Presenting to an Attending

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PreMedAdAG

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So, I work at a student run clinic a lot and while I'm getting comfortable with patients and getting somewhat of a differential set up in my head, I find that when i go to present, I'm just all over the place. Then since I'm a first year, I have no training on how to present, so it's just kinda awkward. Does anyone have any advice on how to present, what order to go in, any good reads on this to see what is the most efficient but thorough?

Thanks

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You're only in 1st year, there's a long long way to go before you'll be comfortable doing full presentations. Part of it is simply repetition and developing your own format...

It might be helpful to think about it like a SOAP note:
Patients' ID data
S- subjective info: CC, HPI, ROS, past medical history etc.
O- what you found on physical, what labs are in so far
A/P- your differential, assessment and plan for the patient

In terms of keeping it concise, hit the pertinent positives/negatives based on what your differential is. If they've got an acute abdomen, an ingrown toenail repair back in '03 isn't really that important to mention in the history, use your common sense. That's a pretty simple way to do it...I found most attendings to be pretty laid back and it's more like a conversation than it is a strict "presentation", you'll get used to it really fast.
 
Just try to go straight in the order of a good H&P -- and keep all the info in its proper place. ie, CC, HPI, Med hx, surg hx, family/social hx, ROS, PE. Keep it relevent (pertinent positives and negatives, but at this stage of the game knowing what's relevent can be tricky...) . Don't start doing in to differentials in the HPI, for example; keep it for the end for your impressions and plan. If you go in the same order all the time, you get into a groove, its organized, and you'll remember how to let it flow.

I had this all drilled into me by an attending, by the way :) I'd give a report and he would literally stop me mid-sentence and say, "that doesn't go there". He was very effective!
 
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burlypie said:
Just try to go straight in the order of a good H&P -- and keep all the info in its proper place. ie, CC, HPI, Med hx, surg hx, family/social hx, ROS, PE. Keep it relevent (pertinent positives and negatives, but at this stage of the game knowing what's relevent can be tricky...) . Don't start doing in to differentials in the HPI, for example; keep it for the end for your impressions and plan. If you go in the same order all the time, you get into a groove, its organized, and you'll remember how to let it flow.

I had this all drilled into me by an attending, by the way :) I'd give a report and he would literally stop me mid-sentence and say, "that doesn't go there". He was very effective!


And there is nothing wrong with putting the information listed above on an index card to remind you. In fact, you can make an outline and copy it so you have several "blanks", and fill in the pertinent info so you have it at your fingertips in the right order. Pretty soon you'll have the order more or less memorized, and it gets much easier with time.

Don't worry, you'll get better with practice. It is a learned skill, and most of us weren't very good at it at first. It gets easier.
 
This was a very early "novice" MS3 H&P I did on my pediatric floors rotation, with that in mind (be gentle)...

Start with ID/CC/HPI
It's also sometimes useful to "kick up" relevant PMH into your one liner to frame the listener's mind. For example:

Instead of

15 y/o Caucasian male complains of epigastric pain since this AM...

say

15 y/o Caucasian male w a h/o Crohn's disease, sclerosing cholangitis, multiple episodes of pancreatitis requiring hospitalizations x many times c/o epigastric pain since this AM

then you can follow this with an HPI including as many of your parameters as you can fit: onset, location, duration, quality, agg/all factors, radiations, timing, severity.

Patient was in his usual state of health until this morning when he awoke with 7/10 sharp pain in the epigastric region without radiations. The pain is described as being persistent with some waxing and waning, worsened by PO intake. He does feel nauseous but has not vomited. Nothing appears to relieve the pain in this instance but similar pain was relieved by Demerol in the past. Patient had an episode of emesis while this writer is writing this H&P without blood or bile present.

In the ED he was worked up for possible recurrence of acute pancreatitis, R/O other etiologies of epigastric pain. In the ED labs ordered were CBC, total CO2, lipase, amylase, AST, ALT, LDH, alkphos, and GGT. In the ED the decision was made to admit the patient for treatment of an episode of acute pancreatitis due to his epigastric pain, clinical presentation, history of presentations, lipase of 2248 and amylase of 523. On arrival of the floor patient claims his epigastric pain is 7/10 sharp without radiations.


This was my written ROS. In an oral ROS you would give pertinent positives and then pertinent negatives.

In the past few days, he denies any changes in the quantity of PO intake, no recent weight loss, no fever or chills, no diarrhea, no rash. He denies having any current oral lesions or anal pain. His normal habitus is one bowel movement per day which is formed stools without hematochezia or melena. Mom claims patient ate "a pound of cheese" 1 day PTA but patient denies such behavior.

