Presenting the Patient Lecture (Dr. Cox) Flashcards
General Notes of Presenting
- Presentations reflect your development and experience
a) Less detail being required as you progress
Preparing for Presentation
Four this to CONSIDER BEFORE you do you Oral Presentation:
1) Message
2) Audience
3) Purpose
4) Occasion (Setting and Circumstances)
Preparing for Presentation
Be prepared to answer the following questions about…
1) Etiology
2) Pathophysiology
3) Diagnosis
4) Complications
5) Differentail Diagnosis
6) Course of Conditions
7) Treatment and Techniques
8) Diagnostic Tests
9) Curent and Past Medications
Preparing for the Presentation
Other Measures to take
- PATIENT EVALUATION:
- History, examination, review of tests, studies, procedures, and Consultant recommendations - SELECTED READING:
- Reference texts- to build a FOUNDATIONAL Understanding - LITERATURE RESEARCH:
- For clarification of any key references, and to bring your understanding “up to date” - WRITE UP (NOTES):
- For Oral Presentation, just key information to serve as a reminder or reference, since you’re not going to be reading your presentation
How to Present a Patient
- Many variations on this theme
- Inpatient vs Outpatient
- Varies by specialty, attending:
a) FM: Ms Smith is a 23 y/o female who presents with…..
b) FM: Ms Smith is a 23 y/o Hispanic married mother of two…
c) OB: Ms Smith is a 23 y/o G3P2….
d) Ortho: Ms Smith is a 23 y/o right-handed typist….
How to Present a Patient
Common Requirement:
- Be Succinct and Logical
- Present from MENTAL TEMPLATE
a) DO NOT Read From Notes
b) Fill in the Boxes in your Mental Template
Type of Presentations
1) New Patient
2) Follow up
3) Bedside
Types of Patient Presentation
NEW PATIENT
- Traditional H & P with assessment and plan
a) Remember, Attending PREFERENCES exist - Give the Chief Complaint and pertinent HPI
- Important PMH, PSH, etc.
- The ROS is often left out
a) Incorporate into HPI - PE-give PERTINENT Positives and Negatives
- The ASSESSMENT and PLAN should include what you think is wrong, WHAT you want to do about it, and WHY
Type of Patient Presentations
FOLLOW- UP
- Patient’s Name, Age, Date of admission or hospital day #, postop day #, etc.
- Recap Major patient ISSUES that have been previously presented (requires chart review) and what has changed
- Briefly REVIEW the present Illness, Physical Exam and Diagnosis
- Report any NEW FINDING, Laboratory Tests, Diagnostic Procedures and CHANGES in meds, assessment and plan for the day
Types of Patient Presentations
BEDSIDE
- The Attending physician will ASK the Patient’s PERMISSION to have the medical student present their case
- After making the Proper Introductions the attending will let the Patient KNOW they may OFFER Input or ASK Questions at any point
a) When presenting at bedside the student should INVOLVE the Patient
Basic Template for Oral Presentation
1) Patient Description
2) Chief Complaint/ History of Chief Complaint
3) Pertinent Review of Symptoms
4) Pertinent Medical, Social, and Family History
5) Physical Exam
6) Labs and Tests
7) Assessment and Plan
Template for Oral Presentation
CHIEF COMPLAIN
- The opening statement should give an OVERVIEW of the Patient, Age, Sex, REASON for Visit and the Duration
- If your patient has a HISTORY of a MAJOR Medical Problem that bears strongly on the Understanding of the present illness, include it
- For ONGOING CARE, give a One Sentence RECAP of the history
Template for Oral Presentation
Starts with HPI
O, L, D, C, A, A, A, R, T, S
HPI- Cold Read:
- Character
- Onset
- Location
- Duration
- Radiation
- Exacerbation
- Alleviate
- Different Today
Template for Oral Presentation
HISTORY OF PRESENT ILLNESS (HPI)
- Very similar to your Written HPI
- Present the MOST IMPORTANT PROBLEM FIRST!!!!!!!!
- If there is more than One Problem, Treat Each SEPARATELY
- Present he Information CHRONOLOGICALLY!!!!!
- Cover one system before moving on
- When you do you first Patient Presentation you may be expected to GO INTO DETAIL
- ONGOING CARE, Present Changes and NEW Complaints
Template for Oral Presentation
PAST MEDICAL HISTORY, PAST SURGICAL HISTORY
- CHRONIC Diseases: DM, HTN, Cancer, COPD, Heart Failure
- Previous Hospitalizations
- INFECTIOUS Diseases: Rheumatic Fever, Polio, TB, Measles, Mumps, Hepatitis
- IMMUNICATIONS: Are they Current, if adult last Flu and Pneumonia Vaccines, Tetanus, PPD
- HEART MAINTENANCE: Screening Tests that are applicable for Age-Colonoscopy, Mammo, PAP Smear, Etc
- SURGERIES
Template for Oral Presentation
MEDICATIONS/ ALLERGIES
- Present ALL CURRENT MEDICATIONS along with Dosage, Route, and Frequency
a) Some Physicians will ONLY want to hear meds related to the Patients Admission - For the Follow-Up Presentation just give any CHANGES in MEDS
a) Some Physicians may want to know “Day 4 on Vancomycin” For Example
Template for Oral Presentations
SOCIAL HISTORY and FAMILY HISTORY
SOCIAL HISTORY:
- Living Situation, Marital Status, Religion, Children, Employment. Also includes use and quantity of ETOH, Tobacco Products, Caffeine, and Illicit Drugs
a) SPECIAL PROBLEMS such as Financial, Social, Family, Physical Limitations, Insurance Concerns should also be discussed
FAMILY HISTORY:
- Relative, Health Problems, Age of Onset, Living/Dead. Include any history of Heart Disease, MI, Diabetes, Cancer, Respiratory Diseases, HTN, and Mental Illness. State of Health of Parents/Sibs
Note about ROS
- Most attending want PERTINENT ROS (Associated Symptoms)
- Can incorporate this in the HPI
ROS: PERTINENT Positive and Negative, vs Complete, Physician Dependent
ROS: General
- Wt. change, fatigue, weakness, fever, chills, night sweats.
