the art of patient presentations

7/28/2019 The Art of Patient Presentations

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The Art of

PatientPresentations

Amit Shah, MD

Clerkship

Director


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What are oral presentations for?

To provide other clinicians with patientinformation in a clear, logical, and reproduciblemanner. They follow a pattern so the listener knows the

organization and can anticipate the type ofinformation that is coming next.

Force you to contemplate and organizedisparate data.

Allow you to demonstrate your clinical reasoningand factual skills. Allow the audience to ask questions

Questions are good.


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What are the not?

A recitation of the written History andPhysical.

A stream of disparate facts

A means of torturing and humiliatingstudents and residents (thats just a funside effect)

A time to interject personal feels (thepatient is a jerk, the nurse didnt doanything right, etc)


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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 goodpresentation 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.


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Types of Presentations

Type Time Use

Comprehensive 5-7 Minutes New patient

presentations,Morning Report

Concise 3-5 Minutes

Consultation,

Clinic

presentation

Bullet 1-2 Minutes

Work rounds,

follow visits


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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


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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


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HPI

The HPI is presented in both a problembased and chronological fashion.

Organize it by problems but describe each

one as a storyALWAYS start at the beginning

chronologically and include only relevant

information.Always includepertinent negative,

positives, and historical facts.


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Example

Mr. H has been HIV + since 1987; his CD4 count in June was 150 and viral loadapproximately 50,000. Past opportunistic infections have included: PCP pneumonia12/95; CMV retinitis 1/96; and Kaposi's Sarcoma first noted on his skin 1/96. Hecurrently takes 3TC, AZT, and Indinavir, all of which he has been receiving forapproximately one year. He also takes Bactrim Single Strength tablets on a dailybasis, 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 notsexually 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 feelingshort of breath. Approximately 1 week ago, he began to feel dyspneic with moderateactivity. This progressed to the point that, 1 day ago, he was breathless after walkingup a single flight of stairs. 3 days ago, he began to develop subjective fevers andchills along with a cough productive of rust-colored sputum. There was associatednausea but no vomiting. He has spent most of the last 24 hours in bed. He denieshead 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 himthen his past episode of PCP.


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ROS

All pertinent information should have been

included in the HPI.

If additional, unrelated positives were obtained

include them in an organ-system approachotherwise 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!


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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.


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PSH/SH/FH

Dont forget to mention these sections.

Include dates if possible for all procedures.

Dont forget to ask about OTC and herbalmedications that the patients take.

Now pause for a breath and give the

audience a chance to ask questionsbefore proceeding to the examination.

Remember Questions are good.


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Pause and take a breath

Any Questions?


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Examination

Vital 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.


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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.


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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 thepertinent(are you beginning to hate

this word yet?) problems

Now is your turn to shine.


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Impression/Plan

Discuss problems in a organized manner

Differential Diagnosis

Diagnostic Plan Therapeutic Plan

Contingency and disposition planning.

Make an argument/ Take a stand.


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Example

Mr. H is an HIV + male with a low CD 4 count and high viralload who presents with an acute pulmonary process. Myprimary concern is infectious most likely bacterial. Thisdiagnosis is supported by the rapid progression, focalityof findings on lung exam and radiography, along with the

sputum gram stain suggest a bacterial infection, inparticular Streptococcal pneumonia. Other pathogens toconsider include H Flu and, less commonly, Legionella.The Differential diagnosis would include other infectiouscauses such as PCP, mycobacterial, viral, and fungal.

The differential also included non-infectious etiologiessuch as vasculitis, lymphoma, pulmonary embolus, andneoplasm, however, at this time the data does notsupport the existence of a noninfectious pulmonaryprocess.


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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.


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Are you ready

to try?

the art of patient presentations

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