arousable; oriented to year but not day or date; knows he’s at a hospital for evaluation of shoulder pain, but doesn’t know the name of the hospital or city
• CV: regular rate and rhythm; normal s1 and s2; no murmurs or extra heart sounds.
• Left shoulder with generalized swelling, warmth and darker coloration compared with Right; generalized pain on palpation, very limited passive or active range of motion in all directions due to pain. Right shoulder appearance and exam normal.
• CXR: normal
• EKG: sr 100; nl intervals, no acute changes
• WBC 13; hemoglobin 14
• Na 134, k 4.6; creat 2.8 (1.8 baseline 4 m ago); bicarb 24
• LFTs and UA normal
• Vancomycin and Zosyn for now
• Orthopedics to see asap to aspirate shoulder for definitive diagnosis
• If aspiration is consistent with infection, will need to go to Operating Room for wash out.
• Urine electrolytes
• Follow-up on creatinine and obtain renal ultrasound if not improved
• Renal dosing of meds
• Strict Ins and Outs.
• follow exam
• obtain additional input from family to assure baseline is, in fact, normal
• Since admission (6 hours) no change in shoulder pain
• This morning, pleasant, easily distracted; knows he’s in the hospital, but not date or year
• T Current 101F Pulse 100 BP 140/80
• Ins and Outs: IVF Normal Saline 3L/Urine output 1.5 liters
• L shoulder with obvious swelling and warmth compared with right; no skin breaks; pain limits any active or passive range of motion to less than 10 degrees in all directions
• Labs this morning remarkable for WBC 10 (from 13), creatinine 2 (down from 2.8)
• Continue with Vancomycin and Zosyn for now
• I already paged Orthopedics this morning, who are en route for aspiration of shoulder, fluid for gram stain, cell count, culture
• If aspirate consistent with infection, then likely to the OR
• Continue IVF at 125/h, follow I/O
• Repeat creatinine later today
• Not on any nephrotoxins, meds renaly dosed
• Continue antibiotics, evaluation for primary source as above
• Discuss with family this morning to establish baseline; possible may have underlying dementia as well
• SC Heparin for DVT prophylaxis
• Code status: full code/full care.

Outpatient-based presentations

There are 4 main types of visits that commonly occur in an outpatient continuity clinic environment, each of which has its own presentation style and purpose. These include the following, each described in detail below.

• The patient who is presenting for their first visit to a primary care clinic and is entirely new to the physician.
• The patient who is returning to primary care for a scheduled follow-up visit.
• The patient who is presenting with an acute problem to a primary care clinic
• The specialty clinic evaluation (new or follow-up)

It’s worth noting that Primary care clinics (Internal Medicine, Family Medicine and Pediatrics) typically take responsibility for covering all of the patient’s issues, though the amount of energy focused on any one topic will depend on the time available, acuity, symptoms, and whether that issue is also followed by a specialty clinic.

The Brand New Primary Care Patient

Purpose of the presentation

• Accurately review all of the patient’s history as well as any new concerns that they might have.
• Identify health related problems that need additional evaluation and/or treatment
• Provide an opportunity for senior listeners to intervene and offer input

Key features of the presentation

• If this is truly their first visit, then one of the main reasons is typically to "establish care" with a new doctor.
• It might well include continuation of therapies and/or evaluations started elsewhere.
• If the patient has other specific goals (medications, referrals, etc.), then this should be stated as well. Note: There may well not be a "chief complaint."
• For a new patient, this is an opportunity to highlight the main issues that might be troubling/bothering them.
• This can include chronic disorders (e.g. diabetes, congestive heart failure, etc.) which cause ongoing symptoms (shortness of breath) and/or generate daily data (finger stick glucoses) that should be discussed.
• Sometimes, there are no specific areas that the patient wishes to discuss up-front.
• Review of systems (ROS): This is typically comprehensive, covering all organ systems. If the patient is known to have certain illnesses (e.g. diabetes), then the ROS should include the search for disorders with high prevalence (e.g. vascular disease). There should also be some consideration for including questions that are epidemiologically appropriate (e.g. based on age and sex).
• Past Medical History (PMH): All known medical conditions (in particular those requiring ongoing treatment) are listed, noting their duration and time of onset. If a condition is followed by a specialist or co-managed with other clinicians, this should be noted as well. If a problem was described in detail during the “acute” history, it doesn’t have to be re-stated here.
• Past Surgical History (PSH): All surgeries, along with the year when they were performed
• Medications and allergies: All meds, including dosage, frequency and over-the-counter preparations. Allergies (and the type of reaction) should be described.
• Social: Work, hobbies, exposures.
• Sexual activity – may include type of activity, number and sex of partner(s), partner’s health.
• Smoking, Alcohol, other drug use: including quantification of consumption, duration of use.
• Family history: Focus on heritable illness amongst first degree relatives. May also include whether patient married, in a relationship, children (and their ages).
• Physical Exam: Vital signs and relevant findings (or their absence).
• Key labs and imaging if they’re available. Also when and where they were obtained.
• Summary, assessment & plan(s) presented by organ system and/or problems. As many systems/problems as is necessary to cover all of the active issues that are relevant to that clinic. This typically concludes with a “health care maintenance” section, which covers age, sex and risk factor appropriate vaccinations and screening tests.

The Follow-up Visit to a Primary Care Clinic

• Organize the presenter (forces you to think things through).
• Accurately review any relevant interval health care events that might have occurred since the last visit.
• Identification of new symptoms or health related issues that might need additional evaluation and/or treatment
• If the patient has no concerns, then verification that health status is stable
• Review of medications
• Provide an opportunity for listeners to intervene and offer input
• Reason for the visit: Follow-up for whatever the patient’s main issues are, as well as stating when the last visit occurred *Note: There may well not be a “chief complaint,” as patients followed in continuity at any clinic may simply be returning for a visit as directed by their doctor.
• Events since the last visit: This might include emergency room visits, input from other clinicians/specialists, changes in medications, new symptoms, etc.
• Review of Systems (ROS): Depth depends on patient’s risk factors and known illnesses. If the patient has diabetes, then a vascular ROS would be done. On the other hand, if the patient is young and healthy, the ROS could be rather cursory.
• PMH, PSH, Social, Family, Habits are all OMITTED. This is because these facts are already known to the listener and actionable aspects have presumably been added to the problem list (presented at the end). That said, these elements can be restated if the patient has a new symptom or issue related to a historical problem has emerged.
• MEDS : A good idea to review these at every visit.
• Physical exam: Vital signs and pertinent findings (or absence there of) are mentioned.
• Lab and Imaging: The reason why these were done should be mentioned and any key findings mentioned, highlighting changes from baseline.
• Assessment and Plan: This is most clearly done by individually stating all of the conditions/problems that are being addressed (e.g. hypertension, hypothyroidism, depression, etc.) followed by their specific plan(s). If a new or acute issue was identified during the visit, the diagnostic and therapeutic plan for that concern should be described.

The Focused Visit to a Primary Care Clinic

• Accurately review the historical events that lead the patient to make the appointment.
• Identification of risk factors and/or other underlying medical conditions that might affect the diagnostic or therapeutic approach to the new symptom or concern.
• Generate an appropriate assessment and plan
• Allow the listener to comment

Key features of the presentation:

• Reason for the visit
• History of Present illness: Description of the sequence of symptoms and/or events that lead to the patient’s current condition.
• Review of Systems: To an appropriate depth that will allow the listener to grasp the full range of diagnostic possibilities that relate to the presenting problem.
• PMH and PSH: Stating only those elements that might relate to the presenting symptoms/issues.
• PE: Vital signs and key findings (or lack thereof)
• Labs and imaging (if done)
• Assessment and Plan: This is usually very focused and relates directly to the main presenting symptom(s) or issues.

The Specialty Clinic Visit

Specialty clinic visits focus on the health care domains covered by those physicians. For example, Cardiology clinics are interested in cardiovascular disease related symptoms, events, labs, imaging and procedures. Orthopedics clinics will focus on musculoskeletal symptoms, events, imaging and procedures. Information that is unrelated to these disciples will typically be omitted. It’s always a good idea to ask the supervising physician for guidance as to what’s expected to be covered in a particular clinic environment.

• Highlight the reason(s) for the visit
• Review key data
• Provide an opportunity for the listener(s) to comment
• 5-7 minutes
• If it’s a consult, state the main reason(s) that the patient was referred as well as who referred them.
• If it’s a return visit, state the reasons why the patient is being followed in the clinic and when the last visit took place
• If it’s for an acute issue, state up front what the issue is Note: There may well not be a “chief complaint,” as patients followed in continuity in any clinic may simply be returning for a return visit as directed
• For a new patient, this highlights the main things that might be troubling/bothering the patient.
• For a specialty clinic, the history presented typically relates to the symptoms and/or events that are pertinent to that area of care.
• Review of systems , focusing on those elements relevant to that clinic. For a cardiology patient, this will highlight a vascular ROS.
• PMH/PSH that helps to inform the current presentation (e.g. past cardiac catheterization findings/interventions for a patient with chest pain) and/or is otherwise felt to be relevant to that clinic environment.
• Meds and allergies: Typically all meds are described, as there is always the potential for adverse drug interactions.
• Social/Habits/other: as relates to/informs the presentation and/or is relevant to that clinic
• Family history: Focus is on heritable illness amongst first degree relatives
• Physical Exam: VS and relevant findings (or their absence)
• Key labs, imaging: For a cardiology clinic patient, this would include echos, catheterizations, coronary interventions, etc.
• Summary, assessment & plan(s) by organ system and/or problems. As many systems/problems as is necessary to cover all of the active issues that are relevant to that clinic.
• Reason for visit: Patient is a 67 year old male presenting for first office visit after admission for STEMI. He was referred by Dr. Goins, his PMD.
• The patient initially presented to the ER 4 weeks ago with acute CP that started 1 hour prior to his coming in. He was found to be in the midst of a STEMI with ST elevations across the precordial leads.
• Taken urgently to cath, where 95% proximal LAD lesion was stented
• EF preserved by Echo; Peak troponin 10
• In-hospital labs were remarkable for normal cbc, chem; LDL 170, hdl 42, nl lfts
• Uncomplicated hospital course, sent home after 3 days.
• Since home, he states that he feels great.
• Denies chest pain, sob, doe, pnd, edema, or other symptoms.
• No symptoms of stroke or TIA.
• No history of leg or calf pain with ambulation.
• Prior to this admission, he had a history of hypertension which was treated with lisinopril
• 40 pk yr smoking history, quit during hospitalization
• No known prior CAD or vascular disease elsewhere. No known diabetes, no family history of vascular disease; He thinks his cholesterol was always “a little high” but doesn’t know the numbers and was never treated with meds.
• History of depression, well treated with prozac
• Discharge meds included: aspirin, metoprolol 50 bid, lisinopril 10, atorvastatin 80, Plavix; in addition he takes Prozac for depression
• Taking all of them as directed.
• Patient lives with his wife; they have 2 grown children who are no longer at home
• Works as a computer programmer
• Smoking as above
• ETOH: 1 glass of wine w/dinner
• No drug use
• No known history of cardiovascular disease among 2 siblings or parents.
• Well appearing; BP 130/80, Pulse 80 regular, 97% sat on Room Air, weight 175lbs, BMI 32
• Lungs: clear to auscultation
• CV: s1 s2 no s3 s4 murmur
• No carotid bruits
• ABD: no masses
• Ext; no edema; distal pulses 2+
• Cath from 4 weeks ago: R dominant; 95% proximal LAD; 40% Cx.
• EF by TTE 1 day post PCI with mild Anterior Hypokinesis, EF 55%, no valvular disease, moderate LVH
• Labs of note from the hospital following cath: hgb 14, plt 240; creat 1, k 4.2, lfts normal, glucose 100, LDL 170, HDL 42.
• EKG today: SR at 78; nl intervals; nl axis; normal r wave progression, no q waves
• Plan: aspirin 81 indefinitely, Plavix x 1y
• Given nitroglycerine sublingual to have at home.
• Reviewed symptoms that would indicate another MI and what to do if occurred
• Plan: continue with current dosages of meds
• Chem 7 today to check k, creatinine
• Plan: Continue atorvastatin 80mg for life
• Smoking cessation: Doing well since discharge without adjuvant treatments, aware of supports.
• Plan: AAA screening ultrasound

How to Give an Excellent Medical Presentation

• By Sulaiman Ahmad
• July 22, 2019
• Medical Student , Pre-med
• Self-improvement

In medicine, we are constantly learning from each other. Professors stand in front of lecture halls to teach the fundamental knowledge needed to pass board exams and to treat our patients. Outside of the classroom, medical students, researchers, and physicians attend conferences to communicate ideas and update their colleagues with oral and poster presentations. In the clinic, students and resident physicians relay pertinent patient information to the physician in charge. Eventually, you will find yourself in front of an audience listening to your talk or an attending grading your clinical presentation. First, I will discuss what it takes to make an excellent presentation.  I will then finish this topic by providing guidelines for perfecting different types of presentations.

