Presentation of a patient

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Teach your students how to present cases to their attendings and preceptors

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Presentation of a patient

  1. 1. Presentation of a Patient “I saw the guy in room 3..”
  2. 2. Anatomy of the Presentation <ul><li>Organization of a large amount of information </li></ul><ul><li>Systematic approach to presentation </li></ul><ul><li>Understanding your audience (the physician to whom you are presenting </li></ul><ul><li>Having a plan </li></ul><ul><li>Presenting with confidence </li></ul>
  3. 3. Anatomy of the Presentation <ul><li>Depending on the setting, your presentation may be brief or more thorough </li></ul><ul><li>Thorough/more in depth presentations </li></ul><ul><ul><li>Primary Care/Internal Medicine,inpatient hospitalization </li></ul></ul><ul><li>Brief, focused presentations </li></ul><ul><ul><li>ER, Urgent Care, Sub-specialties (surgery, dermatology) </li></ul></ul>
  4. 4. Anatomy of the Presentation How much info do I need? <ul><li>Access to information depends on: </li></ul><ul><ul><li>The setting of the patient encounter </li></ul></ul><ul><ul><li>The mental status of the patient </li></ul></ul><ul><ul><li>Presence of a caregiver or other historian </li></ul></ul><ul><ul><li>Availability of prior medical records </li></ul></ul><ul><ul><li>Time frame in which you have to see the patient </li></ul></ul>
  5. 5. Anatomy of the Presentation How much info do I need? <ul><li>Consider your audience (the physician) </li></ul><ul><ul><li>Do they prefer a brief or more thorough presentation? </li></ul></ul><ul><ul><li>What information do they want? </li></ul></ul><ul><ul><li>Do they expect a treatment plan from you? </li></ul></ul><ul><ul><li>Do they want you to examine the patient and report your findings? </li></ul></ul>
  6. 6. Where do I begin?? <ul><li>Before presenting the case, make sure you have done the following: (if time permits) </li></ul><ul><ul><li>Review the chart </li></ul></ul><ul><ul><li>Read nursing notes </li></ul></ul><ul><ul><li>Check the vital signs </li></ul></ul><ul><ul><li>Obtain and review old records </li></ul></ul><ul><ul><ul><li>In hospital-look for previous admissions and/or consults </li></ul></ul></ul><ul><ul><ul><li>In office-check last few office visits </li></ul></ul></ul><ul><ul><ul><li>Compare old and new information (weight, vital signs, EKGs) </li></ul></ul></ul><ul><ul><ul><li>Look at old labs </li></ul></ul></ul><ul><ul><ul><li>Look at old medications and compare with current list </li></ul></ul></ul>
  7. 7. Where do I begin?? <ul><li>Compare the triage/nursing assessment with your own </li></ul><ul><li>Often times the patient’s “story” will change with each assessment </li></ul><ul><ul><li>“ He didn’t tell ME he had chest pain!” </li></ul></ul><ul><li>Do not be discouraged if the patient gives the doctor a completely different chief complaint and history </li></ul><ul><li>If there is a discrepancy between histories, make sure you document this </li></ul><ul><ul><li>i.e. if the patient told you he has chest pain and denied it to the nurse you might write “disagree with triage, patient also complains of chest pain which began 30 minutes ago” </li></ul></ul>
  8. 8. Key points to consider <ul><li>For the grand plan some of the most important pieces of information will be: </li></ul><ul><li>Why is the patient here? </li></ul><ul><li>Where will they best receive treatment? </li></ul><ul><li>Do they need hospitalization or can they be treated as an outpatient </li></ul><ul><li>Do they need specialty referral? </li></ul><ul><li>Is compliance likely? </li></ul>
  9. 9. “ I saw the lady in room 3..now what?” <ul><li>ID the patient and their location </li></ul><ul><ul><li>Use their name and a limited amount of identifying information </li></ul></ul><ul><li>Do’s </li></ul><ul><ul><li>State their name </li></ul></ul><ul><ul><li>State their age </li></ul></ul><ul><ul><li>State their location </li></ul></ul><ul><ul><ul><li>(e.g. Ms. Rodriguez is a 38 year old female in bed 3) </li></ul></ul></ul>
