MSII here. We recently started going to clinic once per week, doing the H&P on a patient that's preselected (solely for learning purposes) and doing a full presentation to a teaching attending. The purpose of this is to prepare us for upcoming 3rd year, which is great except that right now I feel completely out of my depth! I know the basics of what we're supposed to present and can do a decent patient write-up, the problem is that when I present I'm just all over the place. I realized this last week and so this week I decided to rewrite my notes and just read it verbatim when I presented, but it was taking way too long to write. Any ideas on how to organize your notes while doing the H&P so that you're pretty much ready to present when you're done seeing the patient? During 3rd year, how much time do you get after seeing your patient to organize your thoughts before presenting? Please help, I feel so inept and would really like next week to not be a repeat of this one. I would also appreciate any suggestions from residents and attendings about things they like in a presentation.
How to present patients to attendings
- Thread starter DrDrToBe
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I'm guessing that they are making you do a full H&P with every system, social hx, diet etc. etc. etc. Once you hit third year you'll find out that each service has their own focused H&P that hits only the stuff they care about and that you'll want to mention.
Other tips: Speak briskly and confidently. The attendings are keying in on only certain words and will stop you if they need clarification.
How long you need to compose your thoughts varies but shouldn't ever be more than a couple minutes. Your notes that you take in the room should be the order you will present the information.
Practice makes perfect. You'll suck in the beginning just like everyone else.
Other tips: Speak briskly and confidently. The attendings are keying in on only certain words and will stop you if they need clarification.
How long you need to compose your thoughts varies but shouldn't ever be more than a couple minutes. Your notes that you take in the room should be the order you will present the information.
Practice makes perfect. You'll suck in the beginning just like everyone else.
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I remember learning that you have to practice it a few times in your head so that when you present it all comes out so fast that no one has time to stop you and thus losing your train of thought or ending your presentation completely and looking incompetent.
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As you start out it's going to feel bulky no matter what. And a long form H&P is bulky and bloated as it is (especially an M2 H&P when a social history includes what breed of dog the patient owns, their hobbies, and a full breakdown of every cancer, cough, cold and sneeze of every family member. I know that some schools expect a full recall of a typical day's meals as part of their H&P). To stop feeling so "all over the place" keep everything in it's section, no matter how relevant it may seem to something else.
As a third year, 90% of your presentations are going to be daily progress reports, so they're usually just a fraction of that overall H&P. Even when you're presenting new patients, you'll find that you can skip over a fair amount of the minutiae that's not relevant (though part of the M3 learning process is figuring out what's relevant or how to condense information in to a few key terms).
As a third year, 90% of your presentations are going to be daily progress reports, so they're usually just a fraction of that overall H&P. Even when you're presenting new patients, you'll find that you can skip over a fair amount of the minutiae that's not relevant (though part of the M3 learning process is figuring out what's relevant or how to condense information in to a few key terms).
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Try out the free clinics at your school. I do it 2-3x/month just for a hour or two on weekends (maybe see 2 patients, not a big deal or time commitment). They're wonderful because 1. the attenings don't care if you screw up or need to be taught how to do everything 2. you get to practice H&P, blood pressure, draws, physical exam, etc. on real patients instead of actors (I'm usually terrible on the patient actors and wonderful with real patients). It's a lot of fun and you'll learn quickly how to pick out the important things to present in a concise manner. I've gotten to the point where I don't even need to think about it or formulate a presentation plan, I just go to the attending and give the bullet points of the CC, HPI, medical history, and anything that seemed important on ROS.
Haha, and we're taught to ask the full diet history question. To be honest, I've never actually written any of that info on the patient chart unless they're eating McDonald's 5x a day.
Haha, and we're taught to ask the full diet history question. To be honest, I've never actually written any of that info on the patient chart unless they're eating McDonald's 5x a day.
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First of all, don't worry at all about the quality of your presentations for this stuff right now. I would recommend spending the bare minimum preparing your notes/presentations. You'll learn how to give a decent presentation throughout third year, and nothing you do now will make that process easier--that's because what you're doing now has virtually no relation to what you'll be doing next year and beyond.