Critical Elements of an Excellent Presentation

 do some research.

Your audience will consider you an expert on the information you deliver. It is your job to achieve the expected level of comprehension of the topic. After choosing a topic, gather enough background information from diverse but appropriate sources (e.g., journals articles, relevant chapters in textbooks, personal discussion with subject matter experts, online videos).  Your research should provide you with a thorough understanding of the topic and a list of the important facts supporting your take-home message . Any gaps in your knowledge will become evident during your presentation. The goal is to develop confidence in your understanding of the topic and ability to share what you know.

Know Your Audience

Before putting your presentation together, take a moment to assess the baseline understanding of your expected audience . Ultimately your audience should walk away having learned something new. Try to figure out their collective interest, reasons for attending, and prior experience with the topic. Knowing your audience will allow you to focus on information that will keep them engaged and interested. For example, premed students have a different understanding of medical topics than medical students.  A presentation on the same subject should be different for both groups. If your listeners have different levels of expertise, take a moment to explain the fundamental concept, then build up the language and complexity to allow everyone to benefit from the information shared. Your audience is the reason why you are presenting.

Tell a Story

The human brain is wired to remember stories , especially if presented logically. A presentation is about the information shared, but it should also include the presenters’ passion, excitement, and personal style. All topics can be formatted to include characters, a description of the setting, plot, conflict, and a resolution. The story should allow the audience to take a journey with you. The hardest part is identifying the start and endpoint of your story and which details are needed. Make every word count by checking if it adds value to your narrative. Consider using metaphors, real examples, and descriptions that give life to your words .

Practicing your presentation is a vital step in developing an excellent presentation. You can memorize a script. However, memorization can reduce your connection with the audience. But in certain situations, scripts are quick and effective means of communicating important facts. Another approach is drafting bullet points of the main ideas and practicing the natural flow of information . This method allows your personality to shine on stage. To become comfortable speaking, start by practicing on your own . You can also record yourself with a cellphone or tablet and review the recording to evaluate your performance. Next, find a small group to present in front of and ask for their honest assessment . Eventually, your presentation will feel natural, and your stage presence will aid in communicating your main idea.

Q&A Session

Usually, your presentation does not end until after a question and answer session. Most presentations should include approximately five minutes in the end for the audience to ask questions . This part of the presentation allows you to clarify or further explain any part of your presentation. A question can also lead to expanding your presentation beyond what you originally planned to discuss . It is important for you to understand what is being asked and address the specific question directly. And if you do not have an answer, it is okay to admit that you do not know . Questions will force you to be creative and truly test your knowledge of the topic.

Different Types of Presentations

Presentations have many different forms, each with different goals; thus, each form requires a unique approach. In medicine, professors and clinician often provide students with lecture objectives and PowerPoint presentations that guide the students in their hour-long lecture. Conferences are a researcher’s platform to share their lab’s progress and conclusions. The last presentation I will go into is the clinical presentation a student typically performs for the physician in charge.

The main purpose of the lecture is to educate the attendees. We all have had great professors captivate our attention and other experiences that were a complete waste of time. But what makes some lectures better than others? The lecturer’s knowledge on the topic becomes obvious, and their stage presence confirms how comfortable they are with the topic.  If you are tasked with lecturing on a topic or a series, ensure that you have a solid understanding and address your learning objectives in the time allotted . The main concepts should be repeated multiple times throughout the lecture, followed by examples . Your PowerPoint slides should be limited to only main points and images that support your talking points. After difficult concepts are covered, ask questions to gauge your audience’s understanding . It is better to reemphasize a concept before building up to more complex learning objectives.

Research Presentation

Attending a conference is exciting, especially if you are representing your lab with an oral presentation.  It is an opportunity to share your research story, from the point of identifying a question to the process of reaching a conclusion. Realize your audience will include Primary Investigators, post-docs, and Ph.D. students that are also experts in the field . Attempt to grab the audience’s attention from the beginning by providing them with a reason to care. Then continue to explain how your study relates to the published work . After building up the background, address how you arrived at your research question. The most exciting part of your presentation should be explaining your conclusions and the path you took to get there. Finish up strong by discussing the implications of your findings and how they will have an impact in the field . The natural flow of information will come with practice and a deep understanding of your research topic. Presenting as a student usually leads to networking with professors and clinicians that can help you progress in your career.

Patient Presentation

Medical students learn how to take a patient’s history and perform a physical exam, but it is more challenging to reason through your clinical findings and subsequently present to an attending . Your clinical presentation style will change depending on the environment, medical department, and supervising physician . Upon joining a medical team, discuss the expectations and preference with each physician . It may be a good idea to draft a script that can get you started on organizing your patient presentation. The success of your presentation is correlated to your knowledge of the basic sciences and ability to critically assess the patient’s history and physical exam; the more you learn and read, the easier decision making and producing a plan becomes. Another important element is practicing your presentation style until it comes out naturally . Take the time to listen to your peers and experienced colleagues; learn from their mistakes and strengths . After concluding your presentation, ask for feedback and practice implementing the suggestions. You will be the eyes and ears for the physicians in charge, perfecting your patient presentation will help get the care the patients need while making everyone’s job a little easier.

Final remarks

There are some basic steps to achieving an excellent presentation: know the topic well, understand who you’re presenting to, develop a memorable story, and practice until it comes out naturally. A career in medicine is very versatile; you can be at the forefront of the next generation of physicians sharing your experiences or updating the science community with your research conclusions. At the minimum, you will be presenting the patient in the clinic. Thus, presenting is a skill every physician must master.

Sulaiman Ahmad

Anatomy of a Successful Medical Student — 5 Critical Traits

Those who thrive in med school—landing in top residency programs without costing their wellbeing—are different from the pack. This is how they do it.

6 Lifestyle Factors That Are Killing Your Focus

Successful students take a holistic approach to their studying and lifestyle. Here are 6 simple tactics that will help you develop laser focus.

The Anatomy of a Successful Premed — 5 Traits That Will Set You Apart

Success as a premed isn’t about being the smartest student in the room. These are the premed traits that will take you from zero to hero.

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How to present patient cases

• Related content
• Peer review
• Mary Ni Lochlainn , foundation year 2 doctor 1 ,
• Ibrahim Balogun , healthcare of older people/stroke medicine consultant 1
• 1 East Kent Foundation Trust, UK

A guide on how to structure a case presentation

This article contains...

-History of presenting problem

-Medical and surgical history

-Drugs, including allergies to drugs

-Family history

-Social history

-Review of systems

-Findings on examination, including vital signs and observations

-Differential diagnosis/impression

-Investigations

-Management

Presenting patient cases is a key part of everyday clinical practice. A well delivered presentation has the potential to facilitate patient care and improve efficiency on ward rounds, as well as a means of teaching and assessing clinical competence. 1

The purpose of a case presentation is to communicate your diagnostic reasoning to the listener, so that he or she has a clear picture of the patient’s condition and further management can be planned accordingly. 2 To give a high quality presentation you need to take a thorough history. Consultants make decisions about patient care based on information presented to them by junior members of the team, so the importance of accurately presenting your patient cannot be overemphasised.

As a medical student, you are likely to be asked to present in numerous settings. A formal case presentation may take place at a teaching session or even at a conference or scientific meeting. These presentations are usually thorough and have an accompanying PowerPoint presentation or poster. More often, case presentations take place on the wards or over the phone and tend to be brief, using only memory or short, handwritten notes as an aid.

Everyone has their own presenting style, and the context of the presentation will determine how much detail you need to put in. You should anticipate what information your senior colleagues will need to know about the patient’s history and the care he or she has received since admission, to enable them to make further management decisions. In this article, I use a fictitious case to show how you can structure case presentations, which can be adapted to different clinical and teaching settings (box 1).

Box 1: Structure for presenting patient cases

Presenting problem, history of presenting problem, medical and surgical history.

Drugs, including allergies to drugs

Family history

Social history, review of systems.

Findings on examination, including vital signs and observations

Differential diagnosis/impression

Investigations

Case: tom murphy.

You should start with a sentence that includes the patient’s name, sex (Mr/Ms), age, and presenting symptoms. In your presentation, you may want to include the patient’s main diagnosis if known—for example, “admitted with shortness of breath on a background of COPD [chronic obstructive pulmonary disease].” You should include any additional information that might give the presentation of symptoms further context, such as the patient’s profession, ethnic origin, recent travel, or chronic conditions.

“ Mr Tom Murphy is a 56 year old ex-smoker admitted with sudden onset central crushing chest pain that radiated down his left arm.”

In this section you should expand on the presenting problem. Use the SOCRATES mnemonic to help describe the pain (see box 2). If the patient has multiple problems, describe each in turn, covering one system at a time.

Box 2: SOCRATES—mnemonic for pain

Associations

Time course

Exacerbating/relieving factors

“ The pain started suddenly at 1 pm, when Mr Murphy was at his desk. The pain was dull in nature, and radiated down his left arm. He experienced shortness of breath and felt sweaty and clammy. His colleague phoned an ambulance. He rated the pain 9/10 in severity. In the ambulance he was given GTN [glyceryl trinitrate] spray under the tongue, which relieved the pain to 5/10. The pain lasted 30 minutes in total. No exacerbating factors were noted. Of note: Mr Murphy is an ex-smoker with a 20 pack year history”

Some patients have multiple comorbidities, and the most life threatening conditions should be mentioned first. They can also be categorised by organ system—for example, “has a long history of cardiovascular disease, having had a stroke, two TIAs [transient ischaemic attacks], and previous ACS [acute coronary syndrome].” For some conditions it can be worth stating whether a general practitioner or a specialist manages it, as this gives an indication of its severity.

In a surgical case, colleagues will be interested in exercise tolerance and any comorbidity that could affect the patient’s fitness for surgery and anaesthesia. If the patient has had any previous surgical procedures, mention whether there were any complications or reactions to anaesthesia.

“Mr Murphy has a history of type 2 diabetes, well controlled on metformin. He also has hypertension, managed with ramipril, and gout. Of note: he has no history of ischaemic heart disease (relevant negative) (see box 3).”

Box 3: Relevant negatives

Mention any relevant negatives that will help narrow down the differential diagnosis or could be important in the management of the patient, 3 such as any risk factors you know for the condition and any associations that you are aware of. For example, if the differential diagnosis includes a condition that you know can be hereditary, a relevant negative could be the lack of a family history. If the differential diagnosis includes cardiovascular disease, mention the cardiovascular risk factors such as body mass index, smoking, and high cholesterol.

Highlight any recent changes to the patient’s drugs because these could be a factor in the presenting problem. Mention any allergies to drugs or the patient’s non-compliance to a previously prescribed drug regimen.

To link the medical history and the drugs you might comment on them together, either here or in the medical history. “Mrs Walsh’s drugs include regular azathioprine for her rheumatoid arthritis.”Or, “His regular drugs are ramipril 5 mg once a day, metformin 1g three times a day, and allopurinol 200 mg once a day. He has no known drug allergies.”

If the family history is unrelated to the presenting problem, it is sufficient to say “no relevant family history noted.” For hereditary conditions more detail is needed.

“ Mr Murphy’s father experienced a fatal myocardial infarction aged 50.”

Social history should include the patient’s occupation; their smoking, alcohol, and illicit drug status; who they live with; their relationship status; and their sexual history, baseline mobility, and travel history. In an older patient, more detail is usually required, including whether or not they have carers, how often the carers help, and if they need to use walking aids.

“He works as an accountant and is an ex-smoker since five years ago with a 20 pack year history. He drinks about 14 units of alcohol a week. He denies any illicit drug use. He lives with his wife in a two storey house and is independent in all activities of daily living.”

Do not dwell on this section. If something comes up that is relevant to the presenting problem, it should be mentioned in the history of the presenting problem rather than here.