  10. 10. “ I saw the hemorrhoid in room 3” <ul><li>Don’ts </li></ul><ul><ul><li>Refer to the patient by their room number “I saw 3” </li></ul></ul><ul><ul><ul><li>patients get moved from room to room or may be moved to a different department </li></ul></ul></ul><ul><ul><ul><ul><li>Save yourself the embarrassment of having your supervising physician blaming you after he has examined the wrong patient because he took your word for it and went to room 3 while your patient had been moved to room 6 </li></ul></ul></ul></ul><ul><ul><li>Identify the patient by their diagnosis, disease, or complaint </li></ul></ul><ul><ul><ul><li>each patient is a human with one or more immediate health care needs. Patients are PEOPLE not DISEASES </li></ul></ul></ul>
  11. 11. Chief complaint <ul><li>State the chief complaint, and give a limited amount of history of present illness. Provide relevant details. </li></ul><ul><li>How long has the symptom or problem been present? Has the patient had previous episodes? Is this an exacerbation of a previously diagnosed chronic condition (i.e. asthma, GERD, or hypertension) </li></ul><ul><ul><ul><li>“ Ms. Rodriguez is a 38 year old female in bed 3 who c/o cough and SOB x 2 days, which she has had before, but is now worse” </li></ul></ul></ul>
  12. 12. Chief complaint <ul><li>Has the patient sought care regarding the problem in the past? If so, what was done? </li></ul><ul><li>If the symptom is a pain, describe it: </li></ul><ul><ul><li>character of the pain (e.g. sharp, dull, radiating, etc) </li></ul></ul><ul><ul><li>Consistency (constant, intermittent) </li></ul></ul><ul><li>Associated symptoms (nausea, vomiting, chills, etc) </li></ul><ul><li>Aggravating/relieving factors </li></ul><ul><li>Similar problem in the past? </li></ul>
  13. 13. Chief complaint <ul><ul><li>“Ms. Rodriguez is a 38 year old female in bed 3 who c/o cough and SOB x 2 days, which she has had before, but is now worse. She does have some CP, but only with cough and deep inspiration” </li></ul></ul>
  14. 14. Past Medical History <ul><li>Briefly, in 1-2 sentences, indicate the PMH. </li></ul><ul><ul><li>“She has a 10 year history of hypertension, COPD, and has end stage renal disease and has been on dialysis for 3 years.” </li></ul></ul><ul><li>You might also include pertinent negatives: </li></ul><ul><ul><li>“..but no history of diabetes..” </li></ul></ul>
  15. 15. Past Medical History <ul><li>When presenting a neonate, infant, or toddler, consider presenting additional information: </li></ul><ul><ul><li>presence/absence of prenatal care </li></ul></ul><ul><ul><li>birth history (spontaneous, induced) </li></ul></ul><ul><ul><li>Vaginal delivery, C-section, any complications </li></ul></ul>
  16. 16. Past Surgical History <ul><li>This doesn’t necessarily need to be in your presentation for all patients. </li></ul><ul><li>becomes important if the patient’s chief complaint may be suggestive of a surgical problem </li></ul><ul><ul><li>if the patient is a 40 year old female with abdominal pain, nausea, and vomiting but has had an appendectomy at age 25, it is appropriate to mention this </li></ul></ul><ul><ul><li>If the patient had recent surgery and complains of pain and/or drainage at the surgical site </li></ul></ul><ul><ul><li>If the patient had recent surgery and complains of chest pain and/or SOB </li></ul></ul>
  17. 17. Medications <ul><li>List patient’s medications along with their disease processes </li></ul><ul><ul><li>She takes Lisinopril for HTN, Glyburide for DM, and an aspirin daily </li></ul></ul><ul><li>Some patients may not think they have a diagnosis if they are taking medication for it </li></ul><ul><ul><li>“ I see you are taking Lisinopril, which is for HTN..You said you didn’t have any PMH” </li></ul></ul><ul><ul><ul><li>“ Oh yeah…I take that for my blood pressure” </li></ul></ul></ul>