One tip I do have is to avoid falling into the trap of thinking that, because you're a student, you need to be overly thorough. That's prolly the case for giving the complete H&P like you're doing now, but is not a good strategy for 3rd year--remember attendings get bored during rounds just like you do.
One tip I do have is to avoid falling into the trap of thinking that, because you're a student, you need to be overly thorough. That's prolly the case for giving the complete H&P like you're doing now, but is not a good strategy for 3rd year--remember attendings get bored during rounds just like you do.
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It helps understand "how to present" if you understand "how doctors think." Unfortunately, most attendings have learned to think this way, yet they probably could not explain it. This is very easy to do with a diagram, so in text font, it might be a little challenging.
"How Doctor's Think" is all about "Medical Reasoning."
Timing, Course, ---------------> A differential 1
Characteristic of Disease
Specific Questions to alter <------------------- A Differential 1
the probability of your
differentials ---------------> A differential 2
ROS, Social, Fam
Medical, Meds, All
are life-important
but not diagnostically
important *
Specific Questions to alter <------------------- A Differential 2
Manuvers that alter
the probability of your ---------------> A Differential 3, mor concise
differentials
Specific Laboratories <------------------------ A Differential 3, More Concise
to alter the probability
of your differentials ------------------------> Diagnosis!
The Questions you ask, the Physical you Do, and the Labs you get, should all come from and alter the differential. If you have that, then when you present you oral report, then only things that come out of your mouth should speak to the differential and why it would change, without actually saying "we're changing the differential because."
The idea is that the written H&P should be thorough while the spoken case presentation should be concise. Medical reasoning is all about coming to a diagnosis based on a story, then deciding what tests you get at the end to confirm your suspicions or starting a therapy.
What the attending wants to HEAR is only the "pertinent positives and negatives". Well thank you very little, I was going to present all the IRRELEVANT stuff. And this is what I mean by the way people think. The relevant stuff is any question you asked, exam maneuver you did, or laboratory that specifically alters the differential diagnosis.
Here's where students have a lot of trouble. What questions do I ask? How big should my initial differential be? What physical exam maneuvers do I do? Well, that comes with experience and medical knowledge. This is where your resident should be working with you to help narrow down your oral presentation.
* ROS, Med Hx, Surg Hx, Meds, All, Soc Hx, Fam Hx are EXCELLENT ways of getting some hidden insight into the patient, the barriers of care, and their risk factors. They are essential to the written H&P. But, if you are doing the oral case presentation correctly, any relevant info from this section should be included in the "Questions you Asked Specifically to alter the diagnosis" section of the oral report.
Some people reading this might say "well thats all well and good for medicine" but what about everything else? Well, for everything else its the same deal. In surg-onc clinic doing Whipples or the Heme/Onc patient with Lymphoma here for chemo, the diagnosis is already known. THAT is why surgery notes and reports are generally faster. There is no mystery. There needs to be no extra questions to figure out the differential. The labs are generally done already. Its just a few physical exams and a brief history of how the patient showed up, but the premise is exactly the same.
-----------------------------------------------------------------
Sample ORAL case report italics are my comments:
Mr Johnson is a 24 year old Male complaining of chest pain. The chest pain began this morning at 7am, has been constant for the bast 6 hours, is retrosternal radiating to the left arm and up the patient's jaw. It is a crushing 8/10 chest pain without associated symptoms. Nothing makes it better. Nothing makes it worse. He has never had this pain before.
ALWAYS begin with Name, Age, Gender, Complaint, PERIOD. It centers the attending on which mental filing cabinet they should open, and what their ears should be tuned in for. The first section is just the description of the complaint that drives a differential, albeit a broad one.
He has no family history of cardiac events, nor does he have any cardiac history. He does not smoke cigarettes, but admits to some recreational drug use. This morning, he smoked crack. He has smoked cracked in the past but has never had a complication like this before. There was no trauma to the chest. The pain is unrelated to swallowing, moving, or breathing.