“Systems review showed long standing occasional lower back pain, responsive to paracetamol.”

Findings on examination

Initially, it can be useful to practise presenting the full examination to make sure you don’t leave anything out, but it is rare that you would need to present all the normal findings. Instead, focus on the most important main findings and any abnormalities.

“On examination the patient was comfortable at rest, heart sounds one and two were heard with no additional murmurs, heaves, or thrills. Jugular venous pressure was not raised. No peripheral oedema was noted and calves were soft and non-tender. Chest was clear on auscultation. Abdomen was soft and non-tender and normal bowel sounds were heard. GCS [Glasgow coma scale] was 15, pupils were equal and reactive to light [PEARL], cranial nerves 1-12 were intact, and he was moving all four limbs. Observations showed an early warning score of 1 for a tachycardia of 105 beats/ min. Blood pressure was 150/90 mm Hg, respiratory rate 18 breaths/min, saturations were 98% on room air, and he was apyrexial with a temperature of 36.8 ºC.”

Differential diagnoses

Mentioning one or two of the most likely diagnoses is sufficient. A useful phrase you can use is, “I would like to rule out,” especially when you suspect a more serious cause is in the differential diagnosis. “History and examination were in keeping with diverticular disease; however, I would like to rule out colorectal cancer in this patient.”

Remember common things are common, so try not to mention rare conditions first. Sometimes it is acceptable to report investigations you would do first, and then base your differential diagnosis on what the history and investigation findings tell you.

“My impression is acute coronary syndrome. The differential diagnosis includes other cardiovascular causes such as acute pericarditis, myocarditis, aortic stenosis, aortic dissection, and pulmonary embolism. Possible respiratory causes include pneumonia or pneumothorax. Gastrointestinal causes include oesophageal spasm, oesophagitis, gastro-oesophageal reflux disease, gastritis, cholecystitis, and acute pancreatitis. I would also consider a musculoskeletal cause for the pain.”

This section can include a summary of the investigations already performed and further investigations that you would like to request. “On the basis of these differentials, I would like to carry out the following investigations: 12 lead electrocardiography and blood tests, including full blood count, urea and electrolytes, clotting screen, troponin levels, lipid profile, and glycated haemoglobin levels. I would also book a chest radiograph and check the patient’s point of care blood glucose level.”

You should consider recommending investigations in a structured way, prioritising them by how long they take to perform and how easy it is to get them done and how long it takes for the results to come back. Put the quickest and easiest first: so bedside tests, electrocardiography, followed by blood tests, plain radiology, then special tests. You should always be able to explain why you would like to request a test. Mention the patient’s baseline test values if they are available, especially if the patient has a chronic condition—for example, give the patient’s creatinine levels if he or she has chronic kidney disease This shows the change over time and indicates the severity of the patient’s current condition.

“To further investigate these differentials, 12 lead electrocardiography was carried out, which showed ST segment depression in the anterior leads. Results of laboratory tests showed an initial troponin level of 85 µg/L, which increased to 1250 µg/L when repeated at six hours. Blood test results showed raised total cholesterol at 7.6 mmol /L and nil else. A chest radiograph showed clear lung fields. Blood glucose level was 6.3 mmol/L; a glycated haemoglobin test result is pending.”

Dependent on the case, you may need to describe the management plan so far or what further management you would recommend.“My management plan for this patient includes ACS [acute coronary syndrome] protocol, echocardiography, cardiology review, and treatment with high dose statins. If you are unsure what the management should be, you should say that you would discuss further with senior colleagues and the patient. At this point, check to see if there is a treatment escalation plan or a “do not attempt to resuscitate” order in place.

“Mr Murphy was given ACS protocol in the emergency department. An echocardiogram has been requested and he has been discussed with cardiology, who are going to come and see him. He has also been started on atorvastatin 80 mg nightly. Mr Murphy and his family are happy with this plan.”

The summary can be a concise recap of what you have presented beforehand or it can sometimes form a standalone presentation. Pick out salient points, such as positive findings—but also draw conclusions from what you highlight. Finish with a brief synopsis of the current situation (“currently pain free”) and next step (“awaiting cardiology review”). Do not trail off at the end, and state the diagnosis if you are confident you know what it is. If you are not sure what the diagnosis is then communicate this uncertainty and do not pretend to be more confident than you are. When possible, you should include the patient’s thoughts about the diagnosis, how they are feeling generally, and if they are happy with the management plan.

“In summary, Mr Murphy is a 56 year old man admitted with central crushing chest pain, radiating down his left arm, of 30 minutes’ duration. His cardiac risk factors include 20 pack year smoking history, positive family history, type 2 diabetes, and hypertension. Examination was normal other than tachycardia. However, 12 lead electrocardiography showed ST segment depression in the anterior leads and troponin rise from 85 to 250 µg/L. Acute coronary syndrome protocol was initiated and a diagnosis of NSTEMI [non-ST elevation myocardial infarction] was made. Mr Murphy is currently pain free and awaiting cardiology review.”

Originally published as: Student BMJ 2017;25:i4406

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed

• ↵ Green EH, Durning SJ, DeCherrie L, Fagan MJ, Sharpe B, Hershman W. Expectations for oral case presentations for clinical clerks: opinions of internal medicine clerkship directors. J Gen Intern Med 2009 ; 24 : 370 - 3 . doi:10.1007/s11606-008-0900-x   pmid:19139965 . OpenUrl CrossRef PubMed Web of Science
• ↵ Olaitan A, Okunade O, Corne J. How to present clinical cases. Student BMJ 2010;18:c1539.
• ↵ Gaillard F. The secret art of relevant negatives, Radiopedia 2016; http://radiopaedia.org/blog/the-secret-art-of-relevant-negatives .

Effective Presentations: Optimize the Learning Experience With Evidence-Based Multimedia Principles [Incl. Seminar]

TABLE OF CONTENTS

What is an effective presentation.

Professional education requires presentations, from a small discussion or a short video to speaking to a lecture hall with an audience of hundreds.  In fact, presentations are at the core of the educational process. With the effort to view all our educational efforts through an evidence-based lens, the construction of an effective presentation needs to undergo the same scrutiny. Whether a presenter intends to share plans, teach educational information, give updates on project progress, or convey the results of research, the extent to which the audience understands and remembers the presentation relies not only on the quality of the content but also the manner in which that content is presented. While the medium of the presentation may range from written content to graphics, videos, live presentations, or any combination of these and more, each of these mediums can be enhanced and made more effective by the use of evidence-based practices for presenting. Regardless of the medium, effective presentations have the same key features: they are appealing, engaging, informative, and concise. Effective presentations gain attention and captivate the audience, but most importantly, they convey information and ideas memorably.

With the integration of technology and online learning, educators have more opportunities than ever to present rich content that enhances and supports student learning. However, these opportunities can be intimidating to educators striving to engage students, as it can be daunting to create visually appealing and informative materials. Additionally, many educators feel pressured by the continued myth of learning styles: the widespread misconception that learning materials should match students’ visual, auditory, or kinesthetic “styles” to optimize learning (1). Despite being featured in many articles and discussions, there is no compelling evidence that matching educational content to learner’s style preferences increases educational outcomes. However, using multiple modes of delivery such as visuals, audio, and active learning has been shown to benefit all learners. In other words, no matter their stated preference, all learners benefit from a variety of media. Using evidence-based principles for multimedia content such as the principles found in Richard Mayer’s multimedia learning as well as the principles of graphic design and universal design supports learning and increases educational outcomes.

Why effective presentations work

What makes a presentation effective? Is an appealing and engaging presentation also an effective one? Research from cognitive science provides a foundation for understanding how verbal and pictorial information are processed by the learner’s mind during a presentation.

Mayer’s cognitive theory of multimedia learning

Based in cognitive science research, Mayer’s evidence-based approach to multimedia and cognition has greatly influenced both instructional design and the learning sciences. Mayer’s cognitive theory of multimedia learning comprises three learning principles: the dual channel principle, the limited capacity principle, and the active processing principle. Mayer’s cognitive theory of multimedia learning lays the theoretical foundation that underlies the practical applications to boost cognitive processes (2).

The dual channel principle proposes that learners process verbal and pictorial information via two separate channels (see figure below). Within each channel, learners can process limited amounts of information simultaneously due to limits in working memory, a phenomenon known as the limited capacity principle . In addition to these principles describing learning via the verbal and pictorial channels, the active processing principle proposes deeper learning occurs when learners are actively engaged in cognitive processing, such as attending to relevant information, creating mental schema to organize the material cognitively, and then relating to prior knowledge (3). These three principles work in tandem to describe the learning process that occurs when an audience of learners experiences a multimedia presentation.

Cognitive Load Theory, Adapted from Mayer (3) . Depicting how verbal and visual information is processed in dual channels through sensory, working, and long-term memory to create meaningful learning.

As learners listen to a lecture or watch a video, words and images are detected in the sensory memory and held for a very brief period of time. As the learners attend to relevant information, they are selecting words and images , which allows the selected information to move into the working memory where it may be held for a short period of time. However, working memory is limited to about 30 seconds and can only hold a few bits of information at a time. Organizing the words and images creates a coherent cognitive representation (schema) of these bits of information in the working memory. After the words and images are selected and then organized into schema, integrating these bits of information with prior knowledge from long term memory creates meaningful learning.

Cognitive Capacity . Three types of processing combine to determine cognitive capacity. To improve essential processing and generative processing, extraneous processing should be limited as much as possible .

No matter how important the content may be, the capacity of learners to retain ideas from a single presentation is limited. The amount of information a learner can process as they select, organize, and integrate the ideas in a presentation relates to the cognitive load, which includes Essential, Extraneous, and Generative cognitive processing. Essential cognitive processing is required for the learner to create a cognitive representation of necessary and relevant information. This is the desired part of processing but should be managed to not overload the cognitive process. Extraneous processing refers to cognitive processing that does not contribute to learning and is often caused by poor design. Extraneous processing should be eliminated whenever possible to free up cognitive resources. Generative cognitive processing gives meaning to the material and creates deep learning. Learners must be motivated to engage and understand the information for this type of processing to occur.

Foundations in neuroscience

What we know about cognition and learning has been supported and informed by research in neuroscience (4). Neuroscience advances have also allowed us to gain deeper understanding into cognitive science principles, including those on multimedia learning. Researchers have been increasingly tracking learner eye movements to study learners’ attention and interest as a method of validating the impact of multimedia principles, and the results have supported the benefits of proper multimedia design on learner performance (5). Another avenue of research with great potential includes functional MRI (fMRI) readings or electroencephalography (EEG) (6). It has long been established that verbal and pictorial data is processed in different parts of the brain. More recently however, by examining changes in blood flow in different regions of the brain, researchers in Sweden were able to demonstrate that increased extraneous load could impact the effectiveness of learning, in line with the dual channel principle (7).

Evidence for effective presentations

Mayer’s multimedia principles.

Mayer’s Multimedia Principles.

Mayer’s multimedia principles are a set of evidence-based guidelines for producing multimedia based on facilitating essential processing, reducing extraneous processing, and promoting generative processing (8). Mayer’s list of principles often includes fifteen principles, some of which have changed over time, and in a study conducted with medical students, the following nine principles were found to be particularly effective (3). The first three of these principles are used to reduce extraneous processing.

Principles for reducing extraneous processing:

• Coherence principle: eliminate extraneous material 
• Signaling principle: highlight essential material 
• Spatial contiguity principle: place printed words near corresponding graphics

To illustrate these principles, we will use a lesson about the kidneys. The instructor wants to make diagrams of the anatomy to use during discussion. The coherence principle says to only include the information necessary to the lesson. Graphics such as clip art, information that does not relate to anatomy, or unnecessary music reduces cognitive capacity. The signaling principle says to highlight essential material; this might include putting important content in bold or larger font. Or, if the kidney is shown in situ , the rest of the anatomy may be shown in grayscale or a much lighter color to de-emphasize it. The spatial contiguity principle says to place printed words, such as the labels, near the graphics.

Reduce extraneous processing .  Do : keep labels next to diagrams, use only essential material, highlight essential material such as titles.  Don’t: separate labels from diagrams, include extra facts, or have excessive text on a slide, especially with no indication of what is most important.

