Presenting a Patient - Guidelines and Tips CORE Presentation Adapted by Primary Care Associates July 5 th, 2011

Presenting a Patient – Premises  Purpose: To concisely convey information to another health care provider  Present information needed to develop a basic understanding of the patient’s current state of health  This fundamental skill will be part of your professional communications for the remainder of your career  Just as with documentation, standardized format enhances clarity and minimizes confusion

Presenting a Patient – Premises  The format of a formal Patient Presentation differs according to: the service (ambulatory family medicine, surgery, emergency medicine, etc.) the setting (hallway, exam room, “rounds discussion” table, etc.) the listener (preceptor, resident, department staff, etc.)  TIP: Ask the preceptor/resident about oral case presentation guidelines at the start of the rotation

Presenting a Patient – Basics  Rule of thumb: BE BRIEF  Family history, social history and review of systems are frequently excluded from the case presentation Especially the “acute problem” presentation (ED, UC, FM) However, ALL details should be investigated in case they are significant  Elements of the social/family history or ROS that are relevant to the chief complaint (e.g., homelessness, father died of age 40, 20 pack-year smoking history, etc.) may be included in the “history of chief complaint”

Presenting a Patient – Basics  Patient name, age, race, gender  Chief complaint (onset, duration) “Mr. Sullivan is a 24 year-old white man who presents with a 3-day history of a progressively worsening cough, productive of yellow sputum, accompanied over the last 24 hours by sharp, left sided chest pain. “  History of Chief Complaint (O-P-Q-R-S-T; CODIERS)  Relevant SH/FH/ROS  Relevant PMH/PSH  Current Medications  Allergies

Presenting a Patient – Delivery Tips Be interested and energetic … and your audience will respond Know ALL the facts of the story … but don’t automatically tell it all Be confident … never condescending Use notes … but don’t read them Be organized … follow a standardized pattern

Use precise language Positive statements are more powerful than negative statements “Lungs are clear of wheezes or crackles” is better than “Lung auscultation showed no abnormalities” Get to the “bottom line” as quickly as possible … remembering that this varies with the setting, audience, etc. Presenting a Patient – Delivery Tips

Avoid redundancy “On auscultation, the lung sounds were…” “On physical exam, the heart was…” “The patient states…” Avoid judgmental language “The patient is a poor historian…” “ This 26 year-old man is a ‘frequent flyer’ in the ED..” Don’t editorialize “The nurse kept interrupting the interview to administer medications, even though I asked to be left alone…” Presenting a Patient – Delivery Tips

Practice Flexibility to accommodate preceptor preferences Frustration is normal Don’t hesitate to contact us: Presenting a Patient – Questions? Primary Care Associates (FM Fellows) Grosvenor 333 (740)

Leonard Harris is a 78 year-old AA male who presents with his daughter, Jill, to the family doctor’s office. Leonard has “no complaints.” Jill has made this appointment to express concerns re: her father’s recent “absent-mindedness”… Student Doctor Schoeny Student Doctor Manzanillo Practice Case 1: Ambulatory Family Medicine Primary Care Associates (FM Fellows) Grosvenor 333 (740)

Ashlee Pranso is a 32 year-old white female presenting to L&D reporting, “Really bad pain in my belly.” Student Doctor Crye Student Doctor Parks Practice Case 2: Inpatient OB/GYN Primary Care Associates (FM Fellows) Grosvenor 333 (740)

Ms. Brittany Pierce is a 49 year-old white female presenting with a headache 3 days ago, and since that time persistent “dizziness”. Student Doctor Kocoloski Student Doctor Phillips Practice Case 3: Inpatient Internal Medicine Primary Care Associates (FM Fellows) Grosvenor 333 (740)