presentations in medical school

How to Skillfully Present Patients in Medical School

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How do you present patients in medical school? Presenting in front of attendings often makes medical students tense up. It’s very uncomfortable to attempt to sound competent, concise, and thoughtful to a likely evaluator.

But what if I told you that the whole process could be stress-free and easy?

In this post, I’ll break down, step-by-step, exactly how to present patients in medical school to your attendings/residents. This will include the dos and the do not’s of presenting!

If you prefer a video format, check out the following video and more on my YouTube channel!

Tell a Story When Presenting Your Patient:

This is how I learned to present, and I believe it’s the best way to present patients.

Tell a story.

You know how easily we mentally check out during a boring lecture. They often just read off their slides. It becomes a bullet point presentation – just fact after fact.

Medical students are often the boring lecturer when they present. We become so worried about telling all the facts. But we suck at tying it all together.

Think about it; we don’t talk about patient experiences with our peers the way we present. We’re much more casual and hit the high points, Now no I’m not arguing that you should be too casual but learn how to tell a story without hitting unnecessary info.

I’ll break down exactly how I tell my patient’s medical story. Just remember that you want to be interesting and concise.

What Would I Want To Hear?

Imagine yourself as the attending. What would you want to hear?

You certainly wouldn’t want to hear your medical students telling you about lung sounds in a patient with a broken finger.

Ask yourself if a piece of info is important for your patient. You get better over time on identifying what’s important. I discuss some things you should always mention later in the post.

Write Out Your Presentation in Bullet Format

Too often I see my peers reading their typed notes word for word. They rarely look up and don’t even pretend like they’re not just regurgitating their progress note.

I get that it’s hard to memorize a presentation. It’s as scary as actually having to do one.

So use a bullet point outline.

Here’s what I do.

On the first bullet, I’ll often write a shrunk version of my one-liner. I’ll talk about mastering this later in the post.

The next few bullets I’ll break down symptoms, timeline, important features, etc. that I want to discuss when I’m telling my patient’s story.

In the next bullet points, I’ll write the vital ranges and underline anything I want to mention. I’ll also include physical exam findings and labs which are pertinent.

Finally, I’ll include a list of problems with Ddx and suggestions for the plan.

Here’s an example of what this would look like.

Honestly, this is probably more than I’d write down. I have created my abbreviations which tends to cut my bullet point to half what’s shown above.

Unless I’m lost,I don’t have to look down. Thus I’m always making eye contact with my attending – demanding attention.. This makes the presentation seem much more natural. You’re having a discussion with your attending.

Don’t read your note that they can read on their own.

S tep-By-Step Approach To Presenting Patients in Medical School  Master the One-Liner.

Your one-liner will tell the resident if they should take your presentation seriously or not. The same way a great singer grabs your attention with their first note, you have to impress with a solid one-liner.

Here’s how to do it.

Table Of Contents

Who are they?

Include their name, age, and demographics.

Why predisposes them to these symptoms/disease?

What comorbidities do they have? Which are important for their current chief complaint?

Provide some insight into severity here. Do they have HF? If so what’s their ejection fraction?

Do they have diabetes? What’s their A1C?

I discuss other examples later in the post.

Why are they here?

Their chief complaint is the most important part of your one-liner. Here are things you must include.

What caused them to come into the hospital/clinic?

Patients usually come in with symptoms, not diagnoses . So your patient comes in with a chief complaint of chest pain, not a heart attack.

Sometimes a patient may come in for one thing but are getting worked up for a different symptom altogether. You can state, “patient is being evaluated for (insert symptom) that was identified in the emergency room/clinic”. You can include in your HPI what the patient originally came in for to paint the full picture.

Master Your PHI (Present History of Illness)

I remember presenting once in the pediatric emergency room to an attending. My patient was a 6-year old girl with a cat scratch to her eye. It was my first rotation, and I had no idea what I was doing (Maybe I should have looked for such a post back then).

I began with a killer one-liner. But then, instead of talking about her eye, I began to talk about her flu-like symptoms. The attending immediately stopped me and said, “I don’t care! Tell me about her eye!”.

So learn from my mistake. Don’t talk about the flu on a patient with a scratched eye.

Keep your story to the point.

After you understand this important lesson, the next step is to begin to form the order of your story. Often this begins with how the long the symptoms are going and how they first presented. Then provide a chronological order of how the symptoms worsened/improved over time.

Make sure to include why the patient finally came to see a doctor. Why now instead of two days ago when the symptoms first started?

This is also where you include the rest of your PHI. There are several acronyms people use that I haven’t cared to remember. But here are the important details to discuss (if applicable).

How long have the symptoms lasted? How does the patient describe their symptoms/pain? (sharp, dull, throbbing, etc.) Where is it? Does it radiate? How severe on a scale of 1-10 is it? Has this number gotten worse or better over time? What makes it better and what makes it worse? Do they have any other associated symptoms? (Fevers, weakness, headaches, chest pain, etc.)

Remember not everything is important:

Let’s go back to our bullet point outline of our presentation. When you practice it in your head, ask if that fact you plan on saying is important to the person’s story.

Ever watch a movie and wonder why a scene was even needed? Don’t include extra scenes.

The attending should understand who the patient is, why they’re here, and the important events that led them to this point.

What is considered abnormal?

If something is abnormal to a patient, explain how it differs from normal for them. If a patient can’t walk without being SOB, you must explain how far could they walk before.

If they have a headache but also have a history of migraines, then you must include how this headache is different or similar to their condition.

Indicate Pertinent Positive and Negatives on

If a patient comes in with concerns of a heart attack, including the symptoms that they have which make you worried.

It’s equally as important to include symptoms of an MI that they don’t have.

But don’t go through the whole list and indicate random symptoms that don’t matter.

Become Efficient in Telling The Past Medical

Students love to list everything the patient has. But let’s be real, I don’t care if a patient has GERD and they’re coming in for osteomyelitis.

In your PMH include big comorbidities such as diabetes, asthma/COPD, heart failure, liver disease, and kidney issues.

If they do have the above comorbidities here are some things you should include.

For diabetes always include their most recent A1C. State when this was done. Also include what form of treatment they’re on (insulin, metformin, etc.), their dose, and their compliance with their medications. Also ask about their typical blood sugars, how often the measure them, and what time of the day these readings are taken.

For heart failure include their last ejection fraction and date. Indicate what medications they’re currently taking and how compliant they are. Ask the patient how many pillows they sleep with under their head as paroxysmal nocturnal dyspnea is a common symptom. Also, ask about their baseline weight (will go up in a heart failure exacerbation) and what their diet/fluid intake is like.

For asthma , you want to identify what severity they have. Are they severe persistent, moderate intermittent, or something else? How often do they use their rescue inhaler? How many times a week do they wake up at night. Also, ask if they’ve ever had to be intubated before.

