Presenting in the ED

[Cerberus]

I have a hard time striking the right balance when I present in the ED. It seems that I either present too much or not enough (depending on who I present too). I find presenting in the ED more frustrating than most other services, at least on IM they expect me to present a huge amount of superflous facts. Any other students/residents have this problem? Tips?

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[SoCuteMD]

I always asked the senior resident how much that day's attending wanted to hear. They usually know their attendings pretty well. I tried to keep things targeted - brief HPI w/ pertinent positives and negatives, physical exam w/ heart, lungs and then only pertinent body systems, assessment including brief differential and then plan. Was generally well received as a student.

 

[Apollyon]

Right up front, let me tell you - even if you are EXCELLENT at it, in academics, you will NEVER be right. You've hit the nail on the head - either too much, or too little. It doesn't change as a resident - the attending will always, always say you're saying too much, or not enough. I can think of one attending, when I was a resident, that, right up until I graduated, never backed off this. I can see why he's in academics - 'cause he wouldn't cut it in private practice.

What I tell the students and residents is that, in opposition to IM, I need to know in the first 10 seconds why the patient is there. What I need are pertinent positives and negatives - vital signs are vital - if there's something amiss, I need to know. Brief history of the problem. Medical history - yes or no, if the pt has had it before (pneumonia, cardiac, already fractured that ankle and had ORIF). Brief physical exam. But, to be a star, give me an assessment and plan. I know you made it through your 3rd year. Anyone can examine the patient. But what do you DO with them? That is key. What are the 8 things in the chest that can kill the patient? What are the common and uncommon causes of headache (and how do you rule in/rule out)?

62 y/o male, complaining of chest pain, dull, squeezing, mid-sternal, constant, began 2 days ago, occasional nonproductive cough, febrile to 102 here. History of MI 5 years ago with CABG. Also history of hypertension. Tachycardic, but EKG is sinus tach. Chest Xray is pending. I'm thinking pneumonia, or at least bronchitis, but I have to consider cardiac involvement. Diagnostically, Chem7, CBC, cardiac markers, and this is what the BNP was made for. Also blood cultures (although I'm aware of low utility). For treatment, Tylenol 1g, aspirin 81mg times 4, and we can wait for the CXR for the antibiotic. For nitroglycerin, I defer to your discretion. Given my choice, though, I would try it.

 

[dchristismi]

And the debate continues even as an attending, I have some admitting physicians who want to hear the whole story and ask about fine details, PMH, last admission, labs, etc, and one in particular who lets me get about 8 words out before asking to talk to a nurse to give orders.

Those go "Mr Smith, chest painer, EKG and enzymes fine... " "Let me have the nurse."

Apollyon is right on the money. You can't win, just keep trying.

 

[Jeff698]

And the debate continues even as an attending, I have some admitting physicians who want to hear the whole story and ask about fine details, PMH, last admission, labs, etc, and one in particular who lets me get about 8 words out before asking to talk to a nurse to give orders.

One of the nice things about working in a community hospital with a small number of hospitalists is you get to know them and they get to know you. My presentation varies based on who it is.

It may be 67 year old ACS, stable.

Or

67 year old with known CAD s/p CABG with good story, normal ECG, CXR and negative bedside troponin. Remaining labs are pending.

Fortunately, the long version isn't much needed anymore. Of course, the lengthy discussion about the hospital's thoughts of getting rid of free physician meals may take MUCH longer.

Take care,
Jeff

 

[roja]

My .02

Even in the most academic of centers (and recognizing extreme variability into blah blah blah component of h&p desired), one thing is certain: EM doctors ALL want to know if the patient is WELL appearing and what the CC complaint is RIGHT away.

EI:

Ms. X is a well appearing 87 year old here with chest pain.

now, your next paragraph or so will be the HPI. in the HPI is pertinent PMH, your description of the pain, etc... all that fine tuned stuff of what you should be presenting. Key point here is watch the person you are presenting to. If they look bored, start summarizing. If they are listening intently, you are doing okay.

Then go into the PMH, Meds, SH (ie, smoking, drugs, etoh.. not lives with her husband). Allergies

PE interpret the vital signs (ie, she is tachycardic, etc)

Assessment and plan (do NOT summarize your HPI again. ie this is a 67 yo female wiht blah blah blah and chest pain... I got it the first time! )

Your assessment and plan is: I think this is most likely disease x, possibly Y, z, p or q, and unlikely A, B or C. (put in your differential those things you have ruled out by H&P) and then come up with some plan that is tied to your assessment. (EKG, troponins, asa etc)


No one expects you to be correct... but this will get you in the right direction and garner those points you want about thinking about your patients and coming up with plans.

Also, if one particular element is exceptionally long but possibly not acutely relevent (ie a laundry list of medications) ask the attending: She is on multiple medications listed here, would you like me to read them off?

 

[Cerberus]

Thanks for the tips. I'll try to incorporate them into my presentations.

