Presenting cases to ER attending?

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so721

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Hey guys,
I'm currently doing my ER rotation and I have a few questions about what attendings generally want when they ask students to see patients in the ER? I feel like I am giving my attending too much information and the scribe rolls her eyes whenever I tell them anything.

I am a bit nervous when presenting so I do loose my chain of thought but...

I just say: "so and so presented c a PMH significant for HTN and s/p CABG presented tot he ED for chest pain while she was eating dinner. She indicates that the pain is sharp in nature and is localized near the parasternal area, she denies any radiation of the pain to her extremities, she denies any headache, dizziness, blurry vision, dyspnea, recent sick contacts, denies vomitting, or diarrhea."

It seems that they don't want the PSH, Allergies, Meds, FH, stuff because the nurse inputs that stuff.

Then in terms of physical exam findings, it appears that they don't want to hear anything other than what's remarkable.

I am rotating at a very busy ER, and it would be nice for me to be more efficient so I can leave my shift on time as well as seeing more patients. I was wondering if anyone has a template that they use specific for the ED? I lost my Maxwell's a while back but any advice would be helpful.

Thanks
 
so721 said:
Hey guys,
I'm currently doing my ER rotation and I have a few questions about what attendings generally want when they ask students to see patients in the ER? I feel like I am giving my attending too much information and the scribe rolls her eyes whenever I tell them anything.

I am a bit nervous when presenting so I do loose my chain of thought but...

I just say: "so and so presented c a PMH significant for HTN and s/p CABG presented tot he ED for chest pain while she was eating dinner. She indicates that the pain is sharp in nature and is localized near the parasternal area, she denies any radiation of the pain to her extremities, she denies any headache, dizziness, blurry vision, dyspnea, recent sick contacts, denies vomitting, or diarrhea."

It seems that they don't want the PSH, Allergies, Meds, FH, stuff because the nurse inputs that stuff.

Then in terms of physical exam findings, it appears that they don't want to hear anything other than what's remarkable.

I am rotating at a very busy ER, and it would be nice for me to be more efficient so I can leave my shift on time as well as seeing more patients. I was wondering if anyone has a template that they use specific for the ED? I lost my Maxwell's a while back but any advice would be helpful.

Thanks
Click to expand...

I'm at a program where the med student presents to the resident (read: me). When I have a med student present to me, I want to hear a good, focused HPI, relevant PMH/PSH. I only want to hear Allergies, Meds, FH if relevant. Physical exam only if positive.

As an example:

Pt is a 54 yoWM with PMH of HTN, HLD, obesity presents for retrosternal, heavy CP without radiation. Sx started this morning at rest and become worse with exertion. Has associated dyspnea, intermittent nausea and diaphoresis. CP not worse with inspiration. He denies other complaints. Takes daily 81mg ASA which he took today. Father died of MI at 48. He is a smoker. Vital signs are normal. Physical exam is unremarkable. EKG read as sinus without ischemic changes.

I don't care about family history unless it is pertinent and changes what I do - in a guy who had his dad drop dead from a massive MI at 48, that's important. If his dad had prostate cancer at 85 or mom had diabetes and the patient doesn't, I don't care. Social history only if you think it is directly related to the presenting problem. Surgical history only if related - If the patient is here for chest pain and has had a CABG or recently had a total hip replacement with prolonged immobilization, that's huge; if he's had an appendectomy, I couldn't care less. If the patient has nausea/vomitting and had an SBO with colostomy which has since been reversed, it's relevant, if he had a bunion removed - don't care. Review of systems, again, only if relevant. Don't tell (or ask) a women here for dyspnea if she is having vaginal discharge - it isn't causing what she's here for and now I have to do a pelvic. I don't care if the patient is a statin for their hyperlipidemia, I do care if the patient has already taken aspirin.

A lot of this is what residency is for. You don't know all of the medicine yet, so you don't necessarily know what's relevant.

What this presentation tells me is that this is a guy at high risk for ACS, low risk for PTE, dissection, PTX. He needs an additional 81mg ASA X3, a cardiac monitor. I need to get a trop, CXR, basic labs and admit him. If a med student gave me that presentation, I would stand and clap.
 
TimesNewRoman said:
I'm at a program where the med student presents to the resident (read: me). When I have a med student present to me, I want to hear a good, focused HPI, relevant PMH/PSH. I only want to hear Allergies, Meds, FH if relevant. Physical exam only if positive.