Similar to asthma, for your COPD patient also include what GOLD stage they are. You’ll learn about this on your internal medicine rotation if you haven’t already.

These are some classic examples you want to hit every time.

Physical Exam

Start with their vitals.

Do you need to say everything? No.

Some attendings will want ranges for the heart rate and blood pressures. Others are fine if you say, “patient is afebrile, normotensive, and has a regular heart rate” or “vital signs are within normal limits”.

Regarding your physical – only say what you did. Again does everything matter? Nope.

Get away from sounding robotic. “Lungs clear to auscultation bilaterally” can just be “lungs clear bilaterally”.

If you don’t read your notes, you’ll seem more natural when presenting the physical.

What about labs?  Don’t present all labs obviously. No one cares about the WBC for a patient with a broken arm.

State labs of importance such as “lytes were stable; hemoglobin was decreased to (insert value) from (insert value) yesterday. Remaining labs of patients were within normal limits”.

If, however, you did a specific lab/test to confirm/rule out a disease then make sure you state the results. A common example is a urinalysis. If a patient has suspected UTI, make sure you state their UA came back without indications for an infection.

Certains labs are important to trend. This includes Creatinine, BNP, hemoglobin/hematocrit, WBC, Platelets, Lactate, and important electrolytes.

Assessment and

So you finished with the easy part. You knew the story and told it. Now you get to show you know how to doctor and not just interview.

Here’s my format to present my assessment and plan.

“This is Ms. who has (insert pertinent conditions and PMH) who came in for (symptoms). Given her symptoms and (physical exam/lab evidence A, B, C) I think she could have (differential A) given that she has (x,y, and z), she could also have (differential B) because of (x,y,z) and differential C (x,y,z).

To work her up I would do test/treatment (a,b,c) and reevaluate her (insert time frame).

I expect discharge for her pending treatment/workup and hopeful discharge (give a guess if possible).”

Boom! You just rocked that patient presentation!

If your patient has multiple problems, you can break your A/P by problem. For example, you can state, “For her back pain I think she could have (X,Y, or Z). I think we should give her treatment (A or B).” Keep going down her problem list. Some attendings like a system based but the method is the same.

Whenever you’re ready, there are 4 ways I can help you:

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4. Learn the one study strategy that saved my  grades in medical school here (viewed by more than a million students like you). 

So there you have it. Now you can present patients in medical school like a pro!

Here are other posts you may enjoy as well.

How to Build Strong Relationships with Your Patients Dealing With Death in Medical School Regaining Motivation in Medical School Top Resources to Honor Your Pediatrics Rotation

Until next time, my friend…

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Presentations at Medical School: Top Tips

While most of medical school assessment consists of exam after exam, there are other ways to check what you know and encourage you to do research. One of these is doing presentations. This can be a pretty intimidating thought, especially if you aren’t used to presenting or don’t like speaking in front of groups of people. However, just because it might not be your thing doesn’t mean you can’t do a great job. I hope that some of the tips below will help you, so you can make the most of any presentations you deliver at medical school. 

1. Talk about something you’re interested in

Sometimes you are assigned a topic to present, but if you aren’t, choose something you will enjoy researching. If you care about your subject, your enthusiasm will look great and will be obvious to your tutor.  If you are assigned a topic and it’s something you really are not interested in, there’s no harm in asking your tutor if you can swap – the worst they can say is no.

2. Dress to impress

This doesn’t mean don a tuxedo or a sparkly cocktail dress, but wear something that you feel confident in and looks professional – this means a shirt/blouse and trousers/skirt, depending on what you feel most comfortable in.

3. Have water on standby

This is a must in my opinion. No matter how long the presentation is, it is so important to have access to some water to drink within reaching distance. You may never take a sip but it can be a useful way to gather your thoughts if you feel you’re struggling.

4. Present in front of your friends

Nerves are the worst part of public speaking or presenting – and what better way to get over them than to present in front of the people who will make fun of you? Joking aside, your friends can be a great stand-in audience. It gives you the opportunity to practice what you are going to say in front of people who aren’t marking you but will be able to give constructive feedback.

The key to getting over the nerves is being confident in what you have to say and practising in front of people really helps. Make sure you return the favour when it’s their turn to present too!

5. Plant your questions

This one isn’t always possible but when it is – do it! If you are presenting in front of other students you could get someone you know to ask you a question which you can give a great answer to, but don’t make it too obvious. If, for example, you run out of time and thereby don’t talk about a specific drug but someone asks you on it anyway it might arouse suspicion, so be clever about it!

Words: Ruari McGowan

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Presentations 101: Delivering a Great Deck

• By Cailey Talbot
• December 20, 2019
• Medical Student , Pre-med
• High School , Reading , Self-improvement

It’s estimated that as many as 70% of Americans fear public speaking, yet as a working professional, it just comes with the job. While the majority of the work is in finding the right content for the presentation and making sure you thoroughly know the material, going the extra mile in delivering a presentation will make you stand apart from your peers. So what’s the secret?

Before “The Big Day”: Preparation

There are two core components that go into making a good presentation. The brunt of the work is in the preparation— how are you making your slides or blocking your talk? What’s the most effective and concise way of communicating an idea? Assuming that you have the content down and just need to know the best way to prepare the talk, here are a few tips:

Always spruce up your slides

Yes, we try not to judge a book by its cover, but having a pretty deck always makes a difference. Consider the following example:

On the left, we see a slide that only has text, which makes it hard to read and parse easily. It also uses a serif-based font, which takes longer to read. On the right, we use a sans-serif font that is easier to read, and group the information in a logical way. I also recommend having titles that either pose a question or make a statement— titles are a great way to summarize what the take-away from the slides should be. Lastly, people remember icons much easier than they do straight blocks of text— by including even a few cartoon images that summarize the information, the slide immediately becomes more digestible and approachable. And don’t be afraid of using a bit of color! Having an understated color palette throughout the presentation will draw eyes to the important information while still remaining professional.

Include an agenda

So many talks have amazing content but fundamentally lack cohesion because the audience is unaware of the journey that they are being brought on. Make sure that you begin your presentation by giving a clear sense of what the overview is. Who are you, and what are you talking about? What is the one-sentence summary of this talk, and what are the exact steps you are going to take to lead us to this conclusion? And finally, why do we care? I often like to have an “Agenda” slide that I include multiple times in the talk and bold specific sections that you are talking about at the moment. This way, the audience is aware of how much longer the talk is going to take and why this particular section is important to the overall buildup.