Here is where you ask specific questions. What you are conveying is "i asked about familial cardiac disease but there isnt any," and "he doesnt have any risk factors for ACS like an old fat guy does" and "but he is a drug addict who smokes crack, the likely cause of his CP," then "Oh, by the way, just to make sure it wasnt a lung (breathing, pleuritic), bone (trauma, tender), or esophageal (swallowing) problem I asked a little about those too."
Review of systems negative. He has no history, family history noncontributory. He has been shot once for which he had an open lap, he drinks alcohol everyday, usually a 5th of vodka, and he works at a convenient store.
Short and sweet. Just get it out. 15 seconds. The crack smoking was included above, the fact he has had an open lap is interesting to you, but has nothing to do with this new chest pain. This MUST be more detailed in the written report.
Vital Signs are Heart Rate 110, Blood Pressure 160/90, Respirations 24, Satting 100%
Physical exam was normal, specifically, no murmurs rubs or gallops, regular rhythm though tachycardic, perfusing well with two plus pulses distally. He was not tender to palpation.
What you do NOT do is PEARL, EOMI, RRR, CTAB, NT, ND, and rattle off everything down to the onychomycosis. It Doesn't affect the differential
On labs he shows: blah blah blah, all labs normal. EKG shows no changes, troponins have not elevated yet. A tox screen is pending for cocaine, though our suspicion is that it will be positive.
Unless your attending WANTS you do say every lab value, you dont have to. Write them down for them and you can blow past the normals. If you aren't comfortable with that (as in, you might miss something) quickly go through the normals by just saying the number. The important thing is that you convey "i think its cocaine chest pain, so we are looking for myocardial ischemia"
So for this 24 year old man with chest pain our most likely diagnosis is cocaine chest pain for which we are going to do ......
The assessment and plan WITHOUT rehashing the reasons why you think it is what it is, jsut what youre going to do about it. Your Written H&P will be a litany of reasoning and values. Your oral should not.
In addition, he also has some problems with alcohol. While this is not the reason for his visit, we should probably set him up with alcohol and addiction counseling, or at least speak to the PCP about it.
Even though this is not part of the presenting complaint, you must identify all the problems that need eventual fixing. Good hospital doctors will set plans in motion for every problem the patient has, even if they don't fix them at that hospital stay.
-----------------------------------------------
Use Clinical reasoning to drive your questioning, your physical exam, and your labs. Then use the SAME clinical reasoning to drive your oral presentation. Most patients you get as an MS3 should NOT be complex, and should take 15-20minutes to present at initial presentation.
If all else fails, do what Med Students are expected to do (suck) and just read your H&P. You MUST get away from that eventually, but to start, its probably the safest thing.
"How Doctor's Think" is all about "Medical Reasoning."
Timing, Course, ---------------> A differential 1
Characteristic of Disease
Specific Questions to alter <------------------- A Differential 1
the probability of your
differentials ---------------> A differential 2
ROS, Social, Fam
Medical, Meds, All
are life-important
but not diagnostically
important *
Specific Questions to alter <------------------- A Differential 2
Manuvers that alter
the probability of your ---------------> A Differential 3, mor concise
differentials
Specific Laboratories <------------------------ A Differential 3, More Concise
to alter the probability
of your differentials ------------------------> Diagnosis!
The Questions you ask, the Physical you Do, and the Labs you get, should all come from and alter the differential. If you have that, then when you present you oral report, then only things that come out of your mouth should speak to the differential and why it would change, without actually saying "we're changing the differential because."
The idea is that the written H&P should be thorough while the spoken case presentation should be concise. Medical reasoning is all about coming to a diagnosis based on a story, then deciding what tests you get at the end to confirm your suspicions or starting a therapy.
What the attending wants to HEAR is only the "pertinent positives and negatives". Well thank you very little, I was going to present all the IRRELEVANT stuff. And this is what I mean by the way people think. The relevant stuff is any question you asked, exam maneuver you did, or laboratory that specifically alters the differential diagnosis.
Here's where students have a lot of trouble. What questions do I ask? How big should my initial differential be? What physical exam maneuvers do I do? Well, that comes with experience and medical knowledge. This is where your resident should be working with you to help narrow down your oral presentation.
