Presentation of a patient

Presentation of a PatientPresentation of a Patient

““I saw the guy in room 3..”I saw the guy in room 3..”

Anatomy of the Anatomy of the PresentationPresentation

Organization of a large amount of Organization of a large amount of informationinformation

Systematic approach to presentationSystematic approach to presentation Understanding your audience (the Understanding your audience (the

physician to whom you are presentingphysician to whom you are presenting Having a planHaving a plan Presenting with confidencePresenting with confidence


Depending on the setting, your Depending on the setting, your presentation may be brief or more presentation may be brief or more thoroughthorough

Thorough/more in depth presentationsThorough/more in depth presentations Primary Care/Internal Medicine,inpatient Primary Care/Internal Medicine,inpatient

hospitalizationhospitalization Brief, focused presentationsBrief, focused presentations

ER, Urgent Care, Sub-specialties (surgery, ER, Urgent Care, Sub-specialties (surgery, dermatology) dermatology)


How much info do I need?How much info do I need? Access to information depends on:Access to information depends on:

The setting of the patient encounterThe setting of the patient encounter The mental status of the patientThe mental status of the patient Presence of a caregiver or other Presence of a caregiver or other

historianhistorian Availability of prior medical recordsAvailability of prior medical records Time frame in which you have to see the Time frame in which you have to see the

patientpatient


How much info do I need?How much info do I need? Consider your audience (the Consider your audience (the

physician)physician) Do they prefer a brief or more thorough Do they prefer a brief or more thorough

presentation?presentation? What information do they want?What information do they want? Do they expect a treatment plan from Do they expect a treatment plan from

you?you? Do they want you to examine the patient Do they want you to examine the patient

and report your findings?and report your findings?

Where do I begin??Where do I begin??

Before presenting the case, make sure you Before presenting the case, make sure you have done the following: (if time permits)have done the following: (if time permits) Review the chartReview the chart Read nursing notesRead nursing notes Check the vital signsCheck the vital signs Obtain and review old recordsObtain and review old records

In hospital-look for previous admissions and/or In hospital-look for previous admissions and/or consultsconsults

In office-check last few office visitsIn office-check last few office visits Compare old and new information (weight, vital Compare old and new information (weight, vital

signs, EKGs)signs, EKGs) Look at old labsLook at old labs Look at old medications and compare with current listLook at old medications and compare with current list

Where do I begin??Where do I begin?? Compare the triage/nursing assessment Compare the triage/nursing assessment

with your ownwith your own Often times the patient’s “story” will Often times the patient’s “story” will

change with each assessmentchange with each assessment ““He didn’t tell ME he had chest pain!”He didn’t tell ME he had chest pain!”

Do not be discouraged if the patient Do not be discouraged if the patient gives the doctor a completely gives the doctor a completely different chief complaint and historydifferent chief complaint and history

If there is a discrepancy between histories, If there is a discrepancy between histories, make sure you document thismake sure you document this i.e. if the patient told you he has chest pain i.e. if the patient told you he has chest pain

and denied it to the nurse you might write and denied it to the nurse you might write “disagree with triage, patient also complains of “disagree with triage, patient also complains of chest pain which began 30 minutes ago” chest pain which began 30 minutes ago”

Key points to considerKey points to consider

For the grand plan some of the most For the grand plan some of the most important pieces of information will be:important pieces of information will be:

Why is the patient here?Why is the patient here? Where will they best receive Where will they best receive

treatment?treatment? Do they need hospitalization or can Do they need hospitalization or can

they be they be treated as an outpatienttreated as an outpatient Do they need specialty referral?Do they need specialty referral? Is compliance likely?Is compliance likely?

““I saw the lady in room 3..now I saw the lady in room 3..now what?”what?”

ID the patient and their locationID the patient and their location Use their name and a limited Use their name and a limited

amount of identifying informationamount of identifying information Do’sDo’s

State their nameState their name State their ageState their age State their locationState their location

(e.g. Ms. Rodriguez is a 38 year old female (e.g. Ms. Rodriguez is a 38 year old female in bed 3)in bed 3)

““I saw the hemorrhoid in room I saw the hemorrhoid in room 3”3”

Don’tsDon’ts Refer to the patient by their room number “I saw Refer to the patient by their room number “I saw

3”3” patients get moved from room to room or may be patients get moved from room to room or may be

moved to a different department moved to a different department Save yourself the embarrassment of having your Save yourself the embarrassment of having your

supervising physician blaming you after he has examined supervising physician blaming you after he has examined the wrong patient because he took your word for it and the wrong patient because he took your word for it and went to room 3 while your patient had been moved to went to room 3 while your patient had been moved to room 6room 6

Identify the patient by their diagnosis, disease, or Identify the patient by their diagnosis, disease, or complaintcomplaint

each patient is a human with one or more immediate each patient is a human with one or more immediate health care needs. Patients are health care needs. Patients are PEOPLEPEOPLE not DISEASES not DISEASES

Chief complaintChief complaint

State the chief complaint, and give a State the chief complaint, and give a limited amount of history of present limited amount of history of present illness. Provide illness. Provide relevantrelevant details. details.