Anticipate audience questions

Time your presentation and make sure that you are well under the allotted time limit. I often recommend recording yourself practicing the presentation to replay it and confirm that you are speaking in a well-paced and clear tone. Leave time for questions, because people will inevitably want to clarify or poke further into your work. If you think you know what some common questions might be (either based on a practice run you did with a friend or your own intuition), create “backup” or “Appendix” slides that you can refer to in the case that people ask about specific information. A common question is to ask for a citation or reference that backs up data that you are presenting, so always include references or a Works Cited section.

Day Of: Delivery

Once you’re happy with your presentation, move on from the slides. Focus on you! Again, we like to pretend that image and delivery doesn’t matter as much as it does, but impressions have a lasting impact on how people view your presentation.

It’s okay to be a little overdressed

No one faults someone for trying “too hard” at delivering a good presentation— it’s a lot better to wear something slightly more formal than usual. Pick your outfit beforehand and make sure that it is comfortable enough for you to stand up and walk around without feeling self-conscious or hurting your feet. Most importantly, though, wear something that makes you feel confident because that will project to the audience.

Body language is key

Plant your feet shoulder-width apart, and keep your hands out rather than behind your back or in your pockets. Try to keep gestures to a minimum and use them only when they directly accentuate the point you are trying to make. Relax your shoulders so you don’t feel too stiff, and try to keep your torso towards the audience so your position is open and amicable rather than reserved. If you feel awkward and uncomfortable, chances are the audience is reading that too. Delivering a great presentation is a bit like acting— you have to own the part completely, even if you feel nervous.

Don’t speed up or slow down because you’re worried about time.

Your presentation may not go exactly as planned, or perhaps impromptu questions got in the way and took up a lot of time. Either way, the solution isn’t to suddenly speak a lot faster and try and get your point across as quickly as possible. Keep the same calm and measured pace, but decide ahead of time what slides you might be willing to gloss over or skip entirely in the case that you need to prioritize.

Don’t over-practice.

A lot of people I know tend to practice so much that their presentation begins to sound robotic and rehearsed, which takes away from a natural delivery. People want to know that you’re thinking on your feet and telling you a story rather than reciting lines that sound memorized. Practice enough times that you have a general flow and sense of the time you need to take per slide, but not too much that you begin to feel stale.

Tie back the conclusion to the beginning of your presentation.

Remember, delivering a good presentation is just like telling a great story. That means that the audience genuinely must feel like you’ve taken them on a journey and that they ended up exactly where you promised you’d be at the beginning of your presentation. I often like to use my title slide as my concluding slide as well so there’s a visual cue that shows the presentation si ending, and you can then restate the title and give a few quick sentences about why they care about the topic at hand and what you’ve taught them.

Most importantly, trust yourself— you’ve practiced, and now it’s time to show everyone what you’ve put into your work!

Cailey Talbot

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Why Premeds Should Hone Public Speaking Skills

Public speaking can help you on your path to medical school and during your training to become a doctor.

Premed Students and Public Speaking

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Development of public speaking skills is a significant opportunity for personal and professional improvement that is rarely considered in premedical advising.

Many premedical students feel uncomfortable with the prospect of speaking publicly, particularly to a large group and to those more knowledgeable in their field. This makes development of public speaking skills a significant opportunity for personal and professional improvement that is rarely considered in premedical advising .

Premed students can benefit greatly from developing their public speaking skills, and there are several advantages to doing so.

Medical School Interviews

The most immediate application of public speaking skills for premed students will be during interviews for medical school. The ability to convey your opinions, thoughts, beliefs and ideas confidently and eloquently is enormously important for future doctors, and admissions committee members will be impressed to see these capacities in an interviewee.

Put yourself in the position of your interviewers, individuals who have conducted hundreds of interviews with aspiring doctors and are likely fatigued from hearing repetitive, similar phrases and refrains from each candidate.

Do you have a unique motivation to become a physician that is entirely novel? Perhaps, but the vast majority of applicants will not. And that is more than OK because you can express your life story and your motivation to pursue medicine in a strong, powerful, memorable manner through excellent public speaking skills.

The goal in an interview is to be remembered and to leave an impression. If you worry your story may not, work to perfect your delivery such that your public speaking skills leave no doubt. Strong communication skills convey professionalism, passion and preparation, traits that bode extremely well for future doctors.

Scientific Presentations and Research Discussions

Improving your public speaking skills will facilitate communication in scientific presentations and research discussions. When presenting scholarly research, whether your own or others’ novel research findings, strong and clear speaking skills will help to convince your audience that you know what you are talking about.

Clear and effective communication also allows for enhanced dissemination of scientific results, and more effectively spawns productive collaborations. If a career in research is at all in the cards for you, public speaking is an absolutely nonnegotiable skill.

Interpersonal Communication

The practice of medicine relies heavily on interpersonal communication. Because all health care is a team sport, the roles of each member of the care team are intricately intertwined with one another.

Thus, communication is paramount, and you will need to confidently and concisely communicate detailed medical knowledge about your patients to medical students, residents and other health care professionals with a wide range of knowledge bases.

Effective public speaking skills will allow you to thrive in this environment, perform well in interdisciplinary collaboration and, most importantly, advocate persuasively for your patients. As you interact directly with patients, you will appreciate the necessity of clear language and speaking style.

Clear c ommunication with patients is one of the most effective ways to improve patient satisfaction and adherence to treatment plans. Your patients will more fully grasp the nature of their disease process and better appreciate the necessity of various treatments if you distill complicated pathophysiology into clearly understandable parcels of information. Doing so without compromising their feelings of agency and intellect is an art as much as a science, and requires deft public speaking skills and tactful delivery.

The successful doctor will undoubtedly enjoy increased patient satisfaction with their medical care and, most importantly, improved overall disease outcomes.

Professional Development Opportunities

You will also notice that professional development opportunities such as writing up a case study or presenting at a national conference will become available with greater regularity if those at the top of the totem pole – such as attending physicians and chief residents – believe you will represent your institution properly and reflect well on your mentors .

The most obvious advantage of developing improved public speaking skills is professional advancement through effective networking. Medicine remains a relatively small community, particularly once you specialize and begin seeing many of the same individuals at the same conferences and meetings year after year.

An excellent presentation or a memorable conversation can foster valuable connections and spawn working and personal relationships that last for years. These connections can open doors to opportunities you may not even be aware of in medicine, science, research or life outside of work.

For career advancement, particularly in the realm of academic medicine and research, persuasive public speaking skills are imperative, and the earlier you begin to improve, the better.

Importance of Practicing Public Speaking

To improve your speaking skills and delivery, there is absolutely no substitute for practice. No improvement can be expected without the devotion of hours of practice.

Pursue opportunities to speak about your undergraduate research at conferences and lab meetings, as well as in your club meetings and in your job. Remember that while you are speaking, all eyes are on you. Own the moment, stand up straight, speak forcefully and clearly enunciate. You deserve this moment of your audience’s attention, so act accordingly and deliver your information with confidence.