Principles for managing essential processing:

• Pre-training principle: provide pre-training in names and characteristics of key concepts
• Segmenting principle: break lessons into learner-controlled segments 
• Modality principle: present words in spoken form

The next three principles are used to manage essential processing. If the kidney lesson moves into diseased states or diagnostics, the pre-training principle says that learners should be given information on any unfamiliar terminology before the lesson begins. To satisfy the segmenting principle , the learner should be able to control each piece of the lesson. For example, a “next” button may allow them to progress from pre-training to anatomy to diseased states and then diagnostics. The modality principle says that words should be spoken when possible. Voice-over can be used and text can be limited to essential material such as key definitions or lists.

Manage essential processing.   Do: Present terms and key concepts first, break lessons into user-controlled segments, and present words in spoken form.  Don’t: Give long blocks of text for students to read without priming students for key concepts.

Principles for fostering generative processing: 

• Multimedia principle: present words and pictures rather than words alone 
• Personalization principle: present words in conversational or polite style 
• Voice principle: use a human voice rather than a machine voice

Mayer’s work also includes principles to increase generative processing. The multimedia principle is a direct result of the dual channel principle and limited capacity principle. Words and pictures together stimulate both channels and allow the memory to process more information than words alone. To adhere to the personalization principle to promote deeper learning, a case study is better presented as a story than a page of diagnostics and patient demographics. Finally, the voice principle says that a human voice is more desirable, so it is better to use the instructor’s voice when doing voice-overs rather than auto-generated readers.

Foster generative processing. Do: Present words and pictures, present words in conversational style, and use a human voice.  Don’t: Present text only, present words as a list of facts or overly technical language, or use a computer-generated voice.

Additional multimedia principles: 

• Temporal contiguity principle: present words and pictures simultaneously rather than successively
• Redundancy principle: for a fast paced lesson, people learn better from graphics and narration rather than graphics, narration, and text 
• Image principle: people do not learn better if a static image of the instructor is added to the presentation

Additional principles include the temporal contiguity principle , which states that words and pictures should be shown simultaneously rather than successively. This also includes narration and images or animation. For example, if an animation demonstrates normal cell division, the narration should be given during the animation, not after. The redundancy principle states that people do not necessarily learn better if text is added to graphics and narration. The duplication of information creates extraneous processing as learners try to process print and spoken text. The image principle states that learners do not learn better if a static image of the instructor is added to a presentation. For example, if students are watching an animation with normal cell division, they do not learn better if an image of their instructor is placed next to the animation.

Additional principles for fostering generative processing: 

• Embodiment principle: onscreen instructors should display high embodiment not low
• Immersion principle: 3D virtual reality is not necessarily better than 2D presentations 
• Generative activity principle: use generative learning activities during learning

In the newest edition of Mayer’s Multimedia Learning (8), three additional principles have been added. The embodiment principle states that onscreen instructors should display high embodiment rather than low embodiment, meaning they should use natural gestures, look at the camera as if making eye contact, and if drawing, show the image being drawn. If demonstrating something like a surgical procedure, a first-person perspective should be used so the learner sees the perspective of the person performing. Low embodiment would include standing still, lack of eye contact, and using a third-person perspective. The immersion principle states that 3D immersive virtual reality is not necessarily more effective than 2D presentations, such as on a computer screen. This is thought to be caused by the cognitive load on the learning involved in using 3D immersive technology but more studies are needed. Lastly, the generative activity principle states that learners should use generative learning activities while learning such as summarizing, mapping, drawing, imagining, self-testing, self-explaining, teaching, and enacting. These activities help learners cognitively select and organize new material and then integrate with prior knowledge.

Other Design Principles

Mayer’s design principles are functional but do not address aesthetics per se . Anyone can master the basic graphic design principles as discussed by Reynolds (9) to captivate and engage an audience. 

• Create graphics that are designed for the back of the room. Whatever the venue, the person in the back needs to be able to see and gather information from the graphics. Ensure font size is appropriate, image size and clarity is sufficient, and that font type and spacing allow words to be seen clearly from a distance. For online materials, this principle may mean designing for the person who will be viewing on the smallest screen (such as a phone) rather than assuming viewers will use a large monitor (10).
• Limit the types of fonts. Too many fonts or fonts that don’t coordinate well can make graphics seem jarring and unpleasant. Some programs will suggest font families that are appealing, and a safe guideline is to limit to two or three fonts maximum per graphic. 
• Use contrasting colors. Colors that are too similar or using type on top of images that lack contrast can make type difficult to read. Color family suggestions can be found online or in software such as Powerpoint.

Graphic design principles.  Do: Use coordinating fonts and color schemes with contrasting colors.  Don’t: use multiple fonts, excessive colors, and/or non-contrasting colors that may be difficult to distinguish.

In addition to singular graphics or presentations, online course presentation makes a difference in how learners perceive and utilize a course. When designing online learning experiences, consider using guidelines such as Quality Matters to assess the functionality. Quality Matters rubrics look at key components that have been proven to facilitate learning by making navigation and presentation of course elements explicit. Key components include providing information on how to get started, including learning objectives, allowing learners to track their progress, and using learning activities and technology tools that support active learning. Navigation among course components should facilitate access to materials.

In addition to all of these principles, accessibility must be considered in all forms of presentation. In education, designing for accessibility can be guided by universal design principles . Some schools may even require all courses and materials to be fully accessible. Providing accessible options has been shown to benefit all learners, not just those with a documented need for accommodations (11). Some basic accommodations that should be offered in any class include offering media in multiple modes. For example, videos should have the option of captioning and/or access to a transcript, and photos and graphics should have captions that describe the image. Many learning management systems and software programs now have options to check for accessibility. Additionally, most schools can provide assistance in assessing and developing accessible materials.

Practical Applications for Presentations in Health Professions Education

Implementation in the classroom.

When planning how to present materials in the classroom, first consider the most effective form of presentation for the given information. It may be a Powerpoint, a video, a graphic, or a handout. Consider using a variety of media appropriate for the intended outcomes. Creating high quality materials may seem daunting, but quality content can be reused, shared, and has been shown to enhance student learning.

Powerpoint has been much maligned for overuse and abuse, but well-designed presentations can be remarkably effective (12). When designing in Powerpoint, limit the amount of text per slide. One rule to remember is the 5/5/5 rule: Use no more than 5 lines of text with 5 words each or 5 text-heavy slides in a row and try to avoid bullets (13). Graphics are preferable to text or tables when representing data, but graphs and labels should be kept as simple as possible using 2D graphics and simplified labels that are easy for viewers to see (14). When presenting, refrain from reading from the slides. Slides should highlight important concepts and provide visual aids, not present everything. In addition, keep Powerpoint and video presentations short; most listeners will lose attention in 6–10 minutes (15,16). Whenever possible, engage the audience by interspersing active learning elements. Between sections or topics, transition slides can be used to indicate pauses for activity or reflection or to cue students to changes in topic (14).

When planning a presentation, consider presenting some of the information online before class for students to review. This flipped classroom technique allows for more class to be spent using active learning and facilitates the presentation of multiple forms of media and accessible options. 

Implementation online

Videos often become an integral part of the online learning experience. To facilitate learning, consider the following tips for your own video production (17,18): 

• Align the video with learning objectives and course outcomes. Focus on pertinent instructional points to reduce extraneous processing and thereby reduce cognitive load. 
• Limit the length of videos and use interactive elements to promote active learning. To help maintain student engagement and deepen learning, include interactive elements such as discussions, quizzes or embedded questions to maintain student attention. 
• Limit extraneous information, graphics, and sounds that do not pertain to the learning goals (19). Busy backgrounds, music, or animations that don’t contribute to understanding concepts unnecessarily add to a learner’s cognitive load.
• When using existing videos, ensure the source is reliable and the video is high quality. Video production can take time, so using professional videos can be beneficial if they come from credible sources that target the learning objectives with up-to-date and accurate information.

Additionally, Schooley et al. (18) have proposed a 25-item quality checklist that can help educators create and curate high-quality videos. Many of the items in the checklist have been discussed here such as length, captioning, using relevant graphics, and self-assessment opportunities, but also included are other points an educator should consider, such as the offering learners the ability to download files and adjust playback speed as well as providing them with recommendations for further reading.

For a course in any modality, creating and curating content online can save time and facilitate student learning. As you consider what material to create and use for your courses, assess existing material using the guidelines above to determine if it could be made more beneficial to learners. Does it follow Mayer’s principles? Does it follow graphic design principles and universal design principles? Consider using a Quality Matters rubric to check the course design for best practices.

Recommendations

Educator’s perspective.

• Use Mayer’s multimedia design principles to revise existing presentations and review new creations for simple changes that can make a big difference (12).
• When delivering a presentation, start by discussing an unusual case, presenting an interesting story or an unexpected statistic, or explain how the topic impacts the listeners. This personalization will help gain their attention from the start (13).
• When designing your own materials and graphics, “less is more” is often a good guideline: limit the amount of information on slides, limit the types of fonts, and limit the excessive use of colors (9,12).
• Videos should be limited to 5–6 minutes when possible and avoid exceeding 10 minutes. Break up longer videos and intersperse interactive elements to keep students engaged (15–17).
• When using technology and online delivery, universal design and accessibility considerations can be complicated. See if your school has an expert that can review your materials to ensure all students will benefit.

Student perspective

• When creating presentations, reports, and charts, follow Mayer’s multimedia design principles to ensure your audience gets the most from your presentation.
• Avoid copy/pasting but rather try and present concepts in an original way in order to augment your understanding of the material.
• When looking at materials online, look for options such as captioning, transcripts, or audio buttons for accessing additional media output.
• If a presentation is lengthy, pause and insert your own activities to help yourself stay focused. Taking notes, pausing for reflection, and self-quizzing can help deepen your learning and keep your mind from wandering.
• If a variety of media aren’t offered, consider finding your own to supplement your learning. Credible sources with learning objectives that align with your course can augment your learning experience.

(Please select all that apply) 

1. When creating a graphic about the current status of heart disease in the US, which of the following would align with best practices?

a. Gaining the audience’s attention with a picture of your dog.

b. Using 3 colors that coordinate well on a contrasting background.

c. A 2D graph with simple labels rather than a table of data.

d. An image on the left with labels listed separately on the right.

e. An image next to a paragraph of text that you will read for the audience.

2. Which of the following are true about educational videos?

a. They need to be created by professionals to be high-quality.

b. They should be less than 10 minutes.

c. There should be an option for closed captioning or a written transcript.

d. Longer videos may be used but should be broken up with active learning elements.

e. Videos don’t need to align to objectives as long as they’re well-made.

3. Which of the following would be examples of Mayer’s multimedia principles?

a. Using a human voice rather than a machine voice.

b. Using formal language instead of conversational language.

c. Playing soothing music in the background of a video.

d. Providing new words and definitions before the presentation begins.

e. Putting important words in bold for emphasis.

4. Which of these would follow best practices for online content?

a. Creating a module where all the material is on one page for easy access.

b. Adding buttons for next, back, and table of contents options for students to navigate.

c. Breaking material into 7-minute videos with practice questions between them.

d. Adding fun clip art and cool images to the pages even if it doesn’t directly relate to the content.

e. Having text only because images are distracting.

Answers: (1) b,c. (2) b,c,d. (3) a,d,e. (4) b,c.

Online Seminar

This online seminar and its accompanying article will focus on the topic of Effective Presentations, which have a set of key qualities: they are appealing, engaging, informative, and concise. Effective presentations gain attention and captivate the audience, but most importantly, they convey information and ideas memorably and efficiently. Using evidence-based principles in educational multimedia can ensure the development of high-quality learning experiences. Our host, Dr. Peter Horneffer will be sharing with us some key multimedia concepts that can help facilitate the development and implementation of effective multimedia into the educational process.

Watch the seminar recording:

Would you like to learn more? Explore the Pulse Seminar Library.

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Meredith Ratliff is a doctoral student in Instructional Design and Technology at the University of Central Florida. Her research interests include evidence-based medical education, branching scenarios, and faculty development. She has received her B.S. and M.A.T. in Mathematics at the University of Florida and her MA in Instructional Design and Technology from UCF. She has been an Associate Faculty member in the mathematics department at Valencia College in Kissimmee, Florida for the past nine years. As part of the Learning Science team at Lecturio, she serves as an educational consultant helping to design and develop materials for medical educators.

