SNAPPS ORAL PRESENTATION TEMPLATE
SNAPPS ORAL PRESENTATION TEMPLATE
This template should only be used to organize your oral presentation, IT SHOULD NOT BE SUBMITTED.
SUMMARIZE
Using a patient seen in the practicum setting, summarize the H&P into an organized and concise format.
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Irregular menses, increase fatigue and feeling dizzy when standing up too fast |
| HPI statement using OLDCARTS data | 24-year old obese African American female presents with a chief complaint of irregular and heavy menses, increased fatigue and feeling dizzy when standing up too fast. She does report that her menses typically last 7 days and heavy on days 2-6 with multiple clots. Her cycles c typically come every 28-30 days. However, she states that recently she has had some spotting between cycles and states her menses has been coming increasingly sooner. She is sexually active and denies uterine pain or pain during intercourse but states she notices spotting after. She reports that her current form of birth control is condom usage. Her last menstrual period was 2 weeks ago and states she is currently spotting. She reports history of Anemia after delivery of her child 2 years ago, that was treated with OTC iron supplements. She is not currently on any medications. SNAPPS ORAL PRESENTATION TEMPLATE
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O— Irregular period started four months ago, increased fatigue started one a month ago, feeling dizzy when standing up too fast started one week ago. L— generalized fatigue D— some of the symptoms are intermittent (like feeling dizzy when standing too fast). And some are constant (like the irregular menses and fatigue). C— On day one, there is spotting. On day 2 through day 4, she states she must wear both a sanitary napkin and tampon and states she must change both every 1-2 hours, she reports passing multiple clots during this time. On day 5 and 6, she changes both sanitary napkin and tampon every 2-4 hours. On day 7, there is spotting again. A— intermittent spotting noted after intercourse. R—There are no relieving factors noted by the patient at this time. T— There are no identifiable treatments noted by the patient at this time. S— The severity has increased. When the fatigue started, she was able to function daily and take care of her daughter. Now she is unable to care for her children without the assistance of her mother daily. The dizziness SNAPPS ORAL PRESENTATION TEMPLATE
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| Pertinent ROS | Constitutional: No current fever, chills, or body aches
Respiratory: No symptoms Gastrointestinal: Denies abd pain, hx of appendix removal Genitourinary: No symptoms Hematology/Lymphatics: no swollen lymph glands, Hx of anemia after baby 2 years ago. Neurologic: No Headache
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| Pertinent PE | Vitas & Measurements
T: 37.1, HR 90, RR 20, BP 101/52, SpO2 96%, BMI 36.2
GEN: A/O X3 In no acute distress, appears stated age, overweight
PULM: Clear to auscultation, no retractions
CARDIO: Tachy with Regular rhythm, no Carotid Bruits, PP equal 2+ x4,
Cap refill less than 3 secs, brittle nails noted with cold fingertips.
ABD: Non tender, BS qual x4, no CVA tenderness
Neuro/{SYCH: sluggish mood noted, no focal deficits.
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NARROW
Based on the H&P key findings, identify an appropriate differential.
| I have narrowed my differential to Anemia secondary to increase blood loss from heavy menstrual cycle. Next, I will analyze my differentials to show you why I came to this conclusion.
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ANALYZE
Analyze the differential by comparing and contrasting the possibilities. Use pertinent positive and negative findings to argue for or against each diagnosis in your differential. Rank your diagnoses in order of most likely to least likely.
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1. My top differential is Iron Deficiency Anemia. The most likely cause of this would be to the increase in blood loss over the past four months. The duration of her symptoms and the fact that this was a gradual onset with worsening symptoms supports this differential over the remaining differentials. 12% of women aged 12 to 49 have iron deficient anemia. Anemia occurs when there are less red blood cells in the body then needed. Carrying oxygen to the body tissues, is the job of the red blood cells. Iron is used by the body to build red blood cells. Low Iron levels due to blood loss is a common cause of anemia. Heavy Menstruation puts women at ran increased risk for low iron levels. Positive signs of anemia fatigue, tachy, pale conjunctiva, brittle nails. Negative, no SOB noted 2. Another differential would be Dysfunctional uterine bleeding due to the increasing heavy bleeding, blood clots, spotting between periods, shifts in time between periods, and fatigue. This is caused by an imbalance of the female hormones estrogen and progesterone. When a menstrual cycle in which no egg is released, is the most common cause of this. Without an egg, the body does not produce progesterone causing the lining of the uterus to thicken by estrogen. 3. Endometriosis can also be a differential due to the heavy menstrual cycle. However, this seems unlikely as the patient is not complaining of abdominal pain or pain with intercourse 4. Rarely, Uterine fibroids can also be a differential due to the bleeding between periods. However, this is also unlikely as the patient denies abdominal or pelvic pain, pain during intercourse, or difficulty urinating. SNAPPS ORAL PRESENTATION TEMPLATE
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PROBE
Verbalize any knowledge gaps, points of confusion or dilemmas that you have regarding your understanding of the case by identifying questions that you would (or did) ask your preceptor.
| I was unsure about the actual differentials for this patient as they all require more testing to be 100% diagnosed. I questioned my preceptor and she explained how the risk of not treating the patient for Iron deficiency anemia until the lab results could be harmful to the patient. The harm to the patient would be to large when the patient could have already started treatment.
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PLAN
At a novice level, propose an appropriate plan to confirm and/or manage the problem.
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1. Fatigue, increased HR, heavy and irregular menstrual cycle with dizziness when getting up too fast.
Ordered: Labs—CBC with type and screen, CMP, HCG -Ferrus sulfate 325mg Daily, Folic acid 1mg daily (will increase both BID if Hbg lower than 9). -Abdominal/ trans vaginal Ultrasound -Referral to OBGYN
Return to the office if symptoms persist. Instructions on rising slowly and maintaining safelty measures. Go to the nearest ER of symptoms worsen
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SELF-DIRECTED LEARNING
Identify one issue for self-directed learning.
| Then knowledge gaps that I had with this patient is treating a diagnosis that you have no “actual” proof of.
Therefore, I have chosen Iron Deficiency anemia as my self-directed learning assignment.
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In the written portion of this assignment, you will present your findings.