Then you can just go through your laundry list of PMH but only relevant bits, probably leave out birth hx, immunizations, WCC, etc.:

Crohn's disease diagnosed age 13, last exacerbation of Crohn's disease more than one year ago
Sclerosing cholangitis diagnosed age 13
Recurrent pancreatitis with 6 recalled exacerbations, last exacerbation 1 year ago
Hospitalizations x 7
Colonoscopy with biopsy in Mar 20xx
Denies having had prior surgery
Birth at 37 weeks NVSD without complications
Immunizations UTD
WCC per AAP guidelines


Then quick medlist/all/FH/SH. Here's what I wrote. I wouldn't spout off all that SH though.

Ursodiol 300 mg by mouth twice daily
Methotrexate 0.8 mL IM once weekly
Folic acid 1 mg by mouth 5 days a week, 2 mg by mouth 2 days a week
MVI once daily by mouth
Celexa 10 mg by mouth once daily
Remicaid Infusion last infused xx/xx given approximately every 8 weeks

Allergies: NKDA, but Toradol, Ibuprofen increase epigastric pain

FH: Cousin with SLE , Cousin with ? IBD vs IBS

SH: Patient is a 10th grader at C------- high school where he is an "As" and "Bs" type student who plays hockey, baseball, and golf. He wears a helmet/mask for hockey and bike helmet (though mom denies bike helmet use). He enjoys surfing at the beach in R-------. He lives in house with mom, dad and sisters aged 17 and 10. Father smokes cigars outside in the woods but there's no exposure to smoke indoors. No pets reside at home. The house has smoke alarms. Patient claims use of seat belts. For diet yesterday patient ate cereal for breakfast, no lunch, chicken nuggets for dinner, and crackers for a midnight snack.


Then your PE: as a med student state your vitals, for things that aren't close to the matter at heart you can say unremarkable. Like cardiac exam was unremarkable. Spend more time talking about your relevant systems, like in this instance your abd exam and rectal.

Physical Exam:

T 98, RR 20, BP 115/53, HR 68, O2sat 98% on RA, weight 69.5 kg

GA: WDWN, uncomfortable, in NAD lying in bed

HEENT: NC/AT; TMs clear B/L; PEERLA, EOMI, RRx2, nonicteric; Nares slightly erythematous, patent; No gross oral lesions, uvula M/L on phonation +MMM

Neck: Supple, no lymph node adenopathy

Resp: CTA B/L without adventitious sounds, good air entry and inspiratory effort

CV: RRR S1 S2 without murmurs; Pulses 2+ rad B/L, 2+ dorsalis pedis B/L

Abd: BS+, soft, ND, +RUQ tenderness, +epigastric tenderness, no rebound, no guarding, no peritoneal signs, no mass, no HSM

Ext: warm and dry; no cyanosis, clubbing, or edema

Neuro: CN II-XII intact, 5/5 strength in all four limbs, sensation intact to sharp and dull

Skin: no rashes, no jaundice

Rectal: heme neg, no visible lesions


State relevant labs then...


can gloss over normal labs like say CBC was WNL, transanimases were normal, bilis normal, e.g.

lipase 2248
amylase 523
AST 24
ALT 17
LDH 235
Alkphos 355
GGT 14


Then your A&P, generally restate pt's age and sex...

15 year old Caucasian male with history of Crohn's disease, sclerosing cholangitis, and recurrent pancreatitis with 6 major episodes in the past exhibits sharp RUQ and epigastric pain as well as increase lipase and amylase tends to favor an acute presentation of pancreatitis consistent with the clinical presentation of previous episodes. WBC is not elevated which suggests a non-infectious etiology. Patient's Crohn's appears to be asymptomatic currently.

Then entertain other things that you might put in a differential:

Acute hepatitis origin: though there is RUQ tenderness no hepatomegaly noted and ALT and AST are not increased
Biliary colic: not generally of a waxing and waning nature, consider U/S to more confidently R/O biliary tree involvement
Biliary obstruction: pain is of constant nature, and somewhat in a corresponding location but bilirubin is not elevated, not suggestive of obstruction, consider US
Sclerosing colangitis: Alkphos is elevated but GGT is not. There also appears to be no bilirubin retention. Consider US to evaluate biliary tree.


Then lastly your plan:

Admit to peds medical/surgical floor
Pancreatitis: Keep NPO for bowel rest, treat pain symptomatically, IVF at 1 times maintenance at approximately 170 cc/h for 70 kg boy
Crohn's disease/GI dz: Patient appears to be in current remission. Recheck rectal. Abd U/S Pending to R/O CBD dilatation and/or obstruction, other ductal involvement
Repeat labs in AM to reassess most likely what is pancreatitis: lipase, amylase (lipase more sensitive). Also order Chem 10 since one was not ordered in ED to assess electrolyte status, renal function
Demerol PCA for pain
GI prophylaxis: IV famotidine 20 mg q 12 h
Nausea treatment/prophylaxis: Zofran IV
GI primary admit, Red inpatient management team to follow
To discuss with resident/team/attending
 
H&Ps (including presentation) will gradually get better as you go through med school. When I first started as an MSI it would take me around an hour to complete the H&P, then another 2-4 to write it up.