Your interview performance, health care interactions, scientific communication, presentations and networking will greatly benefit from improved communication and public speaking skills. This often-overlooked attribute should be a priority as you embark on your journey toward a career in medicine.

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Need a guide through the murky medical school admissions process? Medical School Admissions Doctor offers a roundup of expert and student voices in the field to guide prospective students in their pursuit of a medical education. The blog is currently authored by Dr. Ali Loftizadeh, Dr. Azadeh Salek and Zach Grimmett at Admissions Helpers , a provider of medical school application services; Dr. Renee Marinelli at MedSchoolCoach , a premed and med school admissions consultancy; Dr. Rachel Rizal, co-founder and CEO of the Cracking Med School Admissions consultancy; Dr. Cassie Kosarec at Varsity Tutors , an advertiser with U.S. News & World Report; Dr. Kathleen Franco, a med school emeritus professor and psychiatrist; and Liana Meffert, a fourth-year medical student at the University of Iowa's Carver College of Medicine and a writer for Admissions Helpers. Got a question? Email [email protected] .

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Overview and General Information about Oral Presentation

• Daily Presentations During Work Rounds
• The New Patient Presentation
• The Holdover Admission Presentation
• Outpatient Clinic Presentations
• The structure of presentations varies from service to service (e.g. medicine vs. surgery), amongst subspecialties, and between environments (inpatient vs. outpatient). Applying the correct style to the right setting requires that the presenter seek guidance from the listeners at the outset.
• Time available for presenting is rather short, which makes the experience more stressful.
• Individual supervisors (residents, faculty) often have their own (sometimes quirky) preferences regarding presentation styles, adding another layer of variability that the presenter has to manage.
• Students are evaluated/judged on the way in which they present, with faculty using this as one way of gauging a student’s clinical knowledge.
• Done well, presentations promote efficient, excellent care. Done poorly, they promote tedium, low morale, and inefficiency.

General Tips:

• Practice, Practice, Practice! Do this on your own, with colleagues, and/or with anyone who will listen (and offer helpful commentary) before you actually present in front of other clinicians. Speaking "on-the-fly" is difficult, as rapidly organizing and delivering information in a clear and concise fashion is not a naturally occurring skill.
• Immediately following your presentations, seek feedback from your listeners. Ask for specifics about what was done well and what could have been done better – always with an eye towards gaining information that you can apply to improve your performance the next time.
• Listen to presentations that are done well – ask yourself, “Why was it good?” Then try to incorporate those elements into your own presentations.
• Listen to presentations that go poorly – identify the specific things that made it ineffective and avoid those pitfalls when you present.
• Effective presentations require that you have thought through the case beforehand and understand the rationale for your conclusions and plan. This, in turn, requires that you have a good grasp of physiology, pathology, clinical reasoning and decision-making - pushing you to read, pay attention, and in general acquire more knowledge.
• Think about the clinical situation in which you are presenting so that you can provide a summary that is consistent with the expectations of your audience. Work rounds, for example, are clearly different from conferences and therefore mandate a different style of presentation.
• Presentations are the way in which we tell medical stories to one another. When you present, ask yourself if you’ve described the story in an accurate way. Will the listener be able to “see” the patient the same way that you do? Can they come to the correct conclusions? If not, re-calibrate.
• It's O.K. to use notes, though the oral presentation should not simply be reduced to reading the admission note – rather, it requires appropriate editing/shortening.
• In general, try to give your presentations on a particular service using the same order and style for each patient, every day. Following a specific format makes it easier for the listener to follow, as they know what’s coming and when they can expect to hear particular information. Additionally, following a standardized approach makes it easier for you to stay organized, develop a rhythm, and lessens the chance that you’ll omit elements.

Specific types of presentations

There are a number of common presentation-types, each with its own goals and formats. These include:

• Daily presentations during work rounds for patients known to a service.
• Newly admitted patients, where you were the clinician that performed the H&P.
• Newly admitted patients that were “handed off” to the team in the morning, such that the H&P was performed by others.
• Outpatient clinic presentations, covering several common situations.

Key elements of each presentation type are described below. Examples of how these would be applied to most situations are provided in italics. The formats are typical of presentations done for internal medicine services and clinics.

Note that there is an acceptable range of how oral presentations can be delivered. Ultimately, your goal is to tell the correct story, in a reasonable amount of time, so that the right care can be delivered. Nuances in the order of presentation, what to include, what to omit, etc. are relatively small points. Don’t let the pursuit of these elements distract you or create undue anxiety.

Daily presentations during work rounds of patients that you’re following:

• Organize the presenter (forces you to think things through)
• Inform the listener(s) of 24 hour events and plan moving forward
• Promote focused discussion amongst your listeners and supervisors
• Opportunity to reassess plan, adjust as indicated
• Demonstrate your knowledge and engagement in the care of the patient
• Rapid (5 min) presentation of the key facts

Key features of presentation:

• Opening one liner: Describe who the patient is, number of days in hospital, and their main clinical issue(s).
• 24-hour events: Highlighting changes in clinical status, procedures, consults, etc.
• Subjective sense from the patient about how they’re feeling, vital signs (ranges), and key physical exam findings (highlighting changes)
• Relevant labs (highlighting changes) and imaging
• Assessment and Plan : Presented by problem or organ systems(s), using as many or few as are relevant. Early on, it’s helpful to go through the main categories in your head as a way of making sure that you’re not missing any relevant areas. The broad organ system categories include (presented here head-to-toe): Neurological; Psychiatric; Cardiovascular; Pulmonary; Gastrointestinal; Renal/Genitourinary; Hematologic/Oncologic; Endocrine/Metabolic; Infectious; Tubes/lines/drains; Disposition.

Example of a daily presentation for a patient known to a team:

• Opening one liner: This is Mr. Smith, a 65 year old man, Hospital Day #3, being treated for right leg cellulitis
• MRI of the leg, negative for osteomyelitis
• Evaluation by Orthopedics, who I&D’d a superficial abscess in the calf, draining a moderate amount of pus
• Patient appears well, states leg is feeling better, less painful
• T Max 101 yesterday, T Current 98; Pulse range 60-80; BP 140s-160s/70-80s; O2 sat 98% Room Air
• Ins/Outs: 3L in (2 L NS, 1 L po)/Out 4L urine
• Right lower extremity redness now limited to calf, well within inked lines – improved compared with yesterday; bandage removed from the I&D site, and base had small amount of purulence; No evidence of fluctuance or undrained infection.
• Creatinine .8, down from 1.5 yesterday
• WBC 8.7, down from 14
• Blood cultures from admission still negative
• Gram stain of pus from yesterday’s I&D: + PMNS and GPCs; Culture pending
• MRI lower extremity as noted above – negative for osteomyelitis
• Continue Vancomycin for today
• Ortho to reassess I&D site, though looks good
• Follow-up on cultures: if MRSA, will transition to PO Doxycycline; if MSSA, will use PO Dicloxacillin
• Given AKI, will continue to hold ace-inhibitor; will likely wait until outpatient follow-up to restart
• Add back amlodipine 5mg/d today
• Hep lock IV as no need for more IVF
• Continue to hold ace-I as above
• Wound care teaching with RNs today – wife capable and willing to assist. She’ll be in this afternoon.
• Set up follow-up with PMD to reassess wound and cellulitis within 1 week

