Vinod Kurup, MD 8/12/2010
Be Brief. Gets the listener primed for what type of case is going to be presented.
“This is a 33 year old male with a history of asthma who presents with a chief complaint of dyspnea.”
This is the meat of the presentation. Pretend that you’re telling the patient's story to a friend. How much information would they need to really understand what the patient is going through? Think about it from the patient’s perspective. What was the tipping point that made them seek medical attention? What have they tried to make things better? Stay consistent in your timeline. I like to start at the last point that the patient was completely well. In patients with chronic illness, that is hard, so you may have to start at the last time that they were “relatively” well.
“He was completely well (or “in his usual state of health” for chronically ill patients) until 5 days ago, when he noticed feeling short of breath after walking 300 feet to his mailbox. Over the course of the next 5 days, his dyspnea worsened to the point that he was short of breath at rest. He tried taking his albuterol inhaler, but felt no relief. Etc…”
You may have mentioned a few of these in the CC, but repeat them here. For most conditions, just list the diagnosis, but if it has particular pertinence to the HPI, then provide more detail. Also, try to give some indication of the severity of the condition for certain conditions: CHF (EF), DM (A1C), COPD (FEV1).
“Past medical history includes Asthma. He has been hospitalized twice in the past year, and required mechanical ventilation in April. He also has hypertension and allergic rhinitis.”
List meds like a robot :-) Include doses if they are important. You’ll learn the importance of doses with experience. In general, if the med is related to the HPI, I want to know the dose. You can’t go wrong by just giving me the dose on each med. Just run through them quickly
You should obviously have done these portions of the interview, but if they were important, I would have wanted to hear about it in the HPI. (Pt lives in a nursing home… Pt smokes… etc.) It’s OK to go over it quickly, but probably better to say ‘FH/SH/ROS is unremarkable aside from what was presented in HPI’
List the VS: Temp/HR/BP/RR/O2 sat. Then provide an overall impression: In general, the patient appears tired and seemed to be in mild respiratory distress.
Pertinent negatives and significant positives only: Lung exam was remarkable for diffuse expiratory wheezes with accessory muscle use. Cardiac exam confirmed tachycardia. There was no lower extremity edema and the remainder of the complete physical exam was normal.
Be completely objective. Avoid downplaying your exam skills. It’s OK to get things wrong – it’s often the best way to learn. Avoid patient interpretations here.
If it’s all normal, OK to say it’s all normal, but if any are abnormal, I like to hear each value in that group.
Brief sentence on what happened in the ER before you saw the patient.
Second juicy part of the presentation. Identify each problem and go one by one. Put the most pressing issue first. If the diagnosis is in question, give me a differential diagnosis and let me know what we’re doing to rule out items on the differential. If the diagnosis is relatively certain, present me with various therapeutic options and the reason why you chose the one you did.
Think about “goals of care”, if appropriate
Always mention disposition. What are we looking for before the patient can be discharged? In some cases, this will be nebulous, but at least mention it. “Disposition is unclear at this point because of X”
What happened after you put your plan in place? Brief status report on how patient is doing today.
Subsequent Day Presentations:
1 line about patient: “Ms Jones is our 87 year old woman here with an aspiration pneumonia”
Overnight course: “Since yesterday’s rounds, she has had a speech evaluation and they recommended a video swallow study. She had one temperature spike to 38.5 degrees and blood cultures were drawn. She appears to more comfortable this morning, though she is still confused.”
Exam: Vitals, superquick exam describing pertinents only
Labs: Any new labs that came back since we met for rounds yesterday.
Plan for today: Go by problem again. “Problem 1: aspiration pneumonia, she’s on D3 of Zosyn and we will continue to followup cultures. Overall she seems improved, but we’ll have to continue to monitor her mental status and oxygenation for further improvement. Problem 2: Altered mental status: This is almost certainly due to her pneumonia, but if it does not improve by tomorrow, we may consider other etiologies. At that point, repeat labs, EKG, and head CT may be indicated. … Problem 53: Disposition..."
Be prepared to answer questions if you have been appropiately brief!