Presenting patients.....help!

[banta]

Can any 4th year med students or residents offer some advice/tips/suggestions for new third year students on how to present their patients when doing rounds in the morning? Perhaps a list of what should be included (and in what order) and what should not be included? Mr. Smith is a .....

THANKS FOR THE ASSISTANCE )
SUZY )

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[Starflyr]

Im not a 4th year, but Ive been yelled at a lot in the last 3 weeks about this. Generally, it should be something like:

Miss X is a 6 y.o girl with a PMH signifigant for spina bifida. She presented on 7/7/03 with (insert CC here). She is post op day 1. She had _______ done in OR. (if not in surgery, I guess you say what's been done for them).

On physical exam, her vitals are (normal or say them if abnormal). If there are abnormal physical findings, say them here, e.g. abdomen distended.

- people in surgery seem to always want Is&Os (included breakdown into PO, NG, dophoff, and IVs), ABGs, and urine output in cc/kg/hr.

Labs:
Electrolytes are (normal or abnormal, if abnormal say what is off, whether it's high or low, and if it's low, has it been replaced?)

H&H: Usually they want hemoglobin, where I am now, they want Hct. Say either normal or say what they are if abnormal.

Cultures: Where, what, etc.

Meds: We only have to include antibiotics, diuretics and psychotropics. Dont give dosages, just the names.

I dont know if this helps any, since Im just a 3rd year too. Ive also KNOW that different attendings want different things presented, and that it changes from rotation to rotation.

Ya ;just have to look stupid for awhile every month or so.

good luck!
Star

 

[DrQuinn]

Depends on what rotation you're on...

A good classic example of what NOT to do was on an old episode of ER (where Lucy was presenting a case to Dr. Romano)... she mentioned EVERYTHING... like the patient was helping his daughter move to Michigan, because she had lived in blah blah...

In the ED, your patient presentations shoudl be even SHORTER (we're talking 15-20 seconds). Its pretty hard for medical students to get used to it. What i would do is try to tailor your presentation to whatever specialty you're on.

IM: Loves a good HPI and know today's labs (get old records)
Surgery: Abdominal exam (serial if possible)... imaging, Leukocytosis?
EM: QUICK QUICK QUICK HPI and what tests you want to order, also do you want to give any meds?

Q, DO

 

[southerndoc]

I love some of our attendings...

Seriously, some of my daily presentations of patients have been "she's doing fine, no problems, we're planning on sending her home today with plans for followup in clinic next week." That's no joke.

They don't have time to hear all that crap about "this is hospital day 3 for a 42 years of age female admitted for chest pain and diagnosed with an acute MI."

 

[Renovar]

There is a big difference between the first presentation (ie. "staffing the patient") vs a progress-type presentation of a patient known to the attending.

In medicine/peds any other traditional more talkative specialties, when you are staffing a patient, you have to do the whole 9 yards "59 yo WF with PMH significant for blah blah blah presented to the ED for blah blah blah. PMH is positive for blah, SHx is significant for blah, meds are blah FHx is positive for blah ROS is blah, exam is blah, labs blah, in summary blah, therefore our plans are, 1. from cardiovasular standpoint blah, 2. from pulmonary standpoint blah.... etc etc"

When you are presenting a progress, it goes something like "HD#3 for Mrs X here with blah. Subjectively, overnight blah, objectively, Tm Tc P BP R sats, in/out, exam blah, labs blah, our new plans for today blah, from dispo standpoint: maybe ready to go home blah."

In surgery or other less talkative specialties, divides into 2 types: preop and postop. a typical post-op presentation: "POD #2, subjectively doing blah (pain control, flatus/BM, ambulation, tol po, N/V/D/CP/SOB?) Objectively Tm Tc P BP R sats in/out, exam blah. New plans for today is blah."

For psych, exam focus on mental status exam, assessment and plan focus on axis differential and base your plan on what you said. "Axis I: suspect MDD, recurrent severe. Will start sertraline and will consider psychotherapy consultation. General anxiety disorder. Will increase diazepam dose and add ambian for sleep. Axis II - Cluster C personality trait. Axis III- CAD and HTN, continue lisinopril and metoprolol. Axis V - 55."

Hope this helps. Most of it is really attending dependent, and practice makes perfect.

 

[Sabre_DO]

These are great advices guys, mucho gracius!