The Brand New Patient (admitted by you)

• Provide enough information so that the listeners can understand the presentation and generate an appropriate differential diagnosis.
• Present a thoughtful assessment
• Present diagnostic and therapeutic plans
• Provide opportunities for senior listeners to intervene and offer input
• Chief concern: Reason why patient presented to hospital (symptom/event and key past history in one sentence). It often includes a limited listing of their other medical conditions (e.g. diabetes, hypertension, etc.) if these elements might contribute to the reason for admission.
• The history is presented highlighting the relevant events in chronological order.
• 7 days ago, the patient began to notice vague shortness of breath.
• 5 days ago, the breathlessness worsened and they developed a cough productive of green sputum.
• 3 days ago his short of breath worsened to the point where he was winded after walking up a flight of stairs, accompanied by a vague right sided chest pain that was more pronounced with inspiration.
• Enough historical information has to be provided so that the listener can understand the reasons that lead to admission and be able to draw appropriate clinical conclusions.
• Past history that helps to shed light on the current presentation are included towards the end of the HPI and not presented later as “PMH.” This is because knowing this “past” history is actually critical to understanding the current complaint. For example, past cardiac catheterization findings and/or interventions should be presented during the HPI for a patient presenting with chest pain.
• Where relevant, the patient's baseline functional status is described, allowing the listener to understand the degree of impairment caused by the acute medical problem(s).
• It should be explicitly stated if a patient is a poor historian, confused or simply unaware of all the details related to their illness. Historical information obtained from family, friends, etc. should be described as such.
• Review of Systems (ROS): Pertinent positive and negative findings discovered during a review of systems are generally incorporated at the end of the HPI. The listener needs this information to help them put the story in appropriate perspective. Any positive responses to a more inclusive ROS that covers all of the other various organ systems are then noted. If the ROS is completely negative, it is generally acceptable to simply state, "ROS negative.”
• Other Past Medical and Surgical History (PMH/PSH): Past history that relates to the issues that lead to admission are typically mentioned in the HPI and do not have to be repeated here. That said, selective redundancy (i.e. if it’s really important) is OK. Other PMH/PSH are presented here if relevant to the current issues and/or likely to affect the patient’s hospitalization in some way. Unrelated PMH and PSH can be omitted (e.g. if the patient had their gall bladder removed 10y ago and this has no bearing on the admission, then it would be appropriate to leave it out). If the listener really wants to know peripheral details, they can read the admission note, ask the patient themselves, or inquire at the end of the presentation.
• Medications and Allergies: Typically all meds are described, as there’s high potential for adverse reactions or drug-drug interactions.
• Family History: Emphasis is placed on the identification of illnesses within the family (particularly among first degree relatives) that are known to be genetically based and therefore potentially heritable by the patient. This would include: coronary artery disease, diabetes, certain cancers and autoimmune disorders, etc. If the family history is non-contributory, it’s fine to say so.
• Social History, Habits, other → as relates to/informs the presentation or hospitalization. Includes education, work, exposures, hobbies, smoking, alcohol or other substance use/abuse.
• Sexual history if it relates to the active problems.
• Vital signs and relevant findings (or their absence) are provided. As your team develops trust in your ability to identify and report on key problems, it may become acceptable to say “Vital signs stable.”
• Note: Some listeners expect students (and other junior clinicians) to describe what they find in every organ system and will not allow the presenter to say “normal.” The only way to know what to include or omit is to ask beforehand.
• Key labs and imaging: Abnormal findings are highlighted as well as changes from baseline.
• Summary, assessment & plan(s) Presented by problem or organ systems(s), using as many or few as are relevant. Early on, it’s helpful to go through the main categories in your head as a way of making sure that you’re not missing any relevant areas. The broad organ system categories include (presented here head-to-toe): Neurological; Psychiatric; Cardiovascular; Pulmonary; Gastrointestinal; Renal/Genitourinary; Hematologic/Oncologic; Endocrine/Metabolic; Infectious; Tubes/lines/drains; Disposition.
• The assessment and plan typically concludes by mentioning appropriate prophylactic considerations (e.g. DVT prevention), code status and disposition.
• Chief Concern: Mr. H is a 50 year old male with AIDS, on HAART, with preserved CD4 count and undetectable viral load, who presents for the evaluation of fever, chills and a cough over the past 7 days.
• Until 1 week ago, he 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.
• 3 days ago, he began to develop subjective fevers and chills along with a cough productive of red-green sputum.
• 1 day ago, he was breathless after walking up a single flight of stairs and spent most of the last 24 hours in bed.
• Diagnosed with HIV in 2000, done as a screening test when found to have gonococcal urethritis
• Was not treated with HAART at that time due to concomitant alcohol abuse and non-adherence.
• Diagnosed and treated for PJP pneumonia 2006
• Diagnosed and treated for CMV retinitis 2007
• Became sober in 2008, at which time interested in HAART. Started on Atripla, a combination pill containing: Efavirenz, Tonofovir, and Emtricitabine. He’s taken it ever since, with no adverse effects or issues with adherence. Receives care thru Dr. Smiley at the University HIV clinic.
• CD4 count 3 months ago was 400 and viral load was undetectable.
• He is homosexual though he is currently not sexually active. He has never used intravenous drugs.
• He has no history of asthma, COPD or chronic cardiac or pulmonary condition. No known liver disease. Hepatitis B and C negative. His current problem seems different to him then his past episode of PJP.
• Review of systems: negative for headache, photophobia, stiff neck, focal weakness, chest pain, abdominal pain, diarrhea, nausea, vomiting, urinary symptoms, leg swelling, or other complaints.
• Hypertension x 5 years, no other known vascular disease
• Gonorrhea as above
• Alcohol abuse above and now sober – no known liver disease
• No relevant surgeries
• Atripla, 1 po qd
• Omeprazole 20 mg, 1 PO, qd
• Lisinopril 20mg, qd
• Naprosyn 250 mg, 1-2, PO, BID PRN
• No allergies
• Both of the patient's parents are alive and well (his mother is 78 and father 80). He has 2 brothers, one 45 and the other 55, who are also healthy. There is no family history of heart disease or cancer.
• Patient works as an accountant for a large firm in San Diego. He lives alone in an apartment in the city.
• Smokes 1 pack of cigarettes per day and has done so for 20 years.
• No current alcohol use. Denies any drug use.
• Sexual History as noted above; has sex exclusively with men, last partner 6 months ago.
• Seated on a gurney in the ER, breathing through a face-mask oxygen delivery system. Breathing was labored and accessory muscles were in use. Able to speak in brief sentences, limited by shortness of breath
• Vital signs: Temp 102 F, Pulse 90, BP 150/90, Respiratory Rate 26, O2 Sat (on 40% Face Mask) 95%
• HEENT: No thrush, No adenopathy
• Lungs: Crackles and Bronchial breath sounds noted at right base. E to A changes present. No wheezing or other abnormal sounds noted over any other area of the lung. Dullness to percussion was also appreciated at the right base.
• Cardiac: JVP less than 5 cm; Rhythm was regular. Normal S1 and S2. No murmurs or extra heart sounds noted.
• Abdomen and Genital exams: normal
• Extremities: No clubbing, cyanosis or edema; distal pulses 2+ and equal bilaterally.
• Skin: no eruptions noted.
• Neurological exam: normal
• WBC 18 thousand with 10% bands;
• Normal Chem 7 and LFTs.
• Room air blood gas: pH of 7.47/ PO2 of 55/PCO2 of 30.
• Sputum gram stain remarkable for an abundance of polys along with gram positive diplococci.
• CXR remarkable for dense right lower lobe infiltrate without effusion.
• Monitored care unit, with vigilance for clinical deterioration.
• Hypertension: given significant pneumonia and unclear clinical direction, will hold lisinopril. If BP > 180 and or if clear not developing sepsis, will consider restarting.
• Low molecular weight heparin
• Code Status: Wishes to be full code full care, including intubation and ICU stay if necessary. Has good quality of life and hopes to return to that functional level. Wishes to reconsider if situation ever becomes hopeless. Older brother Tom is surrogate decision maker if the patient can’t speak for himself. Tom lives in San Diego and we have his contact info. He is aware that patient is in the hospital and plans on visiting later today or tomorrow.
• Expected duration of hospitalization unclear – will know more based on response to treatment over next 24 hours.