How long has the symptom or problem How long has the symptom or problem been present? Has the patient had been present? Has the patient had previous episodes? Is this an exacerbation previous episodes? Is this an exacerbation of a previously diagnosed chronic of a previously diagnosed chronic condition (i.e. asthma, GERD, or condition (i.e. asthma, GERD, or hypertension) hypertension)

““Ms. Rodriguez is a 38 year old female in bed 3 who Ms. Rodriguez is a 38 year old female in bed 3 who c/o cough and SOB x 2 days, which she has had c/o cough and SOB x 2 days, which she has had before, but is now worse”before, but is now worse”


Has the patient sought care regarding the Has the patient sought care regarding the problem in the past? If so, what was done? problem in the past? If so, what was done?

If the symptom is a pain, describe it:If the symptom is a pain, describe it: character of the pain (e.g. sharp, dull, character of the pain (e.g. sharp, dull,

radiating, etc)radiating, etc) Consistency (constant, intermittent) Consistency (constant, intermittent)

Associated symptoms (nausea, vomiting, Associated symptoms (nausea, vomiting, chills, etc)chills, etc)

Aggravating/relieving factors Aggravating/relieving factors Similar problem in the past?Similar problem in the past?


““Ms. Rodriguez is a 38 year old female Ms. Rodriguez is a 38 year old female in bed 3 who c/o cough and SOB x 2 in bed 3 who c/o cough and SOB x 2 days, which she has had before, but is days, which she has had before, but is now worse. She does have some CP, but now worse. She does have some CP, but only with cough and deep inspiration”only with cough and deep inspiration”

Past Medical HistoryPast Medical History

Briefly, in 1-2 sentences, indicate the Briefly, in 1-2 sentences, indicate the PMH. PMH. ““She has a 10 year history of She has a 10 year history of

hypertension, COPD, and has end stage hypertension, COPD, and has end stage renal disease and has been on dialysis for renal disease and has been on dialysis for 3 years.”3 years.”

You might also include pertinent You might also include pertinent negatives:negatives: ““..but no history of diabetes..” ..but no history of diabetes..”

Past Medical HistoryPast Medical History

When presenting a neonate, infant, When presenting a neonate, infant, or toddler, consider presenting or toddler, consider presenting additional information:additional information: presence/absence of prenatal carepresence/absence of prenatal care birth history (spontaneous, induced)birth history (spontaneous, induced) Vaginal delivery, C-section, any Vaginal delivery, C-section, any

complicationscomplications

Past Surgical HistoryPast Surgical History

This doesn’t necessarily need to be in your This doesn’t necessarily need to be in your presentation for all patients. presentation for all patients.

becomes important if the patient’s chief becomes important if the patient’s chief complaint may be suggestive of a surgical complaint may be suggestive of a surgical problem problem if the patient is a 40 year old female with abdominal if the patient is a 40 year old female with abdominal

pain, nausea, and vomiting but has had an pain, nausea, and vomiting but has had an appendectomy at age 25, it is appropriate to mention appendectomy at age 25, it is appropriate to mention thisthis

If the patient had recent surgery and complains of pain If the patient had recent surgery and complains of pain and/or drainage at the surgical site and/or drainage at the surgical site

If the patient had recent surgery and complains of chest If the patient had recent surgery and complains of chest pain and/or SOBpain and/or SOB

MedicationsMedications

List patient’s medications along with their List patient’s medications along with their disease processesdisease processes She takes Lisinopril for HTN, Glyburide for DM, She takes Lisinopril for HTN, Glyburide for DM,

and an aspirin dailyand an aspirin daily Some patients may not think they have a Some patients may not think they have a

diagnosis if they are taking medication for itdiagnosis if they are taking medication for it ““I see you are taking Lisinopril, which is for I see you are taking Lisinopril, which is for

HTN..You said you didn’t have any PMH”HTN..You said you didn’t have any PMH” ““Oh yeah…I take that for my blood pressure”Oh yeah…I take that for my blood pressure”

GYN HistoryGYN History

State this if it is applicable to the chief State this if it is applicable to the chief complaintcomplaint if the patient is a 25 year old female with a finger if the patient is a 25 year old female with a finger

laceration and she will need an xray so you would laceration and she will need an xray so you would need to present the LMP at mostneed to present the LMP at most

If the patient is complaining of abdominal pain, If the patient is complaining of abdominal pain, vaginal bleeding, or has symptoms that suggest vaginal bleeding, or has symptoms that suggest any type of endocrine or gynecologic problem, any type of endocrine or gynecologic problem, then more detailed information about the GYN then more detailed information about the GYN history is important and should be presented history is important and should be presented

(i.e. G4P0A3 with a hx of PCOS and fibroids..)(i.e. G4P0A3 with a hx of PCOS and fibroids..)