* ROS, Med Hx, Surg Hx, Meds, All, Soc Hx, Fam Hx are EXCELLENT ways of getting some hidden insight into the patient, the barriers of care, and their risk factors. They are essential to the written H&P. But, if you are doing the oral case presentation correctly, any relevant info from this section should be included in the "Questions you Asked Specifically to alter the diagnosis" section of the oral report.
Some people reading this might say "well thats all well and good for medicine" but what about everything else? Well, for everything else its the same deal. In surg-onc clinic doing Whipples or the Heme/Onc patient with Lymphoma here for chemo, the diagnosis is already known. THAT is why surgery notes and reports are generally faster. There is no mystery. There needs to be no extra questions to figure out the differential. The labs are generally done already. Its just a few physical exams and a brief history of how the patient showed up, but the premise is exactly the same.
-----------------------------------------------------------------
Sample ORAL case report italics are my comments:
Mr Johnson is a 24 year old Male complaining of chest pain. The chest pain began this morning at 7am, has been constant for the bast 6 hours, is retrosternal radiating to the left arm and up the patient's jaw. It is a crushing 8/10 chest pain without associated symptoms. Nothing makes it better. Nothing makes it worse. He has never had this pain before.
ALWAYS begin with Name, Age, Gender, Complaint, PERIOD. It centers the attending on which mental filing cabinet they should open, and what their ears should be tuned in for. The first section is just the description of the complaint that drives a differential, albeit a broad one.
He has no family history of cardiac events, nor does he have any cardiac history. He does not smoke cigarettes, but admits to some recreational drug use. This morning, he smoked crack. He has smoked cracked in the past but has never had a complication like this before. There was no trauma to the chest. The pain is unrelated to swallowing, moving, or breathing.
Here is where you ask specific questions. What you are conveying is "i asked about familial cardiac disease but there isnt any," and "he doesnt have any risk factors for ACS like an old fat guy does" and "but he is a drug addict who smokes crack, the likely cause of his CP," then "Oh, by the way, just to make sure it wasnt a lung (breathing, pleuritic), bone (trauma, tender), or esophageal (swallowing) problem I asked a little about those too."
Review of systems negative. He has no history, family history noncontributory. He has been shot once for which he had an open lap, he drinks alcohol everyday, usually a 5th of vodka, and he works at a convenient store.
Short and sweet. Just get it out. 15 seconds. The crack smoking was included above, the fact he has had an open lap is interesting to you, but has nothing to do with this new chest pain. This MUST be more detailed in the written report.
Vital Signs are Heart Rate 110, Blood Pressure 160/90, Respirations 24, Satting 100%
Physical exam was normal, specifically, no murmurs rubs or gallops, regular rhythm though tachycardic, perfusing well with two plus pulses distally. He was not tender to palpation.
What you do NOT do is PEARL, EOMI, RRR, CTAB, NT, ND, and rattle off everything down to the onychomycosis. It Doesn't affect the differential
On labs he shows: blah blah blah, all labs normal. EKG shows no changes, troponins have not elevated yet. A tox screen is pending for cocaine, though our suspicion is that it will be positive.
Unless your attending WANTS you do say every lab value, you dont have to. Write them down for them and you can blow past the normals. If you aren't comfortable with that (as in, you might miss something) quickly go through the normals by just saying the number. The important thing is that you convey "i think its cocaine chest pain, so we are looking for myocardial ischemia"
So for this 24 year old man with chest pain our most likely diagnosis is cocaine chest pain for which we are going to do ......
The assessment and plan WITHOUT rehashing the reasons why you think it is what it is, jsut what youre going to do about it. Your Written H&P will be a litany of reasoning and values. Your oral should not.
In addition, he also has some problems with alcohol. While this is not the reason for his visit, we should probably set him up with alcohol and addiction counseling, or at least speak to the PCP about it.
Even though this is not part of the presenting complaint, you must identify all the problems that need eventual fixing. Good hospital doctors will set plans in motion for every problem the patient has, even if they don't fix them at that hospital stay.