The holdover admission (presenting data that was generated by other physicians)

• Handoff admissions are very common and present unique challenges
• Understand the reasons why the patient was admitted
• Review key history, exam, imaging and labs to assure that they support the working diagnostic and therapeutic plans
• Does the data support the working diagnosis?
• Do the planned tests and consults make sense?
• What else should be considered (both diagnostically and therapeutically)?
• This process requires that the accepting team thoughtfully review their colleagues efforts with a critical eye – which is not disrespectful but rather constitutes one of the main jobs of the accepting team and is a cornerstone of good care *Note: At some point during the day (likely not during rounds), the team will need to verify all of the data directly with the patient.
• 8-10 minutes
• Chief concern: Reason for admission (symptom and/or event)
• Temporally presented bullets of events leading up to the admission
• Review of systems
• Relevant PMH/PSH – historical information that might affect the patient during their hospitalization.
• Meds and Allergies
• Family and Social History – focusing on information that helps to inform the current presentation.
• Habits and exposures
• Physical exam, imaging and labs that were obtained in the Emergency Department
• Assessment and plan that were generated in the Emergency Department.
• Overnight events (i.e. what happened in the Emergency Dept. and after the patient went to their hospital room)? Responses to treatments, changes in symptoms?
• How does the patient feel this morning? Key exam findings this morning (if seen)? Morning labs (if available)?
• Assessment and Plan , with attention as to whether there needs to be any changes in the working differential or treatment plan. The broad organ system categories include (presented here head-to-toe): Neurological; Psychiatric; Cardiovascular; Pulmonary; Gastrointestinal; Renal/Genitourinary; Hematologic/Oncologic; Endocrine/Metabolic; Infectious; Tubes/lines/drains; Disposition.
• Chief concern: 70 yo male who presented with 10 days of progressive shoulder pain, followed by confusion. He was brought in by his daughter, who felt that her father was no longer able to safely take care for himself.
• 10 days ago, Mr. X developed left shoulder pain, first noted a few days after lifting heavy boxes. He denies falls or direct injury to the shoulder.
• 1 week ago, presented to outside hospital ER for evaluation of left shoulder pain. Records from there were notable for his being afebrile with stable vitals. Exam notable for focal pain anteriorly on palpation, but no obvious deformity. Right shoulder had normal range of motion. Left shoulder reported as diminished range of motion but not otherwise quantified. X-ray negative. Labs remarkable for wbc 8, creat 2.2 (stable). Impression was that the pain was of musculoskeletal origin. Patient was provided with Percocet and told to see PMD in f/u
• Brought to our ER last night by his daughter. Pain in shoulder worse. Also noted to be confused and unable to care for self. Lives alone in the country, home in disarray, no food.
• ROS: negative for falls, prior joint or musculoskeletal problems, fevers, chills, cough, sob, chest pain, head ache, abdominal pain, urinary or bowel symptoms, substance abuse
• Hypertension
• Coronary artery disease, s/p LAD stent for angina 3 y ago, no symptoms since. Normal EF by echo 2 y ago
• Chronic kidney disease stage 3 with creatinine 1.8; felt to be secondary to atherosclerosis and hypertension
• aspirin 81mg qd, atorvastatin 80mg po qd, amlodipine 10 po qd, Prozac 20
• Allergies: none
• Family and Social: lives alone in a rural area of the county, in contact with children every month or so. Retired several years ago from work as truck driver. Otherwise non-contributory.
• Habits: denies alcohol or other drug use.
• Temp 98 Pulse 110 BP 100/70
• Drowsy though arousable; oriented to year but not day or date; knows he’s at a hospital for evaluation of shoulder pain, but doesn’t know the name of the hospital or city
• CV: regular rate and rhythm; normal s1 and s2; no murmurs or extra heart sounds.
• Left shoulder with generalized swelling, warmth and darker coloration compared with Right; generalized pain on palpation, very limited passive or active range of motion in all directions due to pain. Right shoulder appearance and exam normal.
• CXR: normal
• EKG: sr 100; nl intervals, no acute changes
• WBC 13; hemoglobin 14
• Na 134, k 4.6; creat 2.8 (1.8 baseline 4 m ago); bicarb 24
• LFTs and UA normal
• Vancomycin and Zosyn for now
• Orthopedics to see asap to aspirate shoulder for definitive diagnosis
• If aspiration is consistent with infection, will need to go to Operating Room for wash out.
• Urine electrolytes
• Follow-up on creatinine and obtain renal ultrasound if not improved
• Renal dosing of meds
• Strict Ins and Outs.
• follow exam
• obtain additional input from family to assure baseline is, in fact, normal
• Since admission (6 hours) no change in shoulder pain
• This morning, pleasant, easily distracted; knows he’s in the hospital, but not date or year
• T Current 101F Pulse 100 BP 140/80
• Ins and Outs: IVF Normal Saline 3L/Urine output 1.5 liters
• L shoulder with obvious swelling and warmth compared with right; no skin breaks; pain limits any active or passive range of motion to less than 10 degrees in all directions
• Labs this morning remarkable for WBC 10 (from 13), creatinine 2 (down from 2.8)
• Continue with Vancomycin and Zosyn for now
• I already paged Orthopedics this morning, who are en route for aspiration of shoulder, fluid for gram stain, cell count, culture
• If aspirate consistent with infection, then likely to the OR
• Continue IVF at 125/h, follow I/O
• Repeat creatinine later today
• Not on any nephrotoxins, meds renaly dosed
• Continue antibiotics, evaluation for primary source as above
• Discuss with family this morning to establish baseline; possible may have underlying dementia as well
• SC Heparin for DVT prophylaxis
• Code status: full code/full care.