As an example:

Pt is a 54 yoWM with PMH of HTN, HLD, obesity presents for retrosternal, heavy CP without radiation. Sx started this morning at rest and become worse with exertion. Has associated dyspnea, intermittent nausea and diaphoresis. CP not worse with inspiration. He denies other complaints. Takes daily 81mg ASA which he took today. Father died of MI at 48. He is a smoker. Vital signs are normal. Physical exam is unremarkable. EKG read as sinus without ischemic changes.

I don't care about family history unless it is pertinent and changes what I do - in a guy who had his dad drop dead from a massive MI at 48, that's important. If his dad had prostate cancer at 85 or mom had diabetes and the patient doesn't, I don't care. Social history only if you think it is directly related to the presenting problem. Surgical history only if related - If the patient is here for chest pain and has had a CABG or recently had a total hip replacement with prolonged immobilization, that's huge; if he's had an appendectomy, I couldn't care less. If the patient has nausea/vomitting and had an SBO with colostomy which has since been reversed, it's relevant, if he had a bunion removed - don't care. Review of systems, again, only if relevant. Don't tell (or ask) a women here for dyspnea if she is having vaginal discharge - it isn't causing what she's here for and now I have to do a pelvic. I don't care if the patient is a statin for their hyperlipidemia, I do care if the patient has already taken aspirin.

A lot of this is what residency is for. You don't know all of the medicine yet, so you don't necessarily know what's relevant.

What this presentation tells me is that this is a guy at high risk for ACS, low risk for PTE, dissection, PTX. He needs an additional 81mg ASA X3, a cardiac monitor. I need to get a trop, CXR, basic labs and admit him. If a med student gave me that presentation, I would stand and clap.
Click to expand...


Thank you for the wonderful write up. This gives me a great framework. I think I get so used to what I did for the COMLEX 2 PE exam that I just try and focus on every piece of info.
 
TimesNewRoman said:
I'm at a program where the med student presents to the resident (read: me). When I have a med student present to me, I want to hear a good, focused HPI, relevant PMH/PSH. I only want to hear Allergies, Meds, FH if relevant. Physical exam only if positive.

As an example:

Pt is a 54 yoWM with PMH of HTN, HLD, obesity presents for retrosternal, heavy CP without radiation. Sx started this morning at rest and become worse with exertion. Has associated dyspnea, intermittent nausea and diaphoresis. CP not worse with inspiration. He denies other complaints. Takes daily 81mg ASA which he took today. Father died of MI at 48. He is a smoker. Vital signs are normal. Physical exam is unremarkable. EKG read as sinus without ischemic changes.

I don't care about family history unless it is pertinent and changes what I do - in a guy who had his dad drop dead from a massive MI at 48, that's important. If his dad had prostate cancer at 85 or mom had diabetes and the patient doesn't, I don't care. Social history only if you think it is directly related to the presenting problem. Surgical history only if related - If the patient is here for chest pain and has had a CABG or recently had a total hip replacement with prolonged immobilization, that's huge; if he's had an appendectomy, I couldn't care less. If the patient has nausea/vomitting and had an SBO with colostomy which has since been reversed, it's relevant, if he had a bunion removed - don't care. Review of systems, again, only if relevant. Don't tell (or ask) a women here for dyspnea if she is having vaginal discharge - it isn't causing what she's here for and now I have to do a pelvic. I don't care if the patient is a statin for their hyperlipidemia, I do care if the patient has already taken aspirin.

A lot of this is what residency is for. You don't know all of the medicine yet, so you don't necessarily know what's relevant.

What this presentation tells me is that this is a guy at high risk for ACS, low risk for PTE, dissection, PTX. He needs an additional 81mg ASA X3, a cardiac monitor. I need to get a trop, CXR, basic labs and admit him. If a med student gave me that presentation, I would stand and clap.
Click to expand...

Agree with most of this. Like Times, I am at a place where the med students present to me, the resident. The only things I would add/change about what was stated above was I don't like hearing vital signs "Normal/stable", because people seem to apply those terms for a huge variety of things. I don't want to hear "VSS" when the BP is 240/120 and the person is complaining of chest pain, or the HR of 115 is considered "normal" by the med student when this patient has concern for PE. Now granted, I've looked at all the vital signs before the med student even enters the room, but I'd still rather hear as part of the presentation "T 98.9, P 92, R 15, BP 140/90 SpO2 92% RA".

You should be asking social hx, family hx, meds, surgical hx, but yes don't make it part of your presentation unless it is directly relevant. Please for the love of god don't tell me about the grandmother's history of hypertension. In no way do I care about this.