Now, I can churn through performing the H&P and writing it up in less than 30 minutes.
 
Blade28 said:
H&Ps (including presentation) will gradually get better as you go through med school. When I first started as an MSI it would take me around an hour to complete the H&P, then another 2-4 to write it up.

Now, I can churn through performing the H&P and writing it up in less than 30 minutes.

rockstar!
 
LOL, well I'm glad to see that at first this would take a few hours to complete, because after reading that to see what I have ahead of me I was thinking, "WOW, what an amazing amount of time that seems like it would take."

Its good to know that when you start out it will take a ridiculous amount of time to do that, but as you learn it speeds up.
 
so this was very helpful... but this is my situation...

I work in an RV, so i see the patient and then I have about 30 seconds to tell teh doc what's up before he/she goes in there with me

so any thoughts on this time frame?
 
Just start something like this:

"Patient is Shamequa Laprecious Jones, a 16-year-old white female...."
 
PreMedAdAG said:
so this was very helpful... but this is my situation...

I work in an RV, so i see the patient and then I have about 30 seconds to tell teh doc what's up before he/she goes in there with me

so any thoughts on this time frame?

Outpatient medicine is somewhat similar, just everything is condensed. At the end of my MS4 year I spent some time in an outpatient walk in and this is one of the histories I did (off the top of my head). It's a focused H&P:

First:
Patient's age
Patient's sex
Relevant "stuff" you want in your one liner to frame the listener's mind

Mr. Jones is a 46 year old man with no significant past medical history who works in an auto body repair shop...

Second:
The chief complaint

...who seeks medical attention for painful 3rd and 4th digits of the right hand since yesterday PM

Third:
Your History of present illness
- Should contain some of these parameters:
onset, location, duration, quality, aggravating&alleviating factors, radiation, timing, severity

Mr. Jones accidentally slammed his right fingers in a car door yesterday while at work at the auto body shop. He did use some ice which helped reduce the pain on the right 3rd and 4th fingers which hurt 8/10 pain constant, sharp and throbbing radiating toward the hand. He tried Advil yesterday 600 mg twice with minimal relief. Nothing seems to aggravate the pain. Currenty the pain is about the same as it was at onset 8/10 sharp, throbbing.


Fourth:
Your Review of Systems (Head to toe)

ROS was negative

Fifth:
Past History/Allergies/Medications/Family History/Social History

PMH: nothing significant
PSH: none
All: none
Meds: MVI daily
SH: cigs 1/2 ppd x >20 years, EtOH 3 drinks/week on average, denies rec drug use, works at auto body shop as mentioned
FH: noncontrib


Sixth:
Focused Exam:

PE:
Vitals: Afebrile, vital signs stable (AVSS)
Exam: Right hand: Blackened nail at 3rd and 4th fingers of right hand consistent with subungual hematoma. Purpura on palmar surface of distal phalanx. Full flexion and extension of fingers. Fingers are warm, sensation intact to dull and sharp stimuli. Distal 3rd/4th R phalanxes edematous


Lastly:
Your assessment and plan

Assessment: 46 year old man with no significant PMH, 1 day status post (S/P) blunt trauma/crush injury to right 3rd and 4th digits at distal portion, with likely subungual hematomas, pain secondary to initial trauma and pressure from hematoma

Plan:
Evacuate blood from subungual hematoma via trans-nail evacuation with xx gauge needle
Pain medications
RICE: Rest of hand, Ice, +/- Compression, Elevation
Return to office if no improvement of symptamology in the next 2-3 days




If you have no idea what the assessment might be, just try your best to come up with a broad differential. It becomes easier over time. Many times you'll have things down to 2 things: like viral phayngitis vs. strep pharyngitis or something like that. In that case say what's for and against each one. As you become more and more senior, your presentations and notes become shorter, more precise and succinct!
 
I, too, have been doing this for the first time starting last week. I've been trying to listen to the doctor's dictations to get better at presenting and writing in the charts, but I feel like I'm not improving.

My question is what do you do when people come in for multiple things? Do you concentrate on one thing and include that in the HPI and the other things in the ROS? I examined a young girl yesterday that had a rash for a couple of days and a non-productive cough for 2 weeks that was apparently unrelated. When it came time to present and also to write in the chart I wasn't sure where to put her complaints.

Are there any other good threads or websites on this subject? Thanks! :thumbup:
 
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