Presenting in the ER

“…no matter how much compassion and warmth I may have with my patients, my superiors grade me more on how polished I am, how well crafted my presentation is.”

– Fourth-year medical student

As unfair as it may be, your clinical grade in most of your rotations will be based on how well you present your patients. It’s very unlikely that we watch you do your physical exam or observe your interaction with the patient. It all comes down to that short performance. So why not be great at that game?

Presenting a patient can be like telling a story. Much of this is dependent on starting with a good differential diagnosis. As Dr. Gordon says in the video above, there are three parts to this story.

Beginning

☑ Demographics: name, age & gender
☑ Pertinent PMHx only
☑ Reason they are here (chief complaint)

Middle

History
☑ History arranged according to illness script
☑ PMHx, ROS, Soc Hx integrated into narrative

Physical
☑ Vitals: highlight abnormalities (or “unremarkable”)
☑ General Appearance
☑ Physical attributes based on DDx

End

DDx
☑ Most imminent
☑ Most likely
☑ High-risk, do not miss
☑ High-risk, considered but excluded
☑ Low-risk and low probability

Management Plan
☑ Diagnostics
☑ Therapeutics
☑ Disposition

Beginning

This is your introductory statement. It should include the patient demographics (age, gender), pertinent PMHx and the reason they are here. Together these provide a backdrop or frame for the conditions the patient may be at risk.

  • ☑ Demographics: name, age & gender
  • ☑ Pertinent PMHx only
  • ☑ Reason they are here (chief complaint)

Resist the urge to include every past medical history element here. Only include what is relevant to your differential diagnosis.

Bad example
“Um, doc, I have a patient to present to you. He has a history of gout, rheumatoid arthritis, Sjogrens and has not been feeling well for the past few days. Yesterday he went to the store and said he felt nauseated. The day before he was also not feeling well. His cousin…”
Better example
“Doc, I have a patient. Mr. Jones is a 57 year-old male with a prior heart attack coming in with chest pain.”

Middle

This is the crux of the presentation. Your presentation should allow the listener to anticipate your differential diagnosis. Organize the historical elements by diagnosis. If you are considering pulmonary embolus, mention together whether the patient’s pain is pleuritic, they had recent surgery or travel or any leg swelling. These constellation of symptoms characteristic for PE represent its mini-story (aka illness script or pattern of disease).

  • ☑ History arranged according to illness script
  • ☑ PMHx, ROS, Soc Hx integrated into narrative

 

Bad example
“His pain is dull, constant, goes to his arm. He says he has nausea and vomited once. It is worse with walking, bending and driving. He hasn’t traveled anywhere. Has no fever…”
Better example
“His pain is substernal, pressure-like and worsens with exertion. It is not pleuritic, he has no recent surgery or travel, nor has he had a prior PE or DVT. It is not radiating to the back nor tearing in nature. He has no fever, cough or sputum…”

Your physical should also be arranged around your DDx.

  • ☑ Vitals: highlight abnormalities (or “unremarkable”)
  • ☑ General Appearance
  • ☑ Physical attributes based on DDx

End

Also known as your assessment and plant. Here is a common way to arrange your differential diagnosis within your assessment.

  • ☑ Most imminent
  • ☑ Most likely
  • ☑ High-risk, do not miss
  • ☑ High-risk, considered but excluded
  • ☑ Low-risk and low probability

The management plan typically has three parts.

  • ☑ Diagnostics (Dx)
  • ☑ Therapeutics (Tx)
  • ☑ Disposition (Dispo)

I actually like to embed the plan within each diagnosis.

Bad example
“This is a 57 year-old male with HTN, gout and a prior MI coming in with chest pain. The pain started yesterday…”

You said all this already

Better example
“My working diagnosis is an acute coronary syndrome. The pain is exertion and sounds like his prior MI. So my plan for this is to…

  • Dx: Get a troponin
  • Dx: Get a repeat EKG and troponin in 4 hours
  • Dx: Get a stress test once he’s ruled out for an MI
  • Tx: Treat his pain with nitroglycerin, give him an aspirin
  • Dispo: And observe him overnight

“A dangerous condition I wouldn’t want to miss would be an aortic dissection, given his prior vascular disease. I’m not too convinced he has this though. Since my suspicion is low,

  • Dx: I’d like to get a chest x-ray, if the mediastinum appears normal, I feel comfortable this isn’t a dissection
  • Tx: Just in case, we should probably lower his blood pressure

“I’ve excluded pneumothorax, pneumonia and pericarditis because of…”

“A low risk diagnosis I would also consider is a reflux esophagitis since it did worsen with eating.”

  • Tx: We can try some Maalox, but I know this isn’t diagnostic
  • Dx: I would consider this a diagnosis of exclusion, once we’ve rule everything else out.

Leave a Reply