And whatever you do, don't lie when asked if you asked something or checked for something. If I ask you if you asked about travel history in someone who might have a PE, and you forgot, it's ok, I'm not going to think that much less of you. Just say "I didn't ask". It becomes obvious pretty quickly when you have to think about your answer and then mumble something out, and you are definitely going to be thought less of, if not completely chewed out by someone sooner or later.
 
engineeredout said:
Agree with most of this. Like Times, I am at a place where the med students present to me, the resident. The only things I would add/change about what was stated above was I don't like hearing vital signs "Normal/stable", because people seem to apply those terms for a huge variety of things. I don't want to hear "VSS" when the BP is 240/120 and the person is complaining of chest pain, or the HR of 115 is considered "normal" by the med student when this patient has concern for PE. Now granted, I've looked at all the vital signs before the med student even enters the room, but I'd still rather hear as part of the presentation "T 98.9, P 92, R 15, BP 140/90 SpO2 92% RA".

You should be asking social hx, family hx, meds, surgical hx, but yes don't make it part of your presentation unless it is directly relevant. Please for the love of god don't tell me about the grandmother's history of hypertension. In no way do I care about this.

And whatever you do, don't lie when asked if you asked something or checked for something. If I ask you if you asked about travel history in someone who might have a PE, and you forgot, it's ok, I'm not going to think that much less of you. Just say "I didn't ask". It becomes obvious pretty quickly when you have to think about your answer and then mumble something out, and you are definitely going to be thought less of, if not completely chewed out by someone sooner or later.
Click to expand...

Agreed. You're not supposed to be perfect. You're not even a resident yet. Ask all the questions they teach you to ask in med school, know the answers, but don't tell me every one. It's totally OK for you to a) forget to ask something (it happens to all of us) or b) not know that you should have asked something.

Or what's better - "I'll go find out."
 
I only want the data that affects my decision making. Unfortunately, you don't yet know what that data is. So by necessity you will present data I don't want, and probably leave out data I do. You are unlikely to avoid leaving out data by presenting more data I don't want, but everyone will try to be reasonably patient with you as they all know you're learning. And screw the scribe, you'll soon be making 20 times as much as that chump.

And for crying out loud, don't present normal exam findings. I want the HPI, pertinent PMH, pertinent meds, abnormal exam findings, your differential and your plan to work it up. 2 minutes max, preferably 30 seconds.
 
Agree with what others have said. Short and concise is the key. It really should be less than 45 seconds. Your goal of presenting your case is the sell the attending on your plan based on the story you tell, without boring them while telling the story. Here is a good system I like to follow:

1) present age and chief complaint or discovered important complaints gathered during ROS.

2) present all of the background info about the patient that is relevant to the chief complaint. This includes PMHx, Surgical Hx, FHx, medications, allergies, and social Hx. This part allows you to set up the patient. If they have chest pain, this is your chance to say they have a hx of HTN, DM, a brother that died of 40 of CP and they smoke. Most of the time, you won't even need to mention anything about family hx, medications or allergies.

3) Now present your HPI with associated signs and symptoms.

4) Present vitals. Say they are within normal limits if they are.

5) Present key physical exam findings that are normal or abnormal that relate to your chief complaint.

6) Explain what you want to do for the patient

7) Explain why you want to do what you want to do for the patient
 
TimesNewRoman said:
Pt is a 54 yoWM with PMH of HTN, HLD, obesity presents for retrosternal, heavy CP without radiation. Sx started this morning at rest and become worse with exertion. Has associated dyspnea, intermittent nausea and diaphoresis. CP not worse with inspiration. He denies other complaints. Takes daily 81mg ASA which he took today. Father died of MI at 48. He is a smoker. Vital signs are normal. Physical exam is unremarkable. EKG read as sinus without ischemic changes.

I don't care about family history unless it is pertinent and changes what I do - in a guy who had his dad drop dead from a massive MI at 48, that's important. If his dad had prostate cancer at 85 or mom had diabetes and the patient doesn't, I don't care. Social history only if you think it is directly related to the presenting problem. Surgical history only if related - If the patient is here for chest pain and has had a CABG or recently had a total hip replacement with prolonged immobilization, that's huge; if he's had an appendectomy, I couldn't care less. If the patient has nausea/vomitting and had an SBO with colostomy which has since been reversed, it's relevant, if he had a bunion removed - don't care. Review of systems, again, only if relevant. Don't tell (or ask) a women here for dyspnea if she is having vaginal discharge - it isn't causing what she's here for and now I have to do a pelvic. I don't care if the patient is a statin for their hyperlipidemia, I do care if the patient has already taken aspirin.

