Presenting a Patient Insert your own name and date here Developed by Alison Dobbie, MD, UT Southwestern & James Tysinger, PhD, UTHSC-San Antonio, 2007 INSERT SUITABLE PHOTOGRAPH HERE

Objectives State the reasons for presenting a patient Describe the components of a presentation template Given a written case example and the specialty of the attending, present the patient information succinctly and logically.

Why present a patient? Relay clinical information between physicians Get a second opinion Demonstrate your skills  Critical thinking  Clinical decision-making  Applying basic science knowledge to patient care

How to present a patient Many variations on this theme Information varies by specialty and attending –Example: A family physician and a trauma surgeon want to hear different information Common requirements across specialties and attendings include: –Be succinct and logical –Present from a mental template, do NOT read from notes! –“Fill in the boxes in your mental template”

One template 1.Patient description 2.Chief complaint / History of chief complaint 3.Pertinent review of symptoms 4.Pertinent past, social and family history 5.Physical exam 6.Labs and tests 7.Assessment and plan

Notes on the history Some attendings like:  Current medical problems ‘up front’  The “Subjective” in lay language Consider these differences among specialties  FM: Ms. Smith is a 23 y/o African-American…  OB: Ms. Smith is a 23 y/o G3P2….  Ortho: Ms Smith is a 23 y/o right-handed typist….

Critique this presentation to an FP “Mrs. Smith is a 47 y/o AA female with DM2, HTN and hyperlipidemia who presents with a 3 day history of pain on passing urine associated with lower abdominal pain, frequency and nocturia x3. She denies back pain, fever or chills, hematuria or vaginal discharge. The pain is relieved by tylenol. She has tried cranberry juice without effect on the urinary symptoms. She has a history of 2 previous UTIs in the last year, cultured as E. Coli and sensitive to Bactrim.”

Notes on the ROS and PE: Keep the ROS and PE pertinent! Start the PE with the vitals State pertinent positives and negatives State the latest labs and tests, and note what needs done today Know the health maintenance status – even if you don’t initially present it

Notes on the assessment and plan: Every problem needs an assessment Every assessment needs a plan Prepare a differential list, even if you’re sure of the diagnosis – your attending may ask for it Make yourself do assessments and plans: Practice makes perfect

General notes on presenting Practice, practice, practice Look and sound confident and professional Demonstrate your thinking Ask for (and hear and heed) feedback Give your attending what he/she wants BUT Develop your own template variation

Case Examples (see handouts) 1.I’ll present a patient to you 2.Practice presenting to a neighbor

Discussion What did you learn about presenting a patient in this session? How will you use what you learned to change your presenting behavior? What else do you want/need to know about presenting a patient?