  18. 18. GYN History <ul><li>State this if it is applicable to the chief complaint </li></ul><ul><ul><li>if the patient is a 25 year old female with a finger laceration and she will need an xray so you would need to present the LMP at most </li></ul></ul><ul><ul><li>If the patient is complaining of abdominal pain, vaginal bleeding, or has symptoms that suggest any type of endocrine or gynecologic problem, then more detailed information about the GYN history is important and should be presented </li></ul></ul><ul><ul><ul><li>(i.e. G4P0A3 with a hx of PCOS and fibroids..) </li></ul></ul></ul>
  19. 19. Vital Signs <ul><li>“The vital signs don’t lie” </li></ul><ul><li>If the VS are normal you may say that </li></ul><ul><li>If the VS are normal other than one of them, state the abnormal VS first </li></ul><ul><ul><li>i.e. Temperature is 101.3, the rest of the VS are WNL (within normal limits) </li></ul></ul>
  20. 20. Physical Findings <ul><li>You don’t have to state every single detail that you found during the exam. </li></ul><ul><li>Start with the patient’s general appearance </li></ul><ul><ul><li>“ Not ill appearing” or “Looks toxic” or “In no acute distress” or “Pleasant, disheveled, with an odor of alcohol” </li></ul></ul><ul><li>Give the findings from the physical exam that are relevant to the chief complaint and any findings that help to either rule in or rule out disease. </li></ul>
  21. 21. Physical Findings <ul><li>Findings are pertinent if they: </li></ul><ul><ul><li>help rule in or rule out disease </li></ul></ul><ul><ul><li>are related to the chief complaint </li></ul></ul><ul><ul><li>are grossly abnormal finding and requiring either immediate attention </li></ul></ul><ul><li>If the patient complains of cough, onychomycosis is probably not relevant </li></ul><ul><li>“ Lungs are clear” or “Diminshed breath sounds and rales at the right lower lobe” </li></ul>
  22. 22. Make a problem list (at least make one in your head) <ul><li>This should be an ongoing process </li></ul><ul><li>Prioritizing the patient’s issues is also important with regards to deciding which tests or labs should be done. </li></ul><ul><li>Choose which issues should be addressed immediately and which can wait </li></ul>
  23. 23. Make your assessment <ul><li>State your suspected diagnosis </li></ul><ul><li>When you make your assessment, give consideration a differential diagnosis that will tie together the elements of the problem list. </li></ul><ul><ul><li>There may not always be one diagnosis for all of the symptoms </li></ul></ul><ul><li>Some patients will have an isolated, obvious complaint (i.e. laceration) with a clear-cut plan </li></ul>
  24. 24. State your plan <ul><li>The plan should be supported by the chief complaint and the data in your physical exam. </li></ul><ul><li>When you give the plan, have an idea of what you are looking for and how you plan to find it </li></ul><ul><ul><li>If you are ordering a lab test, justify why you are ordering it </li></ul></ul><ul><ul><li>A physician may ask you, “Why are you getting that?” Make sure the test will actually TELL you something </li></ul></ul><ul><ul><li>Do not order tests just for the sake of ordering them-this is not cost effective </li></ul></ul>
  25. 25. Patient disposition <ul><li>Will the patient need inpatient care? </li></ul><ul><li>Can the patient be managed at home? </li></ul><ul><li>Will the patient most likely be compliant? </li></ul><ul><li>Does the patient need referrals? </li></ul><ul><li>When will the patient follow up? </li></ul>
  26. 26. Tips <ul><li>Be organized </li></ul><ul><li>Present the patient as well as the illness . </li></ul><ul><li>Include only the most essential facts; but be ready to answer ANY questions about all aspects of your patient. </li></ul><ul><li>Keep your presentation lively. </li></ul><ul><li>Be confident! </li></ul><ul><li>Do not read the presentation! </li></ul><ul><li>Expect your listeners to ask questions. </li></ul><ul><li>Follow the order of the written case report. </li></ul><ul><li>Keep in mind the limitation of your listeners. </li></ul><ul><li>Beware of jumping back and forth between descriptions of separate problems. </li></ul><ul><li>Use the presentation to build your case. </li></ul><ul><li>Be prepared to discuss your reasoning process </li></ul>

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