-----------------------------------------------
Use Clinical reasoning to drive your questioning, your physical exam, and your labs. Then use the SAME clinical reasoning to drive your oral presentation. Most patients you get as an MS3 should NOT be complex, and should take 15-20minutes to present at initial presentation.
If all else fails, do what Med Students are expected to do (suck) and just read your H&P. You MUST get away from that eventually, but to start, its probably the safest thing.
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I would also include in your opening line any relevant past history. i.e. in this case "this is a 24 yo male with a history of cocaine abuse who presents with sudden onset chest pain"
And then of course you can get to the residency stage, where your whole presentation is..."so we got this 24 yo crackhead with chest pain. EKG and trops are pending and we're treating his hypertension. Do you want to get a CT?"
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The way it was described to me by one of my fellows that makes a lot of sense to me is: "Your presentation is how you try to convince your attending that your patient has what you think they have." Therefore, while you should write everything in your H&P, you don't necessarily need to present a detailed social history or mention how they had 2+ DTRs throughout for a patient who comes in complaining of umbilical pain that has now migrated to 1/3 of the distance between the ASIS and the umbilicus 😉 Even if you don't actually have any idea what's wrong with a patient, you can probably trim some of the fluff.
And yes, when you get started, you'll probably be reading your H&P and telling them way too much way more often than you'd like. God knows I do (only been in clinics for 2 months). You're going to feel stupid at times, but just try to remember there's a reason we're in school--nobody was born knowing how to present patients and that's part of what we're trying to learn here. If you have absolutely no idea what's wrong with your patient, if nothing else, just try to remember to organize things and present them in a logical fashion.
And yes, when you get started, you'll probably be reading your H&P and telling them way too much way more often than you'd like. God knows I do (only been in clinics for 2 months). You're going to feel stupid at times, but just try to remember there's a reason we're in school--nobody was born knowing how to present patients and that's part of what we're trying to learn here. If you have absolutely no idea what's wrong with your patient, if nothing else, just try to remember to organize things and present them in a logical fashion.
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I tell people do NOT do that so they can practice the opening line and keep it the same. The idea being if you start by wondering what history you should include and which not to include, you might get startled. How you start the presentation is important, setting the tone of confidence or incompetence.
That being said, with more confidence, you can definitely start adding in relevant history. Including HTN is useless, everybody has it. Telling the attending the patient has AIDS in the setting of fever and a cough on the other hand, thats important.
The main reason I stay away from this is because the student will likely COPY what they see other people doing, Giving medical history in the opening line, rather than giving the RELEVANT history. That info will come later. I actually consider what you suggest an advanced skill that should be included at the behest of the resident, but should be avoided by the novice presenter.
- Joined
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- 39
It helps understand "how to present" if you understand "how doctors think." Unfortunately, most attendings have learned to think this way, yet they probably could not explain it. This is very easy to do with a diagram, so in text font, it might be a little challenging.
"How Doctor's Think" is all about "Medical Reasoning."
Timing, Course, ---------------> A differential
Characteristic of Disease |
|
|
Specific Questions to alter <-------------------
the probability of your
differentials ---------------> A differential
|
ROS, Social, Fam |
Medical, Meds, All |
are life-important |
but not diagnostically |
important * |
|
|
Specific Questions to alter <-------------------
Manuvers that alter
the probability of your ---------------> A more concise differential
differentials |
|
Specific Laboratories |
to alter the probability <------------------------
of your differentials
The idea is that the written H&P should be thorough while the spoken case presentation should be concise. Medical reasoning is all about coming to a diagnosis based on a story, then deciding what tests you get at the end to confirm your suspicions or starting a therapy.
What the attending wants to HEAR is only the "pertinent positives and negatives". Well thank you very little, I was going to present all the IRRELEVANT stuff. And this is what I mean by the way people think. The relevant stuff is any question you asked, exam maneuver you did, or laboratory that specifically alters the differential diagnosis.
Here's where students have a lot of trouble. What questions do I ask? How big should my initial differential be? What physical exam maneuvers do I do? Well, that comes with experience and medical knowledge. This is where your resident should be working with you to help narrow down your oral presentation.
