The Art of Patient Presentations

Amit Shah, MD Clerkship Director

What are oral presentations for?

To provide other clinicians with patient information in a clear, logical, and reproducible manner.

They follow a pattern so the listener knows the organization and can anticipate the type of information that is coming next.

Force you to contemplate and organize disparate data. Allow you to demonstrate your clinical reasoning and factual skills.

Allow the audience to ask questions Questions are good.

What are the not?

A

recitation of the written History and Physical. A stream of disparate facts A means of torturing and humiliating students and residents (thats just a fun side effect) A time to interject personal feels (the patient is a jerk, the nurse didnt do anything right, etc)

Oral Presentations

They are an art and a skill that take time and practice to perfect. Every patient and situation is different, so there is not complete cookbook approach a good presentation is a custom developed presentation within certain guidelines. The key is know you audience you can then pick the right type of presentation and focus.

Types of Presentations
Type Time Use New patient presentations, Morning Report Consultation, Clinic presentation Work rounds, follow visits

Comprehensive 5-7 Minutes

Concise

3-5 Minutes

Bullet

1-2 Minutes

Comprehensive Presentation

Chief Complaint History of Present Illness Review of Systems Past Medical History Past Surgical History Medications/Allergies Social History Family History Examination Laboratory Data Impression/Plan

Chief Complaint
One

sentence description of the patient and the reason prompting their evaluation.

Mr. H is a 50 year old male with AIDS who presents for the evaluation of fever, chills and a cough over the past 3 days

HPI
The

HPI is presented in both a problem based and chronological fashion. Organize it by problems but describe each one as a story ALWAYS start at the beginning chronologically and include only relevant information. Always include pertinent negative, positives, and historical facts.

Example
Mr. H has been HIV + since 1987; his CD4 count in June was 150 and viral load approximately 50,000. Past opportunistic infections have included: PCP pneumonia 12/95; CMV retinitis 1/96; and Kaposi's Sarcoma first noted on his skin 1/96. He currently takes 3TC, AZT, and Indinavir, all of which he has been receiving for approximately one year. He also takes Bactrim Single Strength tablets on a daily basis, along with Fluconazole troches PRN for thrush. He claims to be 100% compliant with all of his medication. He is homosexual though he is currently not sexually active. He has never used intravenous drugs Until 1 week ago, Mr. H had been quite active, walking up to 2 miles a day without feeling short of breath. Approximately 1 week ago, he began to feel dyspneic with moderate activity. This progressed to the point that, 1 day ago, he was breathless after walking up a single flight of stairs. 3 days ago, he began to develop subjective fevers and chills along with a cough productive of rust-colored sputum. There was associated nausea but no vomiting. He has spent most of the last 24 hours in bed. He denies head ache, photophobia, stiff neck, focal weakness, chest pain, hemoptysis, abdominal pain, diarrhea or other complaints. There is no know history of asthma, COPD or chronic pulmonary condition. His current problem seems different to him then his past episode of PCP.

ROS

All pertinent information should have been included in the HPI. If additional, unrelated positives were obtained include them in an organ-system approach otherwise you can say remainder of ROS was negative. THAT DOES NOT MEAN YOU TAKE SHORT CUTS WHEN YOU DO THE INTERVIEW YOU MUST ACTUALLY DO THE ROS!

Medications/Allergies
List

all medications including dosages, frequency that patient actually takes them, and why they are on those medications. Typically list medications by generic name unless specifically requested otherwise. KNOW WHAT EACH MEDICATION IS AND WHY THEY ARE ON THEM.

PSH/SH/FH
Dont

forget to mention these sections. Include dates if possible for all procedures. Dont forget to ask about OTC and herbal medications that the patients take.
Now

pause for a breath and give the audience a chance to ask questions before proceeding to the examination.

Remember Questions are good.

Pause and take a breath Any Questions?

Examination
signs are VITAL signs always start with complete vital signs including pulse ox if available. General paint a picture. Can focus on pertinent portions of examination and any abnormal finding. Again, dont take shortcuts when doing the examination just when presenting.
Vital

Laboratory
Give

pertinent or abnormal results and then just list normal lab (dont waste time reading all the normal numbers). Always know the lab values as the attending may ask for it specifically. Remember Questions are good.

Impression/Plan
One

of the most difficult parts of the presentation. Your written H&P should have a comprehensive list of all problems, however can focus down the problem list to the pertinent (are you beginning to hate this word yet?) problems Now is your turn to shine.

Impression/Plan
Discuss

problems in a organized manner Differential Diagnosis Diagnostic Plan Therapeutic Plan Contingency and disposition planning. Make an argument/ Take a stand.

Example
Mr. H is an HIV + male with a low CD 4 count and high viral load who presents with an acute pulmonary process. My primary concern is infectious most likely bacterial. This diagnosis is supported by the rapid progression, focality of findings on lung exam and radiography, along with the sputum gram stain suggest a bacterial infection, in particular Streptococcal pneumonia. Other pathogens to consider include H Flu and, less commonly, Legionella. The Differential diagnosis would include other infectious causes such as PCP, mycobacterial, viral, and fungal. The differential also included non-infectious etiologies such as vasculitis, lymphoma, pulmonary embolus, and neoplasm, however, at this time the data does not support the existence of a noninfectious pulmonary process.

Example (cont)
My diagnostic plan includes: monitor blood and sputum cultures. Check sputum for PCP and AFB. My therapeutic plan includes empiric treatment of CAP in an immuno-compromised host with an IV quinolone but hold on treatment for PCP as well as O2 therapy to maintain saturations >92% If the patient fails to improve or worsens would strongly consider a bronchoscopy to evaluate for unusual or atypical cause of infections such as CMV or PCP.

Concise Presentation
focus on the problem at hand skip PSH/SH/FH/ROS unless directly related to the problem at hand. Example would be tailoring the presentation to the pulmunolagist you consult for the bronchoscopy. Often used at the clinic for outpatient return visits.
More

Bullet Presentation
Use

for work rounds on follow up of patients who are already well known. Only focus on recent events (usually over the past 24 hours), vital signs, changes in exam, and labs. Brief, problem based discussion.

Are you ready to try?