--Josh--
Most students would agree that presenting a patient may be one of the most anxiety provoking parts of rotations. Whether you are in a group or one-on-one, all eyes and attention are on you. There is the potential to do or say something incorrect, embarrassing, or perhaps you might not know the answer to a question that you are asked. Also, depending on the level of responsibility that you are given, what you say can have a large impact on the course of a patient’s visit. As if this was not enough, there is the fact that you are being evaluated. And in a busy environment like an emergency department (ED), this may be the only interaction that you have with your attending physician.
The “presentation” in the ED is also very unique compared with many other rotations and specialities that you will experience. In general, they are much shorter and more of a narrative compared with other rotations, such as internal medicine or ICU where the presentation is a system based approach.
The first line should always be “ age of patient, sex of patient, chief complaint”. Ex: 48 year old female presents with chest pain. That is it! Don't add anything else. This at least sets the stage for the presentation.
Your HPI should include chief complaint, PMH, PSH, social hx, family hx. This should be concise and focused directly on the patient’s chief complaint.
Ex: 48 year old female presents with chest pain. She has a PMH of hypertension and takes Norvasc. She is a smoker. Chest pain started 1 hour ago, substernal, pressure like. The pain lasted for 15-20 minutes and has since resolved. Denies radiation to arm, back, or jaw. Denies shortness of breath. Denies nausea, vomiting, or diaphoresis. Denies exertional or pleuritic component. Denies leg swelling. Denies recent travel, recent surgeries, hx of CA, OCP use, or hx of DVT/PE. No pertinent family hx.
Focused review of systems (ROS). As you can see above this can be directly incorporated into your HPI. As you gain more experience, you can narrow down your differential diagnosis and correlate your ROS accordingly in your presentation.
Physical Exam. This again should only include pertinent positives and negatives. Always give the general appearance of patient in the beginning and review the VITAL SIGNS!
Ex: Patient appears very well, sitting in chair in room, she is in no acute distress. VS are unremarkable. Cardiac is regular, rate, and rhythm. Lungs are clear to auscultation bilaterally. Abdomen is without tenderness. Intact upper and lower extremity pulses. No lower extremity edema or calf tenderness bilaterally.
You do not need a summary statement at this point. Go right to the assessment.
The assessment is the first part of the presentation where you may give your opinion of the case. The HPI is communicating information from the patient and medical record. The physical exam is objective findings.
Unfortunately the differential diagnosis and order of assessment varies from attending to attending. Some like to have the most likely diagnosis first, while others want the most life threatening first.
Ex: My top differential includes ACS, Pulmonary Embolism, Aortic Dissection, GERD, Chest wall pain. She is PERC negative and do not feel further work up for PE is indicated. Doubt aortic dissection based on history and exam without sudden onset pain, no back pain or ripping/tearing pain. Also, she is not hypertensive without any pulse deficits appreciated. Her EKG shows normal sinus rhythm without acute T wave or ST changes. I would like to order a CBC, BMP, Cardiac Enzymes, and a Chest X-ray. I would like to give her 324 mg aspirin. If her workup is unremarkable I would like to admit her to the cardiac observation unit for serial cardiac enzymes and cardiac stress test.
Keep your presentation under 5 MINUTES (ideally 3 minutes)!!!