* ROS, Med Hx, Surg Hx, Meds, All, Soc Hx, Fam Hx are EXCELLENT ways of getting some hidden insight into the patient, the barriers of care, and their risk factors. They are essential to the written H&P. But, if you are doing the oral case presentation correctly, any relevant info from this section should be included in the "Questions you Asked Specifically to alter the diagnosis" section of the oral report.
Some people reading this might say "well thats all well and good for medicine" but what about everything else? Well, for everything else its the same deal. In surg-onc clinic doing Whipples or the Heme/Onc patient with Lymphoma here for chemo, the diagnosis is already known. THAT is why surgery notes and reports are generally faster. There is no mystery. There needs to be no extra questions to figure out the differential. The labs are generally done already. Its just a few physical exams and a brief history of how the patient showed up, but the premise is exactly the same.
-----------------------------------------------------------------
Sample ORAL case report italics are my comments:
Mr Johnson is a 24 year old Male complaining of chest pain. The chest pain began this morning at 7am, has been constant for the bast 6 hours, is retrosternal radiating to the left arm and up the patient's jaw. It is a crushing 8/10 chest pain without associated symptoms. Nothing makes it better. Nothing makes it worse. He has never had this pain before.
ALWAYS begin with Name, Age, Gender, Complaint, PERIOD. It centers the attending on which mental filing cabinet they should open, and what their ears should be tuned in for. The first section is just the description of the complaint that drives a differential, albeit a broad one.
He has no family history of cardiac events, nor does he have any cardiac history. He does not smoke cigarettes, but admits to some recreational drug use. This morning, he smoked crack. He has smoked cracked in the past but has never had a complication like this before. There was no trauma to the chest. The pain is unrelated to swallowing, moving, or breathing.
Here is where you ask specific questions. What you are conveying is "i asked about familial cardiac disease but there isnt any," and "he doesnt have any risk factors for ACS like an old fat guy does" and "but he is a drug addict who smokes crack, the likely cause of his CP," then "Oh, by the way, just to make sure it wasnt a lung (breathing, pleuritic), bone (trauma, tender), or esophageal (swallowing) problem I asked a little about those too."
Review of systems negative. He has no history, family history noncontributory. He has been shot once for which he had an open lap, he drinks alcohol everyday, usually a 5th of vodka, and he works at a convenient store.
Short and sweet. Just get it out. 15 seconds. The crack smoking was included above, the fact he has had an open lap is interesting to you, but has nothing to do with this new chest pain. This MUST be more detailed in the written report.
Vital Signs are Heart Rate 110, Blood Pressure 160/90, Respirations 24, Satting 100%
Physical exam was normal, specifically, no murmurs rubs or gallops, regular rhythm though tachycardic, perfusing well with two plus pulses distally. He was not tender to palpation.
What you do NOT do is PEARL, EOMI, RRR, CTAB, NT, ND, and rattle off everything down to the onychomycosis. It Doesn't affect the differential
On labs he shows: blah blah blah, all labs normal. EKG shows no changes, troponins have not elevated yet. A tox screen is pending for cocaine, though our suspicion is that it will be positive.
Unless your attending WANTS you do say every lab value, you dont have to. Write them down for them and you can blow past the normals. If you aren't comfortable with that (as in, you might miss something) quickly go through the normals by just saying the number. The important thing is that you convey "i think its cocaine chest pain, so we are looking for myocardial ischemia"
So for this 24 year old man with chest pain our most likely diagnosis is cocaine chest pain for which we are going to do ......
The assessment and plan WITHOUT rehashing the reasons why you think it is what it is, jsut what youre going to do about it. Your Written H&P will be a litany of reasoning and values. Your oral should not.
In addition, he also has some problems with alcohol. While this is not the reason for his visit, we should probably set him up with alcohol and addiction counseling, or at least speak to the PCP about it.
Even though this is not part of the presenting complaint, you must identify all the problems that need eventual fixing. Good hospital doctors will set plans in motion for every problem the patient has, even if they don't fix them at that hospital stay.