Just to throw my 2 cents in, I found alot of attendings/residents/interns like an HPI w/ pertinent ROS incorporated into it. That saves some time, and makes u look like u're thinking about the C/C and u know wut to look for in ROS.

 

[Winged Scapula]

Something else to have in the back of your mind, to bring out when the occassion arises, is that medical students are in the prime situation of really knowing your patients.

Thus, we might have no idea about a patient's social situation but you can spend some time finding out who the patient lives with, what their health is like, what the ability to perform ADLs, etc. is like. While ultimately the decision to safely send a patient home may rest somewhat with PT/OT or clinical case managers, if pertinent, you may raise the issue early, ie, "Mr Smith is the sole caregiver for his demented wife and may need some help in the home during his recovery period". Or "Mr. Smith is a 80 pk year smoker - perhaps we can offer him a patch since this would be a good time to quit (ie, after his lobectomy)."

 

[Renovar]

Originally posted by Kimberli Cox
Something else to have in the back of your mind, to bring out when the occassion arises, is that medical students are in the prime situation of really knowing your patients.

Thus, we might have no idea about a patient's social situation but you can spend some time finding out who the patient lives with, what their health is like, what the ability to perform ADLs, etc. is like. While ultimately the decision to safely send a patient home may rest somewhat with PT/OT or clinical case managers, if pertinent, you may raise the issue early, ie, "Mr Smith is the sole caregiver for his demented wife and may need some help in the home during his recovery period". Or "Mr. Smith is a 80 pk year smoker - perhaps we can offer him a patch since this would be a good time to quit (ie, after his lobectomy)."

Oh yea! That's one of the surest ways to impress the team. As a medical student, you take care of less patients than anyone of the team, so you should have more time per patient. You visit you patient preround, once during rounds, and always just make a habit of dropping by the patient's room in the afternoon and if anything, just CHAT! (which I am actually good at - I am not a superb presenter to start with, but I gotten better with mucho practice.) Ask them about their life, how things are going at home, etc. All this info can indirectly help you when you are dispoing the patient. And nothing will make you look like a star in front of your attending and it will at the very least make you look like you really know your patient and really takes care of them. All it takes, 10 additional minutes a day per patient.

 

[ependymoma]

How to present patients will vary from service to service as already mentioned above. However, one caveat for inpatient services is to know what has happened with the patient since the last time you rounded. Events of the last twenty four hours are incredible important. Know if the patient has had any change in vital signs overnight. As a resident, I hated to here that a patient was afebrile, but when I checked the flow sheet, there was a temp spike to 103 at midnight (happened more than once). Know if the patient had chest pain or belly pain or shortness of breath overnight and what was done about it. Any changes that have occured since your resident last rounded are important. A sure way to upset your intern or resident is not to tell them about significant events overnight and have the attending confront them about it.

Another important point is to always have a plan of some sort. These are YOUR patients. Your plan doesn't have to be perfect; that's what the interns/residents/attendings are there for. You don't need to come up with some esoteric test. You just need to do something (even if it's doing nothing) for the patient. As a student, good things to focus on are the simple things. Is the patient eating? Can we feed him? Is pain control adequate? Is he peeing/ moving around? Do we need these IV fluids? Can we switch to any po meds? If labs are back, electrolye (esp. K) problems are an easy thing to suggest. Do we need PT/OT/ discharge planning? How long has the patient been on antibiotics? Is blood pressure control adequate? There are a lot more, but these are fairly simple things.

One final important point is when giving a presentation and arriving to the plan part, try to prioritize the problems (if multiple) in order of importance. Chest pain or a fever or something similar overnight is of higher priority than a stable blood sugar in a diabetic. Try to start with active issues and work down to inactive issues/discharge planning.

This is all very difficult in the beginning, especially since everyone expects different things of you, but with practice, it becomes a lot easier. Early in your rotations, try to sound out from the senior residents on the service what they expect of your presentations.

Take care

 

[anonymousEM]

another important thing to look at is trends in labs...it's not necessary (unless your attending is particularly anal) to know exactly, but if the Hb has gone from 15 to 10 during this admit, it's important to know that AND what is this pt.s baseline...were they here 6 months ago with Hb of 10 and just were volume contracted when they arrived, or are they bleeding somewhere!?!
Same for WBC, BUN/CR etc.

 

[anonymousEM]

and for emergency medicine or surgery clinic,

WHY are they here now with pertinent exam and what are we going to do about it. One problem, the rest are addressed on an outpt. basis with few exceptions.