Satria Nur Sya’ban is a doctor from Indonesia who graduated from Universitas Airlangga. While a student, he served as the president of CIMSA, a national medical student NGO, working on a diverse range of issues that included medical education and curriculum advocacy by medical students. Before graduating, he took two gap years to serve as a Regional Director, and subsequently as Vice-President, of the International Federation of Medical Students’ Associations (IFMSA)*, working on and developing various initiatives to better empower medical student organizations to make a change at the national level. At Lecturio, he serves as a Medical Education Consultant, supporting Lecturio in developing and maintaining partnerships with student organizations and universities in Asia, as well as providing counsel on how Lecturio can fit in existing teaching models and benefit students’ learning experience.

*IFMSA has been one of the leading global health organizations worldwide since 1951, representing over 1.3 million medical students as members spanning over 123 countries.

Adonis is a doctor from Lebanon who graduated from the University of Balamand. He was a research fellow at the Department of Emergency Medicine at the American University of Beirut Medical Center and has worked with the World Health Organization Regional Office of the Eastern Mediterranean. During his studies, Adonis served as the president of the Lebanese Medical Students’ International Committee (LeMSIC), a national medical student organization in Lebanon, and moved on to serve as the Regional Director of the Eastern Mediterranean Region of the IFMSA*. Among his roles as Regional Director, he focused on medical education advocacy, oversaw collaborations with external partners, and undertook several medical education projects and initiatives around the region. As a Medical Education Consultant at Lecturio, he advises the Lecturio team on how the platform can fit in existing teaching models and benefit students’ learning experience, develops and maintains partnerships with student organizations and universities in the MENA region, and conducts research on learning science and evidence-based strategies.

Sarah Haidar is an educator and educational specialist from Lebanon who has graduated with a BA in English Linguistics and a Secondary Teaching Diploma (T.D.) from  Haigazian University in Beirut, Lebanon. She has received her M.Ed. in Teaching English as a Second Language (TESOL)  from the Lebanese International University. She has been teaching ESL classrooms at the Deutsche Internationale Schule for four years. As part of the administrative team at the All American Institute of Medical Sciences (AAIMS), she is working on the design and implementation of a set of academic and administrative reforms that can help both faculty and students in their professional and academic endeavors. She has joined Lecturio to support the Learning Science team in the writing and communication based tasks that might be needed to announce and market their services and events that are targeted at medical educators. She is also supporting the Learning Science team with her perspective on educational and pedagogical topics that will inform the general audience of educators.

Sara Keeth is a Ph.D. and certified PMP (Project Management Professional) who graduated from the University of Texas at Dallas. As an educator, she has worked as a Teaching Fellow at  the University of Texas at Dallas, as a full-time professor at Richland College (now Dallas College’s Richland Campus), and has also taught at Austin College. Dr. Keeth has also worked as a consultant for Parker University’s Research Center and has a decade of experience as an operations manager for an advertising agency. As Senior Learning Science and Research Project Manager at Lecturio, she manages the Learning Science department’s activities, shares her education expertise and best practices for medical educators, and develops evidence-based content for both students and faculty.

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3 types of medical presentations (and how to give them)

Here are some tips for presenting the top three types of medical presentations: lectures, research presentations, and case reports.

Derek Murray

Building presentations

With your long to-do list as a medical professional, giving presentations is probably not a high priority. Yet, medical presentations are inevitable. Are you ready to give them when your job requires it? If so, where do you even start?

We want to make it a little easier for you to present data-heavy medical topics in an easy-to-understand way.

So, let’s dive right in with the top three types of medical presentations.

Key Takeaways:

• Structure your medical presentation into a story to make it memorable.
• Medical presentations can be lectures, research, or case presentations.
• Customize the presentation based on the type and goal.

1. Lectures

Medical lectures educate an audience about a medical topic. They’re one of the most challenging presentations. According to the Learning Pyramid , lectures are the most passive learning techniques, which is also why they have the lowest retention rates.

There are several settings for educational lectures, including:

• Conferences
• University or school lectures

Medical lectures help students or an audience comprehend complex medical information and then turn what they learned into actionable strategies.

For example, you may teach students with little medical knowledge about a new medical concept. But they must understand the topic and be able to recall it for examinations.

Tips for giving medical lectures

How can you turn one of the most challenging presentations into an engaging, memorable lecture? Here are a few tips to ace your educational medical lectures:

• Be interactive : Use Q&As, activities, and open discussions.
• Hand out resources: Give physical booklets students can review after the presentation.
• Use multimedia: Add audio-visual elements like images, video, and audio clips.
• Use simple language: Your audience is learning, so they need simple language and plenty of definitions to understand the topic.
• Make it entertaining: Keep your audience’s attention with a more engaging and entertaining presentation.

UnitedHealth Group incorporated imagery and movement to show rather than tell about mental health in 2022 to boost their engagement on the topic.

2. Research presentations

The most information-heavy medical presentation is the research presentation. Research presentations share findings with experienced medical professionals, usually in conference settings. Some of the audience includes:

• Investigators
• Ph.D. students
• Medical professionals and experienced doctors

Research presentations can also be part of healthcare marketing . You may have to introduce a new process, pharmaceutical, or device to encourage other healthcare professionals to adopt it in their practices.

Tips for giving research presentations

Use these tips to improve your research presentations :

• Speak on a higher level: You’re talking to a knowledgeable audience, so they expect a higher level of research.
• Back all facts with data: Use statistics and research to back all claims.
• Use power poses: Build authority with a confident presentation.
• Grab the audience’s attention: Start your presentation by giving your audience a reason to care, like a problem you want to solve.
• Build up the conclusion: Structure the research in a natural, progressive order that builds up to your conclusion.
• Look at the future: Conclude with how the research findings will impact the future of medicine.
• Visualize data : Simplify findings and data with visuals and charts.

Cardinal Health transformed the complex research for Smart Compression into understandable slides using a mix of graphics and storytelling in their medical presentation.

3. Case reports

Medical professionals must give oral case reports when transferring information between providers or a team. These presentations are very brief and often don’t require visuals.

Sometimes a case is especially unique and offers educational value to others. In that case, presenters should transform their quick oral case reports into a longer presentation that incorporates data and visuals.

Tips for giving case reports

Case reports use a similar structure to oral patient presentations, except with more details about each point. You’ll still want to pack as much information in a short presentation as possible.

• Begin the presentation with a patient overview: Start by introducing the patient, including all relevant demographic details in summarized graphics and lists.
• Present the history of the patient: Describe the patient’s history, why they sought care, and the symptoms they presented in charts and visuals.
• Explore medical information: Dive into the medical details, like treatment and history, using a storytelling structure to connect the information.
• Offer a plan: Outline a treatment plan alongside proof.

Summarize details in charts: You’ll pack a large amount of information in a concise presentation, so use plenty of charts and diagrams to summarize data and simplify outcomes.

Tips for preparing engaging medical presentations

Your medical presentations have highly complex topics rich with data. These topics can easily feel overwhelming or even boring if they don’t have the right structure and appearance.

Here are three medical presentation tips we’ve learned to help you prepare and present high-quality medical presentations that engage AND inform.

Know your audience’s knowledge level

Before building and presenting a medical topic, you must know your audience’s knowledge level. A lecture to a class of first-year college students will sound far different from a presentation to doctors with 10+ years of industry experience.

Build a presentation around your audience’s knowledge, so it’s understandable yet challenging. By taking this extra step, you’ll know what points need more explanation and what topics you can dig deeper into based on your audience’s experience.

Build a structured story

A complex topic becomes easy to understand and follow if you use a storytelling structure . You might ask, “How can a lecture on a new treatment be a story?”

Any time you communicate, it’s a story: You have the challenge to solve, potential solutions to try, and a final winner (like when presenting medical research). You can structure that story in a progressive order or by announcing one primary outcome and providing a list of proofs (like with patient case studies).

Focus on a goal

The goal of medical presentations can be educating, training, or persuading the audience, depending on the type of medical presentation. Knowing your goal guides which data is most relevant to bring your desired outcome.

Communicate at the speed of healthcare with Prezent

Whether you’re preparing a lecture, research presentation, or case report, creating presentation slides is probably far down your priority list. The fast-paced healthcare industry has enough duties vying for attention. So how are you supposed to squeeze in hours to build an engaging presentation?

Prezent has your back. No need to sweat the details as we have already developed leading presentation templates perfect for data-driven presentations. Personalize to your audience’s knowledge and presentation preferences with AI-powered technology. Save time and energy with access to 35,000+ custom-built slide templates designed with key business and pharma storylines in mind.

You’ll have an engaging and clear presentation deck in minutes rather than hours. Take back your time and communicate efficiently with Prezent so you can focus on turning your ideas and insights into action.

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Make an impact with an engaging medical presentation

If you want to explain medical concepts or demonstrate a new medical invention, you’d better use medical presentations in PowerPoint. It allows you to make your slides modern & visually appealing with a few creative design moves. Suppose you need to illustrate a healthcare document or make a presentation on a medical topic. In that case, PowerPoint is good for organizing all points to mention, supporting your speech with images, and attracting people with great animation.

You can find plenty of medical presentation examples on the web to inspire or borrow some elements, e.g., icons, colors, themes, etc. If you lack time and skills, you can always address professional services and order medical or business presentation slides . It helps to devote more time to speech and full sleep.

Today, let us help you find out when to use, how to start, and what to add to create modern-looking healthcare PowerPoint visuals.

When to Use Medical PPT Presentation?

Initially, presentations are used to inform, educate or persuade different external and internal audiences. Medicine includes hard and simple explanations, so you can create a healthcare presentation for both children and scientists.

Using the power of words and correct animation, you can deliver the most complex concepts and explain to pupils how blood cells move. So, medical slide presentations are used for:

• Medical conferences;
• Medical cases;
• Medical training;
• Medical networking;
• Medical investment pitch;
• Medical services presentation;
• Medical TED talk;
• Medical university/college/school lecture;
• Medical invention demonstration.

We bet you can make up more situations where medical presentations fit, and we’ve collected the most common causes. Anytime you talk about healthcare problems or news, you need a medical presentation.

How to Start a Presentation on Healthcare?

Medicine topics refer to the section of hard ones, so PowerPoint presentations must be used wisely and correctly to make speech easier to understand. If you have to explain complex concepts, the presentation can be your life-saver if you approach it in a meaningful way.

Step 1: Rely on visuals

The first step is to look for visuals that can accompany your text. PowerPoint was created for animation, but many people incorrectly use slides for paragraphs of scientific information. Meanwhile, we grasp visual information 60,000 times faster than written one.

So, whenever you present technical information, your audience would want relevant visuals to support their understanding. Do not name types of bone fractures or blood cells, show them!

Step 2: Crop and enlarge your images

The next step is the extension of the first one. We recommend using one picture per slide and enlarging it if it contains tiny elements. For example, you want to show a cataract, so increase the image in size for all people to see clearly. Do not be afraid to sacrifice text for the big high-quality picture.

Step 3: Use charts to visualize numbers

Please, forget about bullet points and endless lists on slides. Pity your audience.

• Decide how many numbers or statistics you have to add as separate slides.
• Do not mix pictures with charts or graphs.
• Make them simple but clear.
• Use contrasting backgrounds and comment on every figure.

See, bullet points are only good in articles to make some space and differentiation in a long text.

Step 4: Make your graphics look more professional

Google for medical presentation video tutorials or address custom presentation services to improve PowerPoint presentation . If you need to present in front of professionals, they will most likely have expectations. Thus, use high-resolution images, position every element accordingly, match sizes of arrows/lines within one slide, and just remove all alien elements that clog the animation.

8 Simple Tips to Improve Your Healthcare PowerPoint Presentation

Even though the following tips are simple and easy to implement, they will have a significant impact on your medical slides.

Think ‘Non-Linear’

If you have to explain some definitions, do not present them in a boring linear way. It can easily disengage the audience from the slide. Instead, create an animated explanation with arrows: make the main word big in the middle of the slide and ‘draw’ around it. Why use only words if you work with PowerPoint?

Use simple animated visuals to explain concepts

For example, you have to explain how molecules move in the electric field. A sheet of hard-to-understand text does not attract the audience at all. To engage people better, draw how charged molecules move forward and back. Besides, add an oral explanation for people to visualize better. Thus, the information sticks to the audience’s brains and keeps them involved till the presentation ends.

This slide does not just give a list of 3D printing examples but shows its real usage, which helps the audience visualize the information.