-----------------------------------------------
Use Clinical reasoning to drive your questioning, your physical exam, and your labs. Then use the SAME clinical reasoning to drive your oral presentation. Most patients you get as an MS3 should NOT be complex, and should take 15-20minutes to present at initial presentation.
If all else fails, do what Med Students are expected to do (suck) and just read your H&P. You MUST get away from that eventually, but to start, its probably the safest thing.
"How Doctor's Think" is all about "Medical Reasoning."
Timing, Course, ---------------> A differential
Characteristic of Disease |
|
|
Specific Questions to alter <-------------------
the probability of your
differentials ---------------> A differential
|
ROS, Social, Fam |
Medical, Meds, All |
are life-important |
but not diagnostically |
important * |
|
|
Specific Questions to alter <-------------------
Manuvers that alter
the probability of your ---------------> A more concise differential
differentials |
|
Specific Laboratories |
to alter the probability <------------------------
of your differentials
The idea is that the written H&P should be thorough while the spoken case presentation should be concise. Medical reasoning is all about coming to a diagnosis based on a story, then deciding what tests you get at the end to confirm your suspicions or starting a therapy.
What the attending wants to HEAR is only the "pertinent positives and negatives". Well thank you very little, I was going to present all the IRRELEVANT stuff. And this is what I mean by the way people think. The relevant stuff is any question you asked, exam maneuver you did, or laboratory that specifically alters the differential diagnosis.
Here's where students have a lot of trouble. What questions do I ask? How big should my initial differential be? What physical exam maneuvers do I do? Well, that comes with experience and medical knowledge. This is where your resident should be working with you to help narrow down your oral presentation.
* ROS, Med Hx, Surg Hx, Meds, All, Soc Hx, Fam Hx are EXCELLENT ways of getting some hidden insight into the patient, the barriers of care, and their risk factors. They are essential to the written H&P. But, if you are doing the oral case presentation correctly, any relevant info from this section should be included in the "Questions you Asked Specifically to alter the diagnosis" section of the oral report.
Some people reading this might say "well thats all well and good for medicine" but what about everything else? Well, for everything else its the same deal. In surg-onc clinic doing Whipples or the Heme/Onc patient with Lymphoma here for chemo, the diagnosis is already known. THAT is why surgery notes and reports are generally faster. There is no mystery. There needs to be no extra questions to figure out the differential. The labs are generally done already. Its just a few physical exams and a brief history of how the patient showed up, but the premise is exactly the same.
-----------------------------------------------------------------
Sample ORAL case report italics are my comments:
Mr Johnson is a 24 year old Male complaining of chest pain. The chest pain began this morning at 7am, has been constant for the bast 6 hours, is retrosternal radiating to the left arm and up the patient's jaw. It is a crushing 8/10 chest pain without associated symptoms. Nothing makes it better. Nothing makes it worse. He has never had this pain before.
ALWAYS begin with Name, Age, Gender, Complaint, PERIOD. It centers the attending on which mental filing cabinet they should open, and what their ears should be tuned in for. The first section is just the description of the complaint that drives a differential, albeit a broad one.
He has no family history of cardiac events, nor does he have any cardiac history. He does not smoke cigarettes, but admits to some recreational drug use. This morning, he smoked crack. He has smoked cracked in the past but has never had a complication like this before. There was no trauma to the chest. The pain is unrelated to swallowing, moving, or breathing.
Here is where you ask specific questions. What you are conveying is "i asked about familial cardiac disease but there isnt any," and "he doesnt have any risk factors for ACS like an old fat guy does" and "but he is a drug addict who smokes crack, the likely cause of his CP," then "Oh, by the way, just to make sure it wasnt a lung (breathing, pleuritic), bone (trauma, tender), or esophageal (swallowing) problem I asked a little about those too."
Review of systems negative. He has no history, family history noncontributory. He has been shot once for which he had an open lap, he drinks alcohol everyday, usually a 5th of vodka, and he works at a convenient store.
Short and sweet. Just get it out. 15 seconds. The crack smoking was included above, the fact he has had an open lap is interesting to you, but has nothing to do with this new chest pain. This MUST be more detailed in the written report.