Also, I lol'ed at the people talking about presentation for consults. Today I consulted surgery and neurology on two separate patients.

Surgery (had already text paged the basics): "what's the patient's bednumber? Ok, i'll come see her"

Neurology: (paraphrased) "tell me absolutely everything about this patient, including family hx, dose of meds, where she is followed, she had surgery (totally unrelated to complaint) where and when??"

 

[Seville]

Thanks for the tips. I'll try to incorporate them into my presentations.

Also, I lol'ed at the people talking about presentation for consults. Today I consulted surgery and neurology on two separate patients.

Surgery (had already text paged the basics): "what's the patient's bednumber? Ok, i'll come see her"

Neurology: (paraphrased) "tell me absolutely everything about this patient, including family hx, dose of meds, where she is followed, she had surgery (totally unrelated to complaint) where and when??"

I have found consults to be interesting. You never know who you are going to get on the phone. Sometimes they surprise you and are totally pleasant. Other times you get someone who is just downright nasty to you. I wonder if they are like that to everyone or if it is because I'm calling from the ED or if it is because I am a student.

 

[roja]

I like to call that "please dictate my H&P to me under the guise of a consult'. We have a pretty clear policy on that.

I find that some variation of this statement helps:

"Those are great questions. Unfortunately I can't get into all the details right now, but if you want to talk more, feel free to come find me in the ED. I'll be happy to discuss all the small details then."

 

[iridesingltrack]

I like to call that "please dictate my H&P to me under the guise of a consult'. We have a pretty clear policy on that.

I find that some variation of this statement helps:

"Those are great questions. Unfortunately I can't get into all the details right now, but if you want to talk more, feel free to come find me in the ED. I'll be happy to discuss all the small details then."

When consultants do this it is one of those things that I find particularly irritating, especially when they say, "will you read all the labs to me?" Uh, no.

Roja, Your suggested response is very tactful and pleasent.

As to the OP's question: On the first presentation of the day, I used to ask the attending or Sr. resident if they wanted formal or abbreviated/focused presentations. Not infrequently, presentations would get shorter the more we worked together. Don't worry if someone asks you a question or for additional information when you are presenting; they may have picked up something in your story that you've missed (teaching) or they may just want to clarify a point.

Tell a good story (interesting and accurate), including important pos/negs. As someone said earlier, always have a DDx and plan that addresses your proposed DDx. Most ED attendings are pretty laid back so don't let it get you too frustrated.

 

[daveyjwin]

One thing that an attending told me that I have tried to make stick with all my future presentations is "put your note away, and tell me a story." His logic is that, without having my piece of paper to stare at, I will tell him all the pertinent things to the CC, forget all the stuff he doesn't care about, and not get all Ben Stein on him. Every patient tells a story. You tell their story to the attending.

 

[GeneralVeers]

One thing that an attending told me that I have tried to make stick with all my future presentations is "put your note away, and tell me a story." His logic is that, without having my piece of paper to stare at, I will tell him all the pertinent things to the CC, forget all the stuff he doesn't care about, and not get all Ben Stein on him. Every patient tells a story. You tell their story to the attending.

Hopefully you provide the abridged version, as most "stories" tend to be rambling and full of irrelevancies.

 

[kungfufishing]

"...but wait, I also have a cough and it causes vaginal bleeding AND discharge until I am just out of breath and that is when my belly starts really hurting, y'know right before I lose consciousness..."

 

[NEATOMD]

"...but wait, I also have a cough and it causes vaginal bleeding AND discharge until I am just out of breath and that is when my belly starts really hurting, y'know right before I lose consciousness..."

I'm particularly fond of the ALL positive ROS.

 

[ULTRA nerves]

Thanks for the above posts; they are very helpful.

For history, as a med student, I understand that I need to identify the emergent chief complaint and be clear on whether or not the patient is clinically stable.

What if the patient has multiple medical conditions, ie diabetic patient with concerning ulcer on his feet..which can be managed as outpt...and he came in for chest pain & SOB. Do you want to hear about the exam finding of pt's feet or should I filter according to the attending's style?

My question comes down to this: should we report all the abnormal exam findings or keep more succinct?

 

[Rendar5]

Thanks for the above posts; they are very helpful.

For history, as a med student, I understand that I need to identify the emergent chief complaint and be clear on whether or not the patient is clinically stable.

What if the patient has multiple medical conditions, ie diabetic patient with concerning ulcer on his feet..which can be managed as outpt...and he came in for chest pain & SOB. Do you want to hear about the exam finding of pt's feet or should I filter according to the attending's style?

My question comes down to this: should we report all the abnormal exam findings or keep more succinct?

With both H and P, if it's fairly subtle and obviously unrelated, you can skip it. If it's gonna be obvious, I'd report it regardless since you know the attending will hear it. AS you get more experienced, you can start skipping hte more obvious stuff as long as it's unrelated.