Label your images right

Images are an integral part of any medical presentation, but some presenters misuse them and create eye hops. It means the number of places the eyes have to land on a slide to gather information. When you create a presentation, THINK ABOUT THE AUDIENCE. Try to imagine how their eyes walk through the slide and make this path as convenient as possible.

For example, when you label throat parts, do not create a 1-5 list next to the picture. It may get people tired to walk from the list back to the image and again to the list. It is better to avoid numbers and label parts with names immediately.

Here is a great example of a visually attractive and informative slide. The author has exactly thought about the people because he helped them perceive the information step by step.

Use tables for comparison

Bullet points are good, but slide space is limited, so you’d better use it wisely. Even if you apply custom animation using bullet points, you still present in a linear way. Accordingly, we advise you to use the table to compare two items with a column that defines the characteristics you oppose. It helps the audience of different levels to follow your thoughts. If people do not understand, they distract faster. So, do not let them do it.

Pay attention to information clarity

Make sure the images you place on the slide match with headlines or other marks. Sometimes, people are afraid of many slides and try to put images and text into one. And they disregard the fact that the audience in the back seats sees nothing.

For example, this slide is good and informative, but the text might not be visible for the last lines.

Use charts to present numbers

For example, you want to list etiological factors for a specific disease. Instead of simply saying percentages, show them! People perceive and remember visual information better, so use charts to show the share of each factor. PowerPoint is created for animations, so always look for ways to avoid many words.

Lead with appropriate visuals

We highly do not recommend using photos of wounds, skin/organ diseases, or other body health problems. It may avert some people because these pictures aren’t indeed attractive. Instead, use drawn pictures, e.g., do not show SSI classification on real skin but use cross-section (like the one used in medicine books).

Avoid Using Photos as Slide Backgrounds

Strangely, many medical presenters still use photos for background for some unknown to us purposes. On the contrary, we suppose it is extremely hard for the audience to differentiate the main image or words from the background clog. Background photos do not bring you much value, but people perceive things better on a pure basis. So, please, stop using this habit. The simpler, the better!

Eye-catching animation has never spoiled anyone’s medical presentation. By adding suitable colors and pictures for a neat look, you demonstrate your expertise and support your speech. You will no more get lost if someone interrupts you. Complex topics are better explained with attractive visuals because all people perceive information better if accompanied by images. Therefore, you should use this preference to fit the audience of any size, age, and gender. Master medical presentations in PowerPoint and enjoy people’s attention!

#ezw_tco-2 .ez-toc-widget-container ul.ez-toc-list li.active::before { background-color: #ededed; } Table of contents

• Presenting techniques
• 50 tips on how to improve PowerPoint presentations in 2022-2023 [Updated]
• Keynote VS PowerPoint
• Types of presentations
• Present financial information visually in PowerPoint to drive results

The importance of visual storytelling in presentations (+ effective tips to consider)

• Design Tips

Why presentation of data is important?

8 rules of effective presentation

Formal Lectures and Presentations Infographic Full Text

New section.

About This Graphic

This infographic shows the five strategies associated with the Formal Lectures and Presentations section of the Presentation Skills Toolkit for Medical Students. Each of the five sections includes a heading for the strategy followed by a brief description and an illustration.

Define the objectives of the presentation:

An illustration shows a target with an arrow in the middle and five boxes branching from it to resemble a chart. The text reads, "Describe what specific, measurable, or observable knowledge or skill the audience should acquire because of your presentation."

Design an effective slide set:

An illustration shows an icon of a hand pointing to the center of a gear. There are arrows pointing to the sides of the graphic, two on the left side of the gear and two on the right. The text reads, "Avoid lengthy text, decorative fonts, clip art, graphs, and pictures as these may be distracting."

Practice your performance:

An illustration shows a person wearing a suit holding laptop and gesturing while having a video chat. The text reads, "Know the lecture material but also the slides — without prompts!"

Create a positive learning environment:

An illustration shows a person sitting on a desk with their legs crossed while holding their arms up. There are a coffee cup and office chair next to them. The text reads, "Anticipate questions and allocate sufficient time at the end of the presentation to answer them. Always repeat the questions being asked for the audience's benefit and to ensure your understanding. Some questions may be challenging; be prepared and answer honestly. It is acceptable not to know an answer."

Demonstrate professionalism in presenting:

An illustration shows a person in a business suit holding a notebook and gesturing. The text reads, "Remain calm, collected, and open to feedback."

• presentation

: an activity in which someone shows, describes, or explains something to a group of people

: the way in which something is arranged, designed, etc. : the way in which something is presented

: the act of giving something to someone in a formal way or in a ceremony

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Delivery, face and brow presentation.

Julija Makajeva ; Mohsina Ashraf .

Affiliations

Last Update: January 9, 2023 .

• Continuing Education Activity

Face and brow presentation is a malpresentation during labor when the presenting part is either the face or, in the case of brow presentation, it is the area between the orbital ridge and the anterior fontanelle. This activity reviews the evaluation and management of these two presentations and explains the role of the interprofessional team in managing delivery safely for both the mother and the baby.

• Describe the mechanism of labor in the face and brow presentation.
• Summarize potential maternal and fetal complications during the face and brow presentations.
• Review different management approaches for the face and brow presentation.
• Outline some interprofessional strategies that will improve patient outcomes in delivery cases with face and brow presentation issues.
• Introduction

The term presentation describes the leading part of the fetus or the anatomical structure closest to the maternal pelvic inlet during labor. The presentation can roughly be divided into the following classifications: cephalic, breech, shoulder, and compound. Cephalic presentation is the most common and can be further subclassified as vertex, sinciput, brow, face, and chin. The most common presentation in term labor is the vertex, where the fetal neck is flexed to the chin, minimizing the head circumference.

Face presentation – an abnormal form of cephalic presentation where the presenting part is mentum. This typically occurs because of hyperextension of the neck and the occiput touching the fetal back. Incidence of face presentation is rare, accounting for approximately 1 in 600 of all presentations. [1] [2] [3]

In brow presentation, the neck is not extended as much as in face presentation, and the leading part is the area between the anterior fontanelle and the orbital ridges. Brow presentation is considered the rarest of all malpresentation with a prevalence of 1 in 500 to 1 in 4000 deliveries. [3]

Both face and brow presentations occur due to extension of the fetal neck instead of flexion; therefore, conditions that would lead to hyperextension or prevent flexion of the fetal neck can all contribute to face or brow presentation. These risk factors may be related to either the mother or the fetus. Maternal risk factors are preterm delivery, contracted maternal pelvis, platypelloid pelvis, multiparity, previous cesarean section, black race. Fetal risk factors include anencephaly, multiple loops of cord around the neck, masses of the neck, macrosomia, polyhydramnios. [2] [4] [5]

These malpresentations are usually diagnosed during the second stage of labor when performing a digital examination. It is possible to palpate orbital ridges, nose, malar eminences, mentum, mouth, gums, and chin in face presentation. Based on the position of the chin, face presentation can be further divided into mentum anterior, posterior, or transverse. In brow presentation, anterior fontanelle and face can be palpated except for the mouth and the chin. Brow presentation can then be further described based on the position of the anterior fontanelle as frontal anterior, posterior, or transverse.

Diagnosing the exact presentation can be challenging, and face presentation may be misdiagnosed as frank breech. To avoid any confusion, a bedside ultrasound scan can be performed. [6]  The ultrasound imaging can show a reduced angle between the occiput and the spine or, the chin is separated from the chest. However, ultrasound does not provide much predicting value in the outcome of the labor. [7]

• Anatomy and Physiology

Before discussing the mechanism of labor in the face or brow presentation, it is crucial to highlight some anatomical landmarks and their measurements. 

Planes and Diameters of the Pelvis

The three most important planes in the female pelvis are the pelvic inlet, mid pelvis, and pelvic outlet. 

Four diameters can describe the pelvic inlet: anteroposterior, transverse, and two obliques. Furthermore, based on the different landmarks on the pelvic inlet, there are three different anteroposterior diameters, named conjugates: true conjugate, obstetrical conjugate, and diagonal conjugate. Only the latter can be measured directly during the obstetric examination. The shortest of these three diameters is obstetrical conjugate, which measures approximately 10.5 cm and is a distance between the sacral promontory and 1 cm below the upper border of the symphysis pubis. This measurement is clinically significant as the fetal head must pass through this diameter during the engagement phase. The transverse diameter measures about 13.5cm and is the widest distance between the innominate line on both sides. 

The shortest distance in the mid pelvis is the interspinous diameter and usually is only about 10 cm. 

Fetal Skull Diameters

There are six distinguished longitudinal fetal skull diameters:

• Suboccipito-bregmatic: from the center of anterior fontanelle (bregma) to the occipital protuberance, measuring 9.5 cm. This is the presenting diameter in vertex presentation. 
• Suboccipito-frontal: from the anterior part of bregma to the occipital protuberance, measuring 10 cm 
• Occipito-frontal: from the root of the nose to the most prominent part of the occiput, measuring 11.5cm
• Submento-bregmatic: from the center of the bregma to the angle of the mandible, measuring 9.5 cm. This is the presenting diameter in face presentation where the neck is hyperextended. 
• Submento-vertical: from the midpoint between fontanelles and the angle of the mandible, measuring 11.5cm 
• Occipito-mental: from the midpoint between fontanelles and the tip of the chin, measuring 13.5 cm. It is the presenting diameter in brow presentation. 

Cardinal Movements of Normal Labor

• Neck flexion
• Internal rotation
• Extension (delivers head)
• External rotation (Restitution)
• Expulsion (delivery of anterior and posterior shoulders)

Some of the key movements are not possible in the face or brow presentations.  

Based on the information provided above, it is obvious that labor will be arrested in brow presentation unless it spontaneously changes to face or vertex, as the occipito-mental diameter of the fetal head is significantly wider than the smallest diameter of the female pelvis. Face presentation can, however, be delivered vaginally, and further mechanisms of face delivery will be explained in later sections.

• Indications

As mentioned previously, spontaneous vaginal delivery can be successful in face presentation. However, the main indication for vaginal delivery in such circumstances would be a maternal choice. It is crucial to have a thorough conversation with a mother, explaining the risks and benefits of vaginal delivery with face presentation and a cesarean section. Informed consent and creating a rapport with the mother is an essential aspect of safe and successful labor.

• Contraindications

Vaginal delivery of face presentation is contraindicated if the mentum is lying posteriorly or is in a transverse position. In such a scenario, the fetal brow is pressing against the maternal symphysis pubis, and the short fetal neck, which is already maximally extended, cannot span the surface of the maternal sacrum. In this position, the diameter of the head is larger than the maternal pelvis, and it cannot descend through the birth canal. Therefore the cesarean section is recommended as the safest mode of delivery for mentum posterior face presentations. 

Attempts to manually convert face presentation to vertex, manual or forceps rotation of the persistent posterior chin to anterior are contraindicated as they can be dangerous.

Persistent brow presentation itself is a contraindication for vaginal delivery unless the fetus is significantly small or the maternal pelvis is large.

Continuous electronic fetal heart rate monitoring is recommended for face and brow presentations, as heart rate abnormalities are common in these scenarios. One study found that only 14% of the cases with face presentation had no abnormal traces on the cardiotocograph. [8] It is advised to use external transducer devices to prevent damage to the eyes. When internal monitoring is inevitable, it is suggested to place monitoring devices on bony parts carefully. 

People who are usually involved in the delivery of face/ brow presentation are:

• Experienced midwife, preferably looking after laboring woman 1:1
• Senior obstetrician 
• Neonatal team - in case of need for resuscitation 
• Anesthetic team - to provide necessary pain control (e.g., epidural)
• Theatre team  - in case of failure to progress and an emergency cesarean section will be required.
• Preparation

No specific preparation is required for face or brow presentation. However, it is essential to discuss the labor options with the mother and birthing partner and inform members of the neonatal, anesthetic, and theatre co-ordinating teams.

• Technique or Treatment

Mechanism of Labor in Face Presentation

During contractions, the pressure exerted by the fundus of the uterus on the fetus and pressure of amniotic fluid initiate descent. During this descent, the fetal neck extends instead of flexing. The internal rotation determines the outcome of delivery, if the fetal chin rotates posteriorly, vaginal delivery would not be possible, and cesarean section is permitted. The approach towards mentum-posterior delivery should be individualized, as the cases are rare. Expectant management is acceptable in multiparous women with small fetuses, as a spontaneous mentum-anterior rotation can occur. However, there should be a low threshold for cesarean section in primigravida women or women with large fetuses.