Vital Signs are Heart Rate 110, Blood Pressure 160/90, Respirations 24, Satting 100%
Physical exam was normal, specifically, no murmurs rubs or gallops, regular rhythm though tachycardic, perfusing well with two plus pulses distally. He was not tender to palpation.
What you do NOT do is PEARL, EOMI, RRR, CTAB, NT, ND, and rattle off everything down to the onychomycosis. It Doesn't affect the differential
On labs he shows: blah blah blah, all labs normal. EKG shows no changes, troponins have not elevated yet. A tox screen is pending for cocaine, though our suspicion is that it will be positive.
Unless your attending WANTS you do say every lab value, you dont have to. Write them down for them and you can blow past the normals. If you aren't comfortable with that (as in, you might miss something) quickly go through the normals by just saying the number. The important thing is that you convey "i think its cocaine chest pain, so we are looking for myocardial ischemia"
So for this 24 year old man with chest pain our most likely diagnosis is cocaine chest pain for which we are going to do ......
The assessment and plan WITHOUT rehashing the reasons why you think it is what it is, jsut what youre going to do about it. Your Written H&P will be a litany of reasoning and values. Your oral should not.
In addition, he also has some problems with alcohol. While this is not the reason for his visit, we should probably set him up with alcohol and addiction counseling, or at least speak to the PCP about it.
Even though this is not part of the presenting complaint, you must identify all the problems that need eventual fixing. Good hospital doctors will set plans in motion for every problem the patient has, even if they don't fix them at that hospital stay.
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Use Clinical reasoning to drive your questioning, your physical exam, and your labs. Then use the SAME clinical reasoning to drive your oral presentation. Most patients you get as an MS3 should NOT be complex, and should take 15-20minutes to present at initial presentation.
If all else fails, do what Med Students are expected to do (suck) and just read your H&P. You MUST get away from that eventually, but to start, its probably the safest thing.
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That's good for you, but every resident and attending I've worked with wants the past hx in the opening line. Even if it's just HTN: "This is a 54 year old male, w/ history significant for only htn, who presents with sudden onset chest pain radiating to the back." (Well it's pertinent in that case, but they'd want it even if it were a female w/ pelvic pain)
If they have no history, then it's, "This is a 54 year old male, w/o significant past medical history, who presents with sudden onset chest pain radiating to the back."
Everytime I've omitted the line about past history, the attending stares at me as if I have a dick growing out of my forehead.
Thanks everyone for your responses. This was very helpful. By the way, my attendings so far have all wanted the "relevant" history presented in the first line. One attending told me that regardless of what the patient presents with, always include things like stroke, diabetes, HTN, AIDS, cancer, IV drug use, smoking and alcohol in the first line.
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This has been my experience as well. Knowing that a patient has HIV or DM or HTN or whatever completely changes how you approach the rest of the information.
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That is by far the most important thing to do. It takes about ONE patient to realize what this attending wants. From then on, literally anything any one writes in here is pointless, since they are in charge and should be appeased.
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Great thread guys.
Overactive has hit a lot of it.
I'd start with the chief complaint: SOB
HPI: demographics + relevant past medical history + presenting situation.
Your CC creates a differential (pulmonary or cardiac, which can then be broken down further). Everything weighs into this differential, including the PMH. Think in terms of pertinent positives, and pertinent negatives. Absence of chest/arm/neck pain, angina, crushing in nature, hypercholesterolemia, speaks against heart attack, for example.
Every specialty has its own relevant history and exam, but this structure of organizing information is generalizable to all of them.
Overactive has hit a lot of it.
I'd start with the chief complaint: SOB
HPI: demographics + relevant past medical history + presenting situation.
Your CC creates a differential (pulmonary or cardiac, which can then be broken down further). Everything weighs into this differential, including the PMH. Think in terms of pertinent positives, and pertinent negatives. Absence of chest/arm/neck pain, angina, crushing in nature, hypercholesterolemia, speaks against heart attack, for example.
Every specialty has its own relevant history and exam, but this structure of organizing information is generalizable to all of them.
