H&P presentation

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Hey guys,

I am in Internal Medicine. I have been told to improve my presentation several times during these last few months. I don't have a problem when there is one chief complaints and you go through your CC then HPI. I run into problem, when there are multiple chief complaints, or when it's transfer pt from an outside hospital, or they have a complicated disease course in general. I tend to jump around between different problems because chronologically that's how they come up in history. I often throw in there another problem I noticed during physical exam (cellulitis etc) Do you guys have any suggestions on how to make a more polished presentation? I am usually anxious during presentation but that only partly contributes to it.

Originally Posted by mossyfiber12

Hey guys,

I am in Internal Medicine. I have been told to improve my presentation several times during these last few months. I don't have a problem when there is one chief complaints and you go through your CC then HPI. I run into problem, when there are multiple chief complaints, or when it's transfer pt from an outside hospital, or they have a complicated disease course in general. I tend to jump around between different problems because chronologically that's how they come up in history. I often throw in there another problem I noticed during physical exam (cellulitis etc) Do you guys have any suggestions on how to make a more polished presentation? I am usually anxious during presentation but that only partly contributes to it.

Follow this order.

CC
HPI
PMH
PSH
FAMILY HISTORY
SOCIAL HISTORY
ALLERGIES
MEDS
ROS
VITALS
PHYSICAL EXAM
LABS
IMAGING
OTHER TESTS
ASSESSMENT/PLAN

Also I just googled "history physical order"...this looks like a good form to print off and use http://www.eric.vcu.edu/home/resourc...tient/AHHP.pdf

Also remember CC is suppose to be "in the patients words."

Most people inpatient have many health issues. Its best to number each "problem" under assessment and plan. Even if its just a chronic problem, make it a separate numbered problem.

I found this video helpful when I was looking into this very topic a few weeks ago.

thanks for the suggestions. I usually don't have problem following the order but it's just that pts often presents with multiple complaints instead of one. So presenting the HPI becomes difficult as there is often multiple problems that need to be addressed during the HPI portion of presentation.

you have to go from just regurgitating everything the patient says to you to organizing, prioritizing and eliminating to come up with a coherent story. the fact that the patient mentioned something doesn't automatically make it important and it's your job to decide what's important and what's not. important stuff that is pertinent to why the patient got hospitalized goes in the HPI ...everything else can either be mentioned in passing in ROS or can be completely eliminated. basically you need to transition from just reporting information regardless of whether it's relevant or in proper order to synthesizing information and presenting it in an organized and cohesive manner

A patient may have 10 medical problems. However the only thing that needs a more detailed history and should be presented are the issues relating to why they are in the hospital. Other issues can be mentioned in the past medical history section but not in great detail.

If a multitude of issues seemed to have brought them in make sure the HPI focuses on the patient's story which you have organized based on problem (patients will not know the difference so your questions will have to be more direct and problem focused). Only mention medical problems that brought the patient to the hospital in the HPI. If a pt has CHF, COPD, DM, drug abuse hx, stage I CKD, etc etc but he is having a COPD exacerbation there is no need to go into detail about his CHF and DM.

If it is a CHF vs COPD then it is fine to describe both. But keep the story concise. Focus on how long they've had the disease, how many exacerbations, how compliant they are with meds, etc. That's really about all one needs to know about a past history on most medical issues. The DM can simply be mentioned in the pmhx. I think it's good to gather a lot more detail though because you never know what the attending may want to know - and they will just ask if they want more info.

If you find another new issue that needs to be treated in the hospital such as cellulitis on this patient then that should also be mentioned in the HPI. You could say "mr. jones is a 65 yo male with a complex pmhx presenting today with copd vs chf exacerbation and LLE cellulitis...." Then one paragraph about the exacerbation and one about the cellulitis. Then move to meds, pmhx, fhx, shx, etc.

I suggest practicing and going over your presentation with the resident or intern. Your presentation is the most important point of being a med student on internal medicine and attendings will essentially grade you based on how much they like your presentations... organization, thought process, how complete your assessment and plan is, etc. They have told me that they are able to tell a lot about a student simply based on how well they can present a patient as most have had hundreds of students and been doing this stuff for many years.

Most of the time their secondary problems can go under past medical history.

If there are two acute complaints I talk about the more serious one first and then say "the patient has an additional complaint of X...".

there's typically 1 thing that made them come to the hospital. they might be complaining of some diarrhea for the past week, a runny nose, low back pain, etc but they probably came in because of that chest pain. Present the HPI for the most important/most bothersome complaint. You can then either give a brief description of other problems if they're relevant to that HPI, or you can kind of pawn it off and say "The patient also has several other minor complaints that we may wish to address on this admission" and leave it up to your attending to either ask you for more info or let it go.

Like the others have said, I'd recommend talking to your resident before your presentation to ask how much detail you should go in to the other problems.

Medicine HPIs can be pretty complicated and difficult.

Your resident/intern should be pre-rounding with you prior to morning rounds and giving you some additional tips.

At least that's what I got on my medicine rotation. When we got a new senior, we (the students + interns) all asked to pre-round 20-30 minutes prior to attending rounds. We didn't walk round with the resident, just presentations, mainly on new patients and whoever the student covered.

Bottom line, its all about the differential diagnosis. Your HPI should address all of the probable things in your differential and flesh out the likely diagnosis. When you state a chief complaint, your attending is aready developing a ddx based of the CC and the demographics. As such, (s)he is going to want to hear info in the HPI that will help him to rule in/out items on the ddx and put them in order.

As far as complicated histories, you should first focus on why that person is at the hospital right now, and include past information that is pertinent that may influence management. After that you can include all of the other minor things.

The problem is that you need a solid knowledge base and understanding to give good presentations, so this can be difficult for 3rd years who are just starting. It will come with practice.

Originally Posted by mossyfiber12

Hey guys,

I am in Internal Medicine. I have been told to improve my presentation several times during these last few months. I don't have a problem when there is one chief complaints and you go through your CC then HPI. I run into problem, when there are multiple chief complaints, or when it's transfer pt from an outside hospital, or they have a complicated disease course in general. I tend to jump around between different problems because chronologically that's how they come up in history. I often throw in there another problem I noticed during physical exam (cellulitis etc) Do you guys have any suggestions on how to make a more polished presentation? I am usually anxious during presentation but that only partly contributes to it.

"Alright Dr. DoubleDubDub, this one is a doozey. There's a lot going on with this patient. I'm going to tell you what he's here for, but there are a lot of active issues, with a good amount of history behind each one, and, frankly, all of them could be the reason for admission. Let me get you up to speed on each of them, one at a time. If a question comes up, it will likely be covered in the history of another one of the problems."

Then do an "HPI" for each of them, knowing that likely, it is not a diagnostic mystery, since so much work has been done already.

That being said, if there is a complaint that is not relevant to the diagnosis, or is not an admissible diagnosis, tack it into the review of systems. It says "im going to deal with this because it was positive, but It's not why they are here, and it will just get added to the bottom of my problem list" without actually saying it.