ROS: Skin
- Changes in hair, skin, nails, itching, sores, rashes, lumps or moles
ROS: HEENT
- Trauma, vertigo, syncope, cephalgia, blindness, photophobia, blurred vision, diplopia, cataracts, glaucoma, deafness, tinnitus, pain, discharge, recurrent infections, rhinitis, epistaxis, smell, oral lesions, sore throat, hoarseness, dysphagia, swelling, lymph nodes
ROS: Breasts
- Skin changes, masses/lumps, pain, discharge, nipple change, monthly self breast exam, mammogram
ROS: Respiratory
- Dyspnea, wheeze, cough, sputum, hemoptysis, pneumonia, asthma, bronchitis, emphysema, TB, night sweats, last CXR
ROS: Cardiovascular
- HTN, murmurs, chest pain, palpitations, dyspnea on exertion, orthopnea, claudication, edema, varicosities, thrombosis or emboli, last ECG
ROS: GI
- Appetite, N/V, indigestion, dysphagia, changes in bowel habits (frequency, constipation/diarrhea), hx of hemetemisis, hemorrhoids, melena, hematochizia, abdominal pain, jaundice or hepatitis, pancreatitis, GB
ROS: Urinary
- Frequency, hesitancy, dysuria, urgency, polyuria, hematuria, nocturia, stones, or infections
ROS: Genital
- MALE: discharge or sores, testicular pain or masses, hernias, STD hx.
- FEMALE: menarche, period regularity, frequency, duration, dysmenorrhea, discharge, itching, sores, dyspareunia, pregnancies and complications, miscarriages/abortions, birth control, menopause, hot flashes/sweats, STD hx, PAP
ROS: Musculoskeletal
- Muscle weakness, pain, joint stiffness, range of motion, instability, redness, swelling, arthritis, gout, fracture, dislocation
ROS: Neurologic
- Loss of sensation/ numbness, tingling, tremors, weakness/paralysis, fainting/ blackouts, seizures, balance, speech, coordination
ROS: Hematologic
- Anemia, easy bruising/ bleeding, coagulation defects, petechiae, purpura, transfusions
ROS: Endocrine
- Heat/ Cold intolerance, excessive sweating, polyuria, polydipsia, polyphagia, goiter, thyroid problems or diabetes
ROS: Psychiatric
- Mood, anxiety, depression, tension, memory problems, history of suicide attempt
Notes of Physical Exam
- Start with he Vitals
- State PERTINENT Positives and Negatives
- State the LATEST Labs and TESTS
a) And note what needs done TODAY
Template for Oral Presentations
PHYSICAL EXAM/ LABS/ OTHER TESTS
- Include all significant ABNORMAL findings and any normal findings that contribute to the diagnosis
a) Ongoing Care: MENTION CHANGES
- Give a brief, general description of the patient
including physical appearance
- Try to find out in advance how thorough/detailed you need to be for your Presentation
- Touch on EACH Major System (+/-)
Notes on Assessment and Plan
- Problem needs an ASSESSMENT
- Assessment NEEDS a PLAN
- Prepare a Differential List:
a) Even if you’re sure of the Diagnosis, you attending may ask for it
b) Can have MORE THAN ONE THING going on
c) Associated Symptoms vs Separate Problem
Template for Oral Presentation
ASSESSMENT and PLAN
- Short Summary/ Interpret H&P
- Problem List: Known Dx being addressed
- Formulate the differential Diagnosis
a) Most to Least Likely
b) Support/ Reasoning/ Linkage
c) Plan: Confirm Diagnosis, or Address Known Diagnosis
Plan Considerations
- Medications
- Labs
- Diagnostic testing
- OMT
- F/up, referral
- Guidance/counseling/self help
- Disposition
Presenting a Patient: Final Tips
- Include ONLY THE MSOT ESSENTIAL FACTS
a) Be ready to answer ANY Questions about all aspects - DO NOT READ the Presentation!!!!!!!!
- Expect your Listeners to ASK Questions
- Follow the Order of the Written Case Report
- Stylistic Differences Exist
a) Present to ATTENDING PREFERENCES!!!!!! - Avoid jumping BACK AND FORTH between Descriptions of Separate Problems
- Use the Presentation to BUILD YOUR CASE
- Your Reasoning Process should help the Listeners consider a DIFFERENTIAL DIAGNOSIS
- Present the PATIENT as well as the ILLNESS!!!!!!