When the fetal chin is rotated towards maternal symphysis pubis as described as mentum-anterior; in these cases further descend through the vaginal canal continues with approximately 73% cases deliver spontaneously. [9] Fetal mentum presses on the maternal symphysis pubis, and the head is delivered by flexion. The occiput is pointing towards the maternal back, and external rotation happens. Shoulders are delivered in the same manner as in vertex delivery.

Mechanism of Labor in Brow Presentation

As this presentation is considered unstable, it is usually converted into a face or an occiput presentation. Due to the cephalic diameter being wider than the maternal pelvis, the fetal head cannot engage; thus, brow delivery cannot take place. Unless the fetus is small or the pelvis is very wide, the prognosis for vaginal delivery is poor. With persistent brow presentation, a cesarean section is required for safe delivery.

• Complications

As the cesarean section is becoming a more accessible mode of delivery in malpresentations, the incidence of maternal and fetal morbidity and mortality during face presentation has dropped significantly. [10]

However, there are still some complications associated with the nature of labor in face presentation. Due to the fetal head position, it is more challenging for the head to engage in the birth canal and descend, resulting in prolonged labor.

Prolonged labor itself can provoke foetal distress and arrhythmias. If the labor arrests or signs of fetal distress appear on CTG, the recommended next step in management is an emergency cesarean section, which in itself carries a myriad of operative and post-operative complications.

Finally, due to the nature of the fetal position and prolonged duration of labor in face presentation, neonates develop significant edema of the skull and face. Swelling of the fetal airway may also be present, resulting in respiratory distress after birth and possible intubation.

• Clinical Significance

During vertex presentation, the fetal head flexes, bringing the chin to the chest, forming the smallest possible fetal head diameter, measuring approximately 9.5cm. With face and brow presentation, the neck hyperextends, resulting in greater cephalic diameters. As a result, the fetal head will engage later, and labor will progress more slowly. Failure to progress in labor is also more common in both presentations compared to vertex presentation.

Furthermore, when the fetal chin is in a posterior position, this prevents further flexion of the fetal neck, as browns are pressing on the symphysis pubis. As a result, descend through the birth canal is impossible. Such presentation is considered undeliverable vaginally and requires an emergency cesarean section.

Manual attempts to change face presentation to vertex, manual or forceps rotation to mentum anterior are considered dangerous and are discouraged.

• Enhancing Healthcare Team Outcomes

A multidisciplinary team of healthcare experts supports the woman and her child during labor and the perinatal period. For a face or brow presentation to be appropriately diagnosed, an experienced midwife and obstetrician must be involved in the vaginal examination and labor monitoring. As fetal anomalies, such as anencephaly or goiter, can contribute to face presentation, sonographers experienced in antenatal scanning should also be involved in the care. It is advised to inform the anesthetic and neonatal teams in advance of the possible need for emergency cesarean section and resuscitation of the neonate. [11] [12]

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Disclosure: Julija Makajeva declares no relevant financial relationships with ineligible companies.

Disclosure: Mohsina Ashraf declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Makajeva J, Ashraf M. Delivery, Face and Brow Presentation. [Updated 2023 Jan 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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• Sonographic diagnosis of fetal head deflexion and the risk of cesarean delivery. [Am J Obstet Gynecol MFM. 2020] Sonographic diagnosis of fetal head deflexion and the risk of cesarean delivery. Bellussi F, Livi A, Cataneo I, Salsi G, Lenzi J, Pilu G. Am J Obstet Gynecol MFM. 2020 Nov; 2(4):100217. Epub 2020 Aug 18.
• Review Sonographic evaluation of the fetal head position and attitude during labor. [Am J Obstet Gynecol. 2022] Review Sonographic evaluation of the fetal head position and attitude during labor. Ghi T, Dall'Asta A. Am J Obstet Gynecol. 2022 Jul 6; . Epub 2022 Jul 6.
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• Open access
• Published: 09 April 2024

Late presentations and missed opportunities among newly diagnosed HIV patients presenting to a specialty clinic in Lebanon

• Maya Mahmoud 1 ,
• Tala Ballouz 2 ,
• Chloe Lahoud 3 ,
• Jana Adnan 3 ,
• Paola Abi Habib 3 ,
• Reem Saab 3 ,
• Haya Farhat 3   na1 ,
• Mohammad El Hussein 3   na1 &
• Nesrine Rizk 4  

Scientific Reports volume  14 , Article number:  8296 ( 2024 ) Cite this article

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• HIV infections

Late presentation to medical care of individuals infected with the human immunodeficiency virus (HIV) is linked to poor outcomes and increased morbidity and mortality. Missed opportunities for a prompt diagnosis are frequently reported among late presenters. We aimed to estimate the proportion of late presenters and missed opportunities in diagnosis among newly diagnosed HIV-positive subjects presenting to a specialty clinic in Lebanon. This is a retrospective chart review of all newly diagnosed adult HIV-positive subjects presenting to clinic from 2012 to 2022. Demographic, laboratory, and clinical data were collected at initial HIV diagnosis or presentation to medical care. We defined late presentation as having a CD4 count < 350 or AIDS-defining event regardless of CD4 count. Advanced disease is defined as having a CD4 count below 200 cells/μL or the presence of an AIDS-defining illness, regardless of the CD4 count. A missed opportunity was defined as the presence of an indicator condition (IC) that suggests infection with HIV/AIDS during 3 years preceding the actual HIV diagnosis and not followed by a recommendation for HIV testing. The proportions for demographic, epidemiological, and clinical characteristics are calculated by excluding cases with missing information from the denominator. Our cohort included 150 subjects (92.7% males; 63.6% men who have sex with men (MSM); 33.3% heterosexuals; median age 30.5 years at diagnosis). 77 (51.3%) were late presenters and 53 (35.3% of all subjects, 68.8% of late presenters) had advanced HIV on presentation. Up to 76.5% of late presenters had a presentation with an HIV-related condition at a healthcare provider without getting HIV test within the previous 3 years. The most frequent ICs were weight loss, generalized lymphadenopathy, constitutional symptoms, and chronic idiopathic diarrhea. Overall mortality rate was 4% (6/150 individuals). All-cause mortality among those who presented with AIDS was 15.4% (6/39 subjects). In our setting, late presentations and missed opportunities for HIV diagnosis are common. In the Middle East, AIDS mortality remains high with a large gap in HIV testing. To effectively influence policies, comprehensive analyses should focus on estimating the preventable health and financial burdens of late HIV presentations. Another concern pertains to healthcare providers’ attitudes and competencies.

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Introduction

Antiretroviral therapy (ART) remains one of the most important medical advancements in the twentieth century. There is ample evidence that effective ART improves cellular immunity and subsequently reduces AIDS-related morbidity and mortality. However, achieving the full benefits of ART is dependent on early HIV detection and initiation of treatment 1 . Late diagnosis of HIV has been associated with poorer health outcomes 2 , increased healthcare costs, and risk of onward transmission 3 , 4 , 5 , 6 , 7 . Yet, even in countries with adequate HIV testing recommendations and healthcare resources, late presenters (defined as those with a CD4 count less than 350 cells/mm 3 or the presence of an AIDS-related illness at presentation) still constitute at least half of people living with HIV (PLWH) 8 , 9 , 10 , 11 and continue to be a hurdle to HIV eradication efforts globally 12 .

Several sociodemographic, psychosocial, and structural risk factors—at the patient, provider, and policy level—have been identified to be associated with late presentation. Fear of HIV-related stigma and discrimination, poor social support, and low risk perception are among some of the common patient-related factors preventing people from seeking timely testing. Providers have described insufficient time and resources, the laborious process of counseling and consent, as well as low provider-perceived risk of transmission as barriers to offering an HIV test 13 , 14 . Studies of missed opportunities for earlier diagnoses have shown that individuals with late presentations had often presented to healthcare settings several times, sometimes with indicator conditions (ICs) before an HIV test was eventually made 15 . Meanwhile, the presence of punitive laws and policies, such as the criminalization of sex work and same-sex sexual acts, in some countries deter individuals from seeking HIV testing 16 .

While several studies have been conducted worldwide to investigate late presentations and missed opportunities, only a few have been conducted in the Middle East and North Africa (MENA) region 15 , 17 , 18 , 19 . Although the region has seen significant improvements in HIV services, early HIV diagnosis remains a challenge 7 . Recent numbers from the region show that only 67% of PLWH are aware of their status, and a considerable proportion of individuals newly diagnosed with HIV present with an advanced stage 20 . In Lebanon, the first HIV case was reported in 1984 21 , which has evolved to reach approximately 3000 cases in 2021 22 . The prevalence rate of HIV in Lebanon is less than 0.1%, with indications of a concentrated epidemic among marginalized populations, especially MSM. The prevalence of missed diagnoses and late presentations in Lebanon is unknown.

In this study, we aimed to (1) assess the epidemiologic characteristics of subjects presenting to an HIV clinic in an academic medical center in Lebanon, (2) examine the rate and risk factors of late presentations, and (3) quantify missed opportunities among late presenters.

Materials and methods

Our study is a retrospective chart review of all newly diagnosed, treatment-naïve HIV-positive individuals, aged more than 18 years old, who presented to the American University of Beirut Medical Center (AUBMC) between January 1, 2012 and December 31, 2022. The AUBMC is an academic medical center in Lebanon with over 365 beds and a large outpatient department. The HIV-centered services started in 1984 and includes outpatient and inpatient services. The study was approved by the ethics committee, the Institutional Review Board (IRB) of the American University of Beirut Medical Center (AUBMC). The requirement for informed consent was waived by the Institutional Review Board at AUBMC due to the retrospective nature of the study. All research activities and methods were performed in accordance with the guidelines stated in the declaration of Helsinki and Belmont Report for research involving human subjects.

The subjects’ medical records were reviewed to collect demographic and clinical data including age at diagnosis, gender, nationality, sexual orientation, HIV transmission route, CD4 cell count, AIDS-defining conditions, and clinical indicator diseases at the time of diagnosis of HIV infection. MSM were defined as male participants reporting a homosexual or bisexual HIV-transmission mode and/or a sexual preference at the time of visit.

Outcome definitions

The primary outcome of interest was the proportion of individuals with a late presentation, defined as presenting for care with a CD4 cell count below 350 cells/μL at HIV diagnosis, or presenting with an AIDS-defining event regardless of the CD4 cell count 23 . Secondary outcomes included (1) factors associated with late presentation, (2) the proportion of individuals presenting with advanced HIV disease (AHD), defined as a CD4 count below 200 cells/μL or the presence of an AIDS-defining illness regardless of CD4 count 24 , and (3) missed opportunities for diagnoses, defined as failure to diagnose HIV in the presence of an IC that should have triggered testing for HIV as per guidelines 25 . Indicator conditions (IC) are classified as “AIDS defining illnesses” events and “other events” that are known to be associated with advanced HIV but not categorized as AIDS-defining 26 . Any IC that was present in the 3 years preceding HIV diagnosis, and not followed by a recommendation for HIV testing was considered a missed opportunity for earlier HIV diagnosis. ICs documented within 1 month of HIV diagnosis were considered related to the newly diagnosed disease and therefore not considered as a missed opportunity.

Statistical methods

We used descriptive statistics to analyze participant characteristics and outcomes of interest. Continuous variables are reported as median with interquartile range (IQR); categorical or ordinal variables as frequencies (N) and percentages (%). We explored the associations of several predictor variables with the outcome of late presentation using univariate and multivariable logistic regression model. Model selection was based on findings from other studies and age at diagnosis, gender, mode of transmission, and nationality were included. The calculated proportions for demographic, epidemiological, and clinical characteristics are derived after excluding cases with missing information from the denominator. We reported odds ratio (OR) with 95% confidence intervals (CI). All analyses were conducted in R (version 4.1, May 2021).

Participant characteristics at diagnosis

A total of 150 individuals newly diagnosed with HIV presented to our clinic between 2012 and 2022. The median age was 30.5 years (IQR 26–42 years), and the majority identified as men (N = 139, 92.7%) and Lebanese (N = 119, 79.3%) (Table 1 ). Most of the non-Lebanese individuals were Arab nationals (primarily originating from Iraq, Syria and Saudi Arabia) presenting to Lebanon for medical care. Overall, 82 (63.6%) individuals acquired HIV through MSM contact and 43 (33.3%) through heterosexual contact. Only 3.1% (N = 4) of patients reported IV drug use as the mode of HIV transmission.