 

[Skip Intro]

Yes, vital signs. Don't forget to report the vital signs (I had to pull my attendings dentures out of my rectum the other day he chewed by butt so hard). Always start with the vitals. That's why they're called vitals.

And, QuinnNSU, if you look anything like your avatar, I'm available to be the victim of some shameless public frottering next time I'm in Tampa. I'll be the tall guy standing on the corner of Kennedy and Dale Mabry whistling and not paying attention to any young females who may be passing by...

 

[DrQuinn]

Originally posted by Skip Intro


And, QuinnNSU, if you look anything like your avatar, I'm available to be the victim of some shameless public frottering next time I'm in Tampa. I'll be the tall guy standing on the corner of Kennedy and Dale Mabry whistling and not paying attention to any young females who may be passing by...

Sorry CHarlie. I don't like to hang out by Kinko's (Too many bums).

Q, DO

 

[Sabre_DO]

I have a quick question about SOAP note. Wut should generally go into assessment? Do I list all the problem list w/ the patient, or just the ones that justify pt's staying in hospital another day? The case managers are harping down on me about not D/C patients b/c I put like HTN or anasarca in assessment. I'm tired of presenting the patient to them and update them on patient's most life-threatening condition...etc

 

[shag]

What are "case managers"? Are you referring to non-MD admin folks who review charts or are you referring to your attending/residents?

IMO, you should list any condition for which you are treating the patient in your A/P. It is appropriate in most situations to list a problem as stable. For example, in a pt with DM admitted to GI for a bleed:

A/P
1) LGI Bleed: .....

2) IDDM: Glu stable at 121 this am on 70/30 4u qam, 6u qpm. Accucheck max 135 at 1800.
- Continue current insulin regimen
- Contnue qshift accuchecks
- Continue SSI

Of course, this is team dependent. On medicine services, most teams will expect all problems to be mentioned. Also, if someone is complaining about difficulty d/c'ing pts because of problems mentioned in your note, then likely the pt shouldn't be d/c'ed anyway.

 

[Sabre_DO]

Yes, I'm referring to chart reviewers. In a case like the one u said, most likely they'll say to d/c the patient b/c u can treat DM as outpatient and that if the GI bleed (their admit c/c) has resolved. In one of my cases, the pt has anasarca, which has resolved after appropriate tx. However, the underlying cause of nephrotic syndrome requires more work-up, but the reviewers dunt understand this. They just said the pt has no more edema, send them home quick! I guess it all comes down to mula $$

 

[ENTSteven]

practise is the key!

Good Luck, practices makes it perfect!

 

[shag]

Originally posted by Sabre_DO
Yes, I'm referring to chart reviewers. In a case like the one u said, most likely they'll say to d/c the patient b/c u can treat DM as outpatient and that if the GI bleed (their admit c/c) has resolved. In one of my cases, the pt has anasarca, which has resolved after appropriate tx. However, the underlying cause of nephrotic syndrome requires more work-up, but the reviewers dunt understand this. They just said the pt has no more edema, send them home quick! I guess it all comes down to mula $$

Gotta love the CEO mentality...

 

[chicamedica]

bump

 

[Sessamoid]

Talk to your classmates and your residents and find out what this particular attending likes to hear included and excluded from patient presentations. The nature of rounds is very attending-specific in many cases.

 

[Asher]

When recording vitals, it is helpful to know the range of blood pressure that the patient has had over the past 24 hours. Just telling the attending that the BP was 120/80 at 5 a.m. when it was 178/120 last night doesn't give all the info needed to make decisions about what med adjustments are needed.

Not necessarily for presentations, but just advice is to get to know the social workers working with your team. They can be a great source of information and (at least the ones I've had the pleasure to work with) are amazing when it comes to patient placement.

I also found it helpful to when I would be including information about a patient's CT or whatever to have a printed copy for the attending to read. I've often gone into a recitation of multiple findings only to noticed the attending's eyes glassing over.

 

[Minimalist M]

Just give the important stuff! In Family medicine (!), when I see a clinic patient, I just give the CC and a short relevant 3-4 sentence HPI and any relevant PMH/PSH, then jump into the RELEVANT physical examination, I don't bother with negative findings unless it's relevant.

That format works exceptionally well in surgery (and neurosurgery for that matter).

In IM, they want everything, including the PMH of the great-great-grand cousin!