Outpatient-based presentations

There are 4 main types of visits that commonly occur in an outpatient continuity clinic environment, each of which has its own presentation style and purpose. These include the following, each described in detail below.

• The patient who is presenting for their first visit to a primary care clinic and is entirely new to the physician.
• The patient who is returning to primary care for a scheduled follow-up visit.
• The patient who is presenting with an acute problem to a primary care clinic
• The specialty clinic evaluation (new or follow-up)

It’s worth noting that Primary care clinics (Internal Medicine, Family Medicine and Pediatrics) typically take responsibility for covering all of the patient’s issues, though the amount of energy focused on any one topic will depend on the time available, acuity, symptoms, and whether that issue is also followed by a specialty clinic.

The Brand New Primary Care Patient

Purpose of the presentation

• Accurately review all of the patient’s history as well as any new concerns that they might have.
• Identify health related problems that need additional evaluation and/or treatment
• Provide an opportunity for senior listeners to intervene and offer input

Key features of the presentation

• If this is truly their first visit, then one of the main reasons is typically to "establish care" with a new doctor.
• It might well include continuation of therapies and/or evaluations started elsewhere.
• If the patient has other specific goals (medications, referrals, etc.), then this should be stated as well. Note: There may well not be a "chief complaint."
• For a new patient, this is an opportunity to highlight the main issues that might be troubling/bothering them.
• This can include chronic disorders (e.g. diabetes, congestive heart failure, etc.) which cause ongoing symptoms (shortness of breath) and/or generate daily data (finger stick glucoses) that should be discussed.
• Sometimes, there are no specific areas that the patient wishes to discuss up-front.
• Review of systems (ROS): This is typically comprehensive, covering all organ systems. If the patient is known to have certain illnesses (e.g. diabetes), then the ROS should include the search for disorders with high prevalence (e.g. vascular disease). There should also be some consideration for including questions that are epidemiologically appropriate (e.g. based on age and sex).
• Past Medical History (PMH): All known medical conditions (in particular those requiring ongoing treatment) are listed, noting their duration and time of onset. If a condition is followed by a specialist or co-managed with other clinicians, this should be noted as well. If a problem was described in detail during the “acute” history, it doesn’t have to be re-stated here.
• Past Surgical History (PSH): All surgeries, along with the year when they were performed
• Medications and allergies: All meds, including dosage, frequency and over-the-counter preparations. Allergies (and the type of reaction) should be described.
• Social: Work, hobbies, exposures.
• Sexual activity – may include type of activity, number and sex of partner(s), partner’s health.
• Smoking, Alcohol, other drug use: including quantification of consumption, duration of use.
• Family history: Focus on heritable illness amongst first degree relatives. May also include whether patient married, in a relationship, children (and their ages).
• Physical Exam: Vital signs and relevant findings (or their absence).
• Key labs and imaging if they’re available. Also when and where they were obtained.
• Summary, assessment & plan(s) presented by organ system and/or problems. As many systems/problems as is necessary to cover all of the active issues that are relevant to that clinic. This typically concludes with a “health care maintenance” section, which covers age, sex and risk factor appropriate vaccinations and screening tests.

The Follow-up Visit to a Primary Care Clinic

• Organize the presenter (forces you to think things through).
• Accurately review any relevant interval health care events that might have occurred since the last visit.
• Identification of new symptoms or health related issues that might need additional evaluation and/or treatment
• If the patient has no concerns, then verification that health status is stable
• Review of medications
• Provide an opportunity for listeners to intervene and offer input
• Reason for the visit: Follow-up for whatever the patient’s main issues are, as well as stating when the last visit occurred *Note: There may well not be a “chief complaint,” as patients followed in continuity at any clinic may simply be returning for a visit as directed by their doctor.
• Events since the last visit: This might include emergency room visits, input from other clinicians/specialists, changes in medications, new symptoms, etc.
• Review of Systems (ROS): Depth depends on patient’s risk factors and known illnesses. If the patient has diabetes, then a vascular ROS would be done. On the other hand, if the patient is young and healthy, the ROS could be rather cursory.
• PMH, PSH, Social, Family, Habits are all OMITTED. This is because these facts are already known to the listener and actionable aspects have presumably been added to the problem list (presented at the end). That said, these elements can be restated if the patient has a new symptom or issue related to a historical problem has emerged.
• MEDS : A good idea to review these at every visit.
• Physical exam: Vital signs and pertinent findings (or absence there of) are mentioned.
• Lab and Imaging: The reason why these were done should be mentioned and any key findings mentioned, highlighting changes from baseline.
• Assessment and Plan: This is most clearly done by individually stating all of the conditions/problems that are being addressed (e.g. hypertension, hypothyroidism, depression, etc.) followed by their specific plan(s). If a new or acute issue was identified during the visit, the diagnostic and therapeutic plan for that concern should be described.

The Focused Visit to a Primary Care Clinic

• Accurately review the historical events that lead the patient to make the appointment.
• Identification of risk factors and/or other underlying medical conditions that might affect the diagnostic or therapeutic approach to the new symptom or concern.
• Generate an appropriate assessment and plan
• Allow the listener to comment

Key features of the presentation:

• Reason for the visit
• History of Present illness: Description of the sequence of symptoms and/or events that lead to the patient’s current condition.
• Review of Systems: To an appropriate depth that will allow the listener to grasp the full range of diagnostic possibilities that relate to the presenting problem.
• PMH and PSH: Stating only those elements that might relate to the presenting symptoms/issues.
• PE: Vital signs and key findings (or lack thereof)
• Labs and imaging (if done)
• Assessment and Plan: This is usually very focused and relates directly to the main presenting symptom(s) or issues.