A lot of this is what residency is for. You don't know all of the medicine yet, so you don't necessarily know what's relevant.

What this presentation tells me is that this is a guy at high risk for ACS, low risk for PTE, dissection, PTX. He needs an additional 81mg ASA X3, a cardiac monitor. I need to get a trop, CXR, basic labs and admit him. If a med student gave me that presentation, I would stand and clap.
Click to expand...

Eh. Next day stress maybe
 
Reuben Strayer has a great lecture about this. 30 minutes of your time as a student or early resident will save you countless time later in life once you realize how emergency physicians think.

Go to the 1:30 mark to get past the poor audio. You won't miss anything.
 
Thanks for all the excellent feedback. I honestly did not expect to love my ER rotation so much. Granted, it's at a community hospital in a senior community, but the lifestyle and thrill of the job is quite amazing. I matched into Psychiatry, but I really wish I would have had this experience during 3rd year as I think this is a specialty i may have considered more
 
Dr.McNinja said:
Reuben Strayer has a great lecture about this. 30 minutes of your time as a student or early resident will save you countless time later in life once you realize how emergency physicians think.

Go to the 1:30 mark to get past the poor audio. You won't miss anything.
Click to expand...


Bookmarked for later. Have to see if I've been doing it wrong for nine months.
 
Dr.McNinja said:
Reuben Strayer has a great lecture about this. 30 minutes of your time as a student or early resident will save you countless time later in life once you realize how emergency physicians think.

Go to the 1:30 mark to get past the poor audio. You won't miss anything.
Click to expand...


Thanks, for the tip. Fascinating vid!
 
so721 said:
Hey guys,
I'm currently doing my ER rotation and I have a few questions about what attendings generally want when they ask students to see patients in the ER? I feel like I am giving my attending too much information and the scribe rolls her eyes whenever I tell them anything.

I am a bit nervous when presenting so I do loose my chain of thought but...

I just say: "so and so presented c a PMH significant for HTN and s/p CABG presented tot he ED for chest pain while she was eating dinner. She indicates that the pain is sharp in nature and is localized near the parasternal area, she denies any radiation of the pain to her extremities, she denies any headache, dizziness, blurry vision, dyspnea, recent sick contacts, denies vomitting, or diarrhea."

It seems that they don't want the PSH, Allergies, Meds, FH, stuff because the nurse inputs that stuff.

Then in terms of physical exam findings, it appears that they don't want to hear anything other than what's remarkable.

I am rotating at a very busy ER, and it would be nice for me to be more efficient so I can leave my shift on time as well as seeing more patients. I was wondering if anyone has a template that they use specific for the ED? I lost my Maxwell's a while back but any advice would be helpful.

Thanks
Click to expand...
Gather 'round Padawans, and listen. Force yourself to make your presentations 3 sentences or less:

1. Chief complaint. 2. Top 3 life/limb threatening things you're ruling out. 3. Desired work up.

Anything else is likely to take your audience down a rabbit hole they wished they'd never knew existed.

It's better to have your attending have to ask pertinent questions of you to pull the details out, as opposed to having him/her roll their eyes in a humiliating way, as if they'd rather be tied to a bed of nails watching c-span reruns from the 1990's, while being water boarded with rubbing alcohol, than listen to another minute of a tortuous and non-pertinent case presentation about a case he knows the work up AND dispo of after simply reading the age and chief complaint. In other words, after your attending sees "75 year old male chest pain" he really doesn't need to know the crazy but interesting nugget about Harold's grandmother dying of drug resistant crabs during the War of 1812. He wants something more like,

"1. 75 yr old male with history of CAD with non-pleuritic non-radiating chest pain, EKG is non-specific, normal vitals. 2. I suspect ACS, and there are no risk factors for PE, dissection, esophageal rupture, tamponade, tension pneumothorax or aortic aneurysm. 3. Needs cardiac workup and admit."

In fact, he'll probably have to excuse himself to cry tears of joy for a minute, if he gets that presentation from medical student. On a beginners EM rotation, it's likely better to be brief, focused, and wrong, as opposed to appearing disorganized, inefficient, and focused on irrelevant and annoying minutia.

When your attending starts to call out loudly in a panic asking for a fog lantern to cut through the confusing fog that's being created by your case presentation, go back and read this post. Stay focused, pertinent and think in life/limb threat rule outs, not non-urgent zebras, and

you'll

be

fine.


(Even if you don't, you'll still be fine.)
 
Last edited:
thanks, this is my first ER rotation as a 4th year and I am truly amazed how much I love it.
 
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