Twenty-four (16%) of our newly diagnosed patients were aged more than 50 years old. Among them, 23 were males, and 1 was female. Within this sub-group, the median age at diagnosis was 58 years old. The median CD4 count was 197 cells/mm 3 , compared to 353 in our patients aged less than 50 years, with 13 (54.2%) patients presenting with a CD4 count less than 200. Fifteen were heterosexuals, and nine were men who have sex with men (Supplementary Table 1 ).

Late presentation

Overall, 77 individuals (51.3%) were late presenters and had a CD4 cell count of < 350 cells/mm 3 at the time of HIV diagnosis. Among those, 43 (55.8%) had a CD4 cell count of < 200 cells/mm 3 and 39 (50.6%) presented with AIDS-related conditions. A total of six individuals out of 150 died (15.4% of those presenting with an AIDS defining illness, 4.0% of all participants). The median CD4 cell count at HIV diagnosis was 506.5 (436.2–638.8) and 191.0 (67.0–258.0) cells/mm3 in non-late presenters and late presenters, respectively.

Late presentation was significantly associated with older age (OR 1.05, 95% CI 1.02–1.09, p = 0.003). Although an association with MSM transmission was observed, it did not reach statistical significance (OR 2.47, 95% CI 0.98–6.66, p = 0.062) (Supplementary Table 2 ).

Missed opportunities for earlier HIV testing

To identify indicator conditions, we reviewed medical records before the presentation and HIV diagnosis. Comprehensive data on indicator conditions were present in 51 of 77 charts of late presenters (66.2%). In total, there were 68 ICs among 39 participants (76.5%) in the preceding 3 years prior to HIV testing. Of the 39 participants with a missed opportunity for HIV diagnosis, 27 (69.2%) subjects had one or more AIDS-defining conditions and 9 (23.1%) subjects had ICs consistent with AIDS defining conditions. The most frequent ICs were unexplained weight loss (18/68, 26.5%), unexplained lymphadenopathy (9/68, 13.2%) unexplained fatigue and malaise (7/68, 10.3%), unexplained chronic diarrhea (6/68, 8.8%) and unexplained fever with no apparent etiology (6/68, 8.8%). Seven AIDS-defining ICs were identified. Those included recurrent pneumonia in five cases, four of which were confirmed to be pneumocystis jirovecii pneumonia (PCP) (Table 2 ).

Late presenters with advanced HIV

Among the 77 late presenters, 53 (68.8% of late presenters and 35.3% of all newly diagnosed) presented with an advanced HIV stage. Of these 53 participants, 39 (73.6%) had at least one AIDS defining illness at the time of diagnosis (44 conditions in total). The most frequent presentations were HIV wasting (16/44, 36.4%), PCP (9/44, 20.5%), candida esophagitis (4/44, 9.1%), cerebral toxoplasmosis (3/44, 6.8%), mycobacterium tuberculosis infection (2/44, 4.5%), Kaposi sarcoma (2/44, 4.5%), and Burkitt lymphoma (2/44, 4.5%) (Table 3 ).

Key findings

To the best of our knowledge, this is one of few studies in the MENA region assessing late presentations of HIV and missed opportunities for earlier diagnosis 17 , 18 , 19 , 27 , 28 . We found that more than half of the newly diagnosed subjects in our cohort (51.3%) were late presenters and 35.3% had advanced HIV disease on presentation. Mortality from HIV-related death was around 5% among our cohort while mortality from HIV in the world is approximately 2% 29 . Mortality among those presenting with AIDS in our cohort was approximately 16%. Almost three in four of late presenters had attended a medical facility for an IC in the 3 years preceding diagnosis; of these, almost one in four presented with an AIDS defining conditions without getting tested for HIV.

Evidence in context

As of December 2022, Lebanon had an estimated 2600 PLWH, with an incidence rate below 0.03% 30 . It is important to note that reported numbers likely underestimate the true count of PLWH in Lebanon, primarily due to reliance on passive reporting. Our findings correspond with those presented in the national report. In fact, the 2018 UNAIDS report revealed that 26% of individuals newly diagnosed with HIV in Lebanon presented at an advanced stage, characterized by an initial CD4 count below 200 cells/mm 3 31 . Few studies have described late presentations in the MENA region 32 , 33 . Our results are in line with data from Turkey and Iran. Studies conducted in Turkey found that 50–69% of the PLWH presented late to medical care, and 25–40% of subjects had advanced HIV at the time of diagnosis 26 , 34 , 35 , 36 , 37 . Similarly, a large retrospective cohort study conducted in Iran revealed a prevalence of late diagnosis in around 58.2% of subjects 17 . Surveillance studies from Yemen and Saudi Arabia showed higher prevalence of late HIV. The cohort study from Yemen showed that 83% of PLWH presented with a CD4 less than 350 and 52% with CD4 count less than 200 18 . The study from Saudi Arabia included 977 subjects and revealed that 20% of HIV positive subjects had a CD4 < 350 at diagnosis, and 50% presented with AIDS at diagnosis 19 . Late diagnosis indicates a gap in HIV testing 38 , 39 , which is a notable observation from the countries of the MENA region. In fact, according to the UNAIDS, by the end of 2018, more than half of PLWH in the MENA region were not aware of their seropositivity status 40 .

In our study, subjects who presented late were older and were men who had sex with men. Interestingly, women only represented 7.3% of our population (11 out of 150), indicating potential additional social obstacles that women encounter when seeking HIV care. This aligns with national data from Lebanon, indicating that the country faces a concentrated HIV epidemic among MSM, comprising 12% of cases 41 . While our study did not specifically address barriers to testing, the increased prevalence of late presenters among individuals aged more than 50 years and MSM in our cohort may be attributed to persistent barriers to adequate HIV testing 39 . This phenomenon could be linked to lower testing rates in these demographics, potentially influenced by social, cultural and legal barriers such as criminalization of homosexuality, stigma preventing adequate sexual education, lack of access to HIV testing and poor comprehensive sexual and reproductive health provision 42 . Around six out of ten people with HIV are from marginalized groups, including MSM, transgender individuals, IV drug users, sex workers, and their clients 43 . However, it is precisely these marginalized communities who encounter significant challenges in accessing HIV prevention, testing, treatment, and care services due to stigma and discrimination. We performed subgroup analyses for the subgroups late presenters with and without advanced disease (presented in Supplemental Table 3 ). As expected, the only difference was the CD4 count, 281 and 89 cells/mml for the without and with advanced disease, respectively.

PLWH in Lebanon continue to face social stigmatization and discrimination impacting different aspects of their lives. Particularly, the MSM population experiences homophobia and legal consequences, given that the Lebanese penal code prohibits sexual relations deemed "contradicting the laws of nature", punishable by up to a year in prison. Nevertheless, Lebanon is relatively more accepting of sexual rights compared to other countries in the MENA region, making it a favorable location for getting tested and treated for HIV 44 . HIV testing is available at medical laboratories, hospitals, or free of charge at Voluntary Counseling and Testing (VCT) centers in Lebanon. These centers are spread throughout the country, ensuring accessibility for the entire population, including refugees. Lebanon follows a comprehensive "treatment for all" strategy in addressing HIV/AIDS 45 . The Ministry of Public Health (MOPH) provides free treatment to over 60% of individuals aware of their HIV status including Syrian and Palestinian refugees.

There is a paucity of published data on missed opportunities in the MENA region. Similar to our findings, a study from Morocco reported that 69% of their 650-subject cohort had missed opportunities for HIV testing 15 . In contrast, studies from countries outside the MENA region such as Italy, Sweden, Germany and UK showed that 21–27% of newly diagnosed HIV subjects who sought medical care for ICs were not offered HIV testing 46 , 47 , 48 , 49 , 50 . The missed opportunity proportion is higher in our cohort. Limited awareness or knowledge among healthcare workers, along with negative perceptions and stigma associated with HIV within this group, may account for missed opportunities. Risk factors for HIV infection might not be adequately addressed by the treating physician. Firstly, subjects may not have disclosed their sexual activity, sexual orientation, and gender identity because of fear of discrimination and stigma. Secondly, healthcare workers with negative perceptions towards specific populations—sex workers, IV drug users, LGBTQ + community- and lack of adequate training regarding sexual health matters often fail to properly address the behaviors and sexual orientations of their subjects 51 .

Missed opportunities can lead to late detection and diagnosis of HIV with consequent associated complications including higher morbidity and mortality, altered response to antiretroviral therapy (ART) , increased cost of medical care, and HIV transmission within the community 46 , 52 , 53 . More efforts are needed to provide HIV-specific training and to eliminate stigma and discrimination related to HIV among healthcare providers.

Limitations

Our study has several limitations that may have influenced our findings. Firstly, being a single-center study could restrict the generalizability of our results to the broader Lebanese population or other populations. The retrospective nature of our study also posed limitations on data collection, particularly regarding socioeconomic aspects such as housing situation, poverty, and risky sexual practices, which could have offered additional insights into factors associated with late presentation and missed opportunities.

Moreover, there is a potential underestimation of the proportion of missed opportunities in our population. Our results rely on data collected from medical records, and other opportunities may have been present but not documented. Conversely, we cannot guarantee that verbal recommendations for HIV testing by healthcare providers were documented or, if refused by the subject, leading to a possible overestimation of missed opportunities.

The collected data also lacked crucial clinical details on management and follow-up. Notably, some subjects were discharged to home with hospice care, despite their initial diagnosis being conducted at our center. The initiation of Antiretroviral Therapy (ART) presents an intriguing aspect; however, our data collection did not encompass this specific information for all subjects. Similarly, details regarding the time to death and potential Immune Reconstitution Inflammatory Syndrome (IRIS) were not included in our data collection.

Unforeseen circumstances significantly impacted our study, especially after 2019, affecting clinic follow-up, detailed history, and thorough evaluation and diagnostic investigation. Lebanon faced political turmoil and economic failure starting in 2019, resulting in disruptions to clinical operations and ongoing follow-up. The subsequent COVID-19 pandemic further compounded the situation by imposing additional movement restrictions through lockdowns, leading to several subjects either being lost to follow-up or conducting virtual visits.

In our cohort, and likely in the MENA region, late presentation with HIV and missed opportunities for HIV diagnosis are common, even in instances where HIV testing is clearly indicated. To effectively influence policies, it is imperative to expand research efforts and conduct comprehensive analyses to quantify the proportion of late presenters and missed opportunities in the region, and to explore the factors contributing to these findings. Future studies should prioritize the estimation of the preventable financial burden associated with late HIV presentation resulting from diminished productivity and increased healthcare expenditure. Another concern pertaining to healthcare providers’ attitudes and competencies should trigger a serious reform in the healthcare provider curricula regarding sexual health and reproductive health issues.

Data availability

De-identified participant data that underlie the results reported in this article can be shared upon reasonable requests to the corresponding author. Data requestors will need to sign a data access agreement form.

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These authors contributed equally: Haya Farhat and Mohammad El Hussein.

Authors and Affiliations

Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon

Maya Mahmoud

Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich (UZH), Zurich, Switzerland

Tala Ballouz

Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon

Chloe Lahoud, Jana Adnan, Paola Abi Habib, Reem Saab, Haya Farhat & Mohammad El Hussein

Division of Infectious Diseases, Department of Internal Medicine, American University of Beirut Medical Center, Riad El Solh, Beirut, 1107 2020, Lebanon

Nesrine Rizk

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M.M: data collection, data interpretation, manuscript writing, manuscript review and editing. T.B: manuscript writing and conceptualization, data analysis and interpretation. C.L: data collection, manuscript review and editing. J.A: data collection, manuscript review and editing. P.A.H: data collection, manuscript review and editing. R.S: data collection, manuscript review and editing. H.F: data collection, manuscript review and editing. M.E.H: data collection. N.R: manuscript writing, manuscript review and editing, and conceptualization.

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Mahmoud, M., Ballouz, T., Lahoud, C. et al. Late presentations and missed opportunities among newly diagnosed HIV patients presenting to a specialty clinic in Lebanon. Sci Rep 14 , 8296 (2024). https://doi.org/10.1038/s41598-024-55277-1

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DOI : https://doi.org/10.1038/s41598-024-55277-1

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