The Art of Patient Presentations

1
The Art of Patient Presentations

• Amit Shah, MD
• Clerkship Director

2
What are oral presentations for?

• To provide other clinicians with patient
  information in a clear, logical, and reproducible
  manner.
• They follow a pattern so the listener knows the
  organization and can anticipate the type of
  information that is coming next.
• Force you to contemplate and organize disparate
  data.
• Allow you to demonstrate your clinical reasoning
  and factual skills.
• Allow the audience to ask questions
• Questions are good.

3
What are the not?

• A recitation of the written History and Physical.
• A stream of disparate facts
• A means of torturing and humiliating students and
  residents (thats just a fun side effect)
• A time to interject personal feels (the patient
  is a jerk, the nurse didnt do anything right,
  etc)

4
Oral Presentations

• They are an art and a skill that take time and
  practice to perfect.
• Every patient and situation is different, so
  there is not complete cookbook approach a good
  presentation is a custom developed presentation
  within certain guidelines.
• The key is know you audience you can then pick
  the right type of presentation and focus.

5
Types of Presentations
6
(No Transcript)
7
Comprehensive Presentation

• Chief Complaint
• History of Present Illness
• Review of Systems
• Past Medical History
• Past Surgical History
• Medications/Allergies
• Social History
• Family History
• Examination
• Laboratory Data
• Impression/Plan

8
Chief Complaint

• One sentence description of the patient and the
  reason prompting their evaluation.
• Mr. H is a 50 year old male with AIDS who
  presents for the evaluation of fever, chills and
  a cough over the past 3 days

9
HPI

• The HPI is presented in both a problem based and
  chronological fashion.
• Organize it by problems but describe each one as
  a story
• ALWAYS start at the beginning chronologically and
  include only relevant information.
• Always include pertinent negative, positives, and
  historical facts.

10
Example

• Mr. H has been HIV since 1987 his CD4 count in
  June was 150 and viral load approximately
  50,000. Past opportunistic infections have
  included PCP pneumonia 12/95 CMV retinitis
  1/96 and Kaposi's Sarcoma first noted on his
  skin 1/96. He currently takes 3TC, AZT, and
  Indinavir, all of which he has been receiving for
  approximately one year. He also takes Bactrim
  Single Strength tablets on a daily basis, along
  with Fluconazole troches PRN for thrush. He
  claims to be 100 compliant with all of his
  medication. He is homosexual though he is
  currently not sexually active. He has never used
  intravenous drugs
• Until 1 week ago, Mr. H had been quite active,
  walking up to 2 miles a day without feeling short
  of breath. Approximately 1 week ago, he began to
  feel dyspneic with moderate activity. This
  progressed to the point that, 1 day ago, he was
  breathless after walking up a single flight of
  stairs. 3 days ago, he began to develop
  subjective fevers and chills along with a cough
  productive of rust-colored sputum. There was
  associated nausea but no vomiting. He has spent
  most of the last 24 hours in bed. He denies head
  ache, photophobia, stiff neck, focal weakness,
  chest pain, hemoptysis, abdominal pain, diarrhea
  or other complaints. There is no know history of
  asthma, COPD or chronic pulmonary condition. His
  current problem seems different to him then his
  past episode of PCP.

11
ROS

• All pertinent information should have been
  included in the HPI.
• If additional, unrelated positives were obtained
  include them in an organ-system approach
  otherwise you can say remainder of ROS was
  negative.
• THAT DOES NOT MEAN YOU TAKE SHORT CUTS WHEN YOU
  DO THE INTERVIEW YOU MUST ACTUALLY DO THE ROS!

12
Medications/Allergies

• List all medications including dosages, frequency
  that patient actually takes them, and why they
  are on those medications.
• Typically list medications by generic name unless
  specifically requested otherwise.
• KNOW WHAT EACH MEDICATION IS AND WHY THEY ARE ON
  THEM.

13
PSH/SH/FH

• Dont forget to mention these sections.
• Include dates if possible for all procedures.
• Dont forget to ask about OTC and herbal
  medications that the patients take.
• Now pause for a breath and give the audience a
  chance to ask questions before proceeding to the
  examination.
• Remember Questions are good.

14
Pause and take a breathAny Questions?
15
Examination

• Vital signs are VITAL signs always start with
  complete vital signs including pulse ox if
  available.
• General paint a picture.
• Can focus on pertinent portions of examination
  and any abnormal finding.
• Again, dont take shortcuts when doing the
  examination just when presenting.

16
Laboratory

• Give pertinent or abnormal results and then just
  list normal lab (dont waste time reading all the
  normal numbers).
• Always know the lab values as the attending may
  ask for it specifically.
• Remember Questions are good.

17
Impression/Plan

• One of the most difficult parts of the
  presentation.
• Your written HP should have a comprehensive list
  of all problems, however can focus down the
  problem list to the pertinent (are you beginning
  to hate this word yet?) problems
• Now is your turn to shine.

18
Impression/Plan

• Discuss problems in a organized manner
• Differential Diagnosis
• Diagnostic Plan
• Therapeutic Plan
• Contingency and disposition planning.
• Make an argument/ Take a stand.

19
Example

• Mr. H is an HIV male with a low CD 4 count and
  high viral load who presents with an acute
  pulmonary process. My primary concern is
  infectious most likely bacterial. This diagnosis
  is supported by the rapid progression, focality
  of findings on lung exam and radiography, along
  with the sputum gram stain suggest a bacterial
  infection, in particular Streptococcal pneumonia.
  Other pathogens to consider include H Flu and,
  less commonly, Legionella. The Differential
  diagnosis would include other infectious causes
  such as PCP, mycobacterial, viral, and fungal.
  The differential also included non-infectious
  etiologies such as vasculitis, lymphoma,
  pulmonary embolus, and neoplasm, however, at this
  time the data does not support the existence of a
  noninfectious pulmonary process.

20
Example (cont)

• My diagnostic plan includes monitor blood and
  sputum cultures. Check sputum for PCP and AFB.
• My therapeutic plan includes empiric treatment of
  CAP in an immuno-compromised host with an IV
  quinolone but hold on treatment for PCP as well
  as O2 therapy to maintain saturations 92
• If the patient fails to improve or worsens would
  strongly consider a bronchoscopy to evaluate for
  unusual or atypical cause of infections such as
  CMV or PCP.

21
(No Transcript)
22
Concise Presentation

• More focus on the problem at hand skip
  PSH/SH/FH/ROS unless directly related to the
  problem at hand.
• Example would be tailoring the presentation to
  the pulmunolagist you consult for the
  bronchoscopy.
• Often used at the clinic for outpatient return
  visits.

23
Bullet Presentation

• Use for work rounds on follow up of patients who
  are already well known.
• Only focus on recent events (usually over the
  past 24 hours), vital signs, changes in exam, and
  labs.
• Brief, problem based discussion.

24
Are you ready to try?