Vital SignsVital Signs

““The vital signs don’t lie”The vital signs don’t lie” If the VS are normal you may say If the VS are normal you may say

thatthat If the VS are normal other than one If the VS are normal other than one

of them, state the abnormal VS firstof them, state the abnormal VS first i.e. Temperature is 101.3, the rest of the i.e. Temperature is 101.3, the rest of the

VS are WNL (within normal limits)VS are WNL (within normal limits)

Physical FindingsPhysical Findings

You don’t have to state every single detail You don’t have to state every single detail that you found during the exam. that you found during the exam.

Start with the patient’s Start with the patient’s general appearancegeneral appearance ““Not ill appearing” or “Looks toxic” or “In no Not ill appearing” or “Looks toxic” or “In no

acute distress” or “Pleasant, disheveled, with an acute distress” or “Pleasant, disheveled, with an odor of alcohol” odor of alcohol”

Give the findings from the physical exam Give the findings from the physical exam that are relevant to the chief complaint and that are relevant to the chief complaint and any findings that help to either rule in or any findings that help to either rule in or rule out disease. rule out disease.

Physical FindingsPhysical Findings

Findings are pertinent if they:Findings are pertinent if they: help rule in or rule out diseasehelp rule in or rule out disease are related to the chief complaintare related to the chief complaint are grossly abnormal finding and requiring are grossly abnormal finding and requiring

either immediate attention either immediate attention If the patient complains of cough, If the patient complains of cough,

onychomycosis is probably not relevant onychomycosis is probably not relevant ““Lungs are clear” or “Diminshed breath Lungs are clear” or “Diminshed breath

sounds and rales at the right lower lobe”sounds and rales at the right lower lobe”

Make a problem listMake a problem list(at least make one in your (at least make one in your

head)head) This should be an ongoing processThis should be an ongoing process Prioritizing the patient’s issues is also Prioritizing the patient’s issues is also

important with regards to deciding important with regards to deciding which tests or labs should be done.which tests or labs should be done.

Choose which issues should be Choose which issues should be addressed immediately and which addressed immediately and which can waitcan wait

Make your assessmentMake your assessment

State your suspected diagnosisState your suspected diagnosis When you make your assessment, give consideration When you make your assessment, give consideration

a a differential diagnosisdifferential diagnosis that will tie together the that will tie together the elements of the problem list.elements of the problem list. There may not always be one diagnosis for all of There may not always be one diagnosis for all of

the symptomsthe symptoms Some patients will have an isolated, obvious complaint Some patients will have an isolated, obvious complaint

(i.e. laceration) with a clear-cut plan(i.e. laceration) with a clear-cut plan

State your planState your plan

The plan should be supported by the chief The plan should be supported by the chief complaint and the data in your physical exam.complaint and the data in your physical exam.

When you give the plan, have an idea of what When you give the plan, have an idea of what you are looking for and how you plan to find ityou are looking for and how you plan to find it If you are ordering a lab test, justify why you are If you are ordering a lab test, justify why you are

ordering itordering it A physician may ask you, “Why are you getting A physician may ask you, “Why are you getting

that?” Make sure the test will actually TELL you that?” Make sure the test will actually TELL you somethingsomething

Do not order tests just for the sake of ordering them-Do not order tests just for the sake of ordering them-this is not cost effective this is not cost effective

Patient dispositionPatient disposition

Will the patient need inpatient care?Will the patient need inpatient care? Can the patient be managed at Can the patient be managed at

home?home? Will the patient most likely be Will the patient most likely be

compliant?compliant? Does the patient need referrals?Does the patient need referrals? When will the patient follow up?When will the patient follow up?

TipsTips Be organizedBe organized Present the Present the patientpatient as well as the as well as the illnessillness.. Include only the most essential facts; but be ready to Include only the most essential facts; but be ready to

answer ANY questions about all aspects of your patient. answer ANY questions about all aspects of your patient. Keep your presentation lively. Keep your presentation lively. Be confident!Be confident! Do not read the presentation! Do not read the presentation! Expect your listeners to ask questions. Expect your listeners to ask questions. Follow the order of the written case report. Follow the order of the written case report. Keep in mind the limitation of your listeners. Keep in mind the limitation of your listeners. Beware of jumping back and forth between descriptions Beware of jumping back and forth between descriptions

of separate problems. of separate problems. Use the presentation to build your case. Use the presentation to build your case. Be prepared to discuss your reasoning process Be prepared to discuss your reasoning process

Presentation of a patient

Health & Medicine

Transcript of Presentation of a patient