The Specialty Clinic Visit

Specialty clinic visits focus on the health care domains covered by those physicians. For example, Cardiology clinics are interested in cardiovascular disease related symptoms, events, labs, imaging and procedures. Orthopedics clinics will focus on musculoskeletal symptoms, events, imaging and procedures. Information that is unrelated to these disciples will typically be omitted. It’s always a good idea to ask the supervising physician for guidance as to what’s expected to be covered in a particular clinic environment.

• Highlight the reason(s) for the visit
• Review key data
• Provide an opportunity for the listener(s) to comment
• 5-7 minutes
• If it’s a consult, state the main reason(s) that the patient was referred as well as who referred them.
• If it’s a return visit, state the reasons why the patient is being followed in the clinic and when the last visit took place
• If it’s for an acute issue, state up front what the issue is Note: There may well not be a “chief complaint,” as patients followed in continuity in any clinic may simply be returning for a return visit as directed
• For a new patient, this highlights the main things that might be troubling/bothering the patient.
• For a specialty clinic, the history presented typically relates to the symptoms and/or events that are pertinent to that area of care.
• Review of systems , focusing on those elements relevant to that clinic. For a cardiology patient, this will highlight a vascular ROS.
• PMH/PSH that helps to inform the current presentation (e.g. past cardiac catheterization findings/interventions for a patient with chest pain) and/or is otherwise felt to be relevant to that clinic environment.
• Meds and allergies: Typically all meds are described, as there is always the potential for adverse drug interactions.
• Social/Habits/other: as relates to/informs the presentation and/or is relevant to that clinic
• Family history: Focus is on heritable illness amongst first degree relatives
• Physical Exam: VS and relevant findings (or their absence)
• Key labs, imaging: For a cardiology clinic patient, this would include echos, catheterizations, coronary interventions, etc.
• Summary, assessment & plan(s) by organ system and/or problems. As many systems/problems as is necessary to cover all of the active issues that are relevant to that clinic.
• Reason for visit: Patient is a 67 year old male presenting for first office visit after admission for STEMI. He was referred by Dr. Goins, his PMD.
• The patient initially presented to the ER 4 weeks ago with acute CP that started 1 hour prior to his coming in. He was found to be in the midst of a STEMI with ST elevations across the precordial leads.
• Taken urgently to cath, where 95% proximal LAD lesion was stented
• EF preserved by Echo; Peak troponin 10
• In-hospital labs were remarkable for normal cbc, chem; LDL 170, hdl 42, nl lfts
• Uncomplicated hospital course, sent home after 3 days.
• Since home, he states that he feels great.
• Denies chest pain, sob, doe, pnd, edema, or other symptoms.
• No symptoms of stroke or TIA.
• No history of leg or calf pain with ambulation.
• Prior to this admission, he had a history of hypertension which was treated with lisinopril
• 40 pk yr smoking history, quit during hospitalization
• No known prior CAD or vascular disease elsewhere. No known diabetes, no family history of vascular disease; He thinks his cholesterol was always “a little high” but doesn’t know the numbers and was never treated with meds.
• History of depression, well treated with prozac
• Discharge meds included: aspirin, metoprolol 50 bid, lisinopril 10, atorvastatin 80, Plavix; in addition he takes Prozac for depression
• Taking all of them as directed.
• Patient lives with his wife; they have 2 grown children who are no longer at home
• Works as a computer programmer
• Smoking as above
• ETOH: 1 glass of wine w/dinner
• No drug use
• No known history of cardiovascular disease among 2 siblings or parents.
• Well appearing; BP 130/80, Pulse 80 regular, 97% sat on Room Air, weight 175lbs, BMI 32
• Lungs: clear to auscultation
• CV: s1 s2 no s3 s4 murmur
• No carotid bruits
• ABD: no masses
• Ext; no edema; distal pulses 2+
• Cath from 4 weeks ago: R dominant; 95% proximal LAD; 40% Cx.
• EF by TTE 1 day post PCI with mild Anterior Hypokinesis, EF 55%, no valvular disease, moderate LVH
• Labs of note from the hospital following cath: hgb 14, plt 240; creat 1, k 4.2, lfts normal, glucose 100, LDL 170, HDL 42.
• EKG today: SR at 78; nl intervals; nl axis; normal r wave progression, no q waves
• Plan: aspirin 81 indefinitely, Plavix x 1y
• Given nitroglycerine sublingual to have at home.
• Reviewed symptoms that would indicate another MI and what to do if occurred
• Plan: continue with current dosages of meds
• Chem 7 today to check k, creatinine
• Plan: Continue atorvastatin 80mg for life
• Smoking cessation: Doing well since discharge without adjuvant treatments, aware of supports.
• Plan: AAA screening ultrasound

• Recommended

A medical student’s first patient presentation

In medical school, you’re not taught how to give stellar patient presentations. Yes, you’re shown the traditional order of things: “Give an effective one-liner first, then tell the HPI [history of present illness] but only give pertinent info, etc.” Just exactly how to deliver the punch that impresses your attending is an art. And it’s an art that takes some time to perfect.

My very first time presenting a patient was terrifying, and it was during my neurology rotation. My attending was the head of the neurology and rehabilitation department, and I was the only first-year med student. On the team were two third-years, one fellow, and three residents.

David was a 21-year-old Asian male who came to the ER for upper extremity weakness. He and his mom spoke Cantonese to each other and me, so our interactions were assisted by one of the mobile translator stations. It had a tablet attached to a pole about 4 or so feet off the ground, and once you selected your language, an interpreter was online within a minute.

As is usual with new patients, students are the first to meet them and to gather the HPI. Then, the residents see the same patients, and with the students together formulate the differential diagnosis and management plan for each patient. The resident I worked with, Catherine, was wonderful, and an MD/PhD. Though, she notoriously had high expectations of students.

“Alright, tell me your presentation.”

“David is a 21-year-old Asian male who came to the ER this morning for a three-day history of upper extremity weakness in both arms.”

“Good. Keep going.”

“This is new to him, and he was not in an accident or any incidence of trauma recently or in the past.”

“No. What did you learn? OLDCARTS. Onset. Location. Duration. Character. Aggravating or Alleviating factors. Radiation. Timing. Severity. You already said onset, location, and duration. Did he feel any pain prior to or during his weakness? Does the weakness come and go? Anything he does make it better or worse? You have to go in order; if not I won’t follow you.”

“OK …”

I was ready to give it another go-around, but by that time the team phone rang and it was the attending on speakerphone.

“Good morning everyone. Ready for rounds?”

“Yes, Dr. Lezinsky,” said one of the residents.

“Great, meet me outside room 13-A.”

Wonderful. That’s the room my patient was in.

As I walked in the middle of the pack of alternating short and long white coats to my patient’s room, I felt my heart beat at an alarming rate. My watch even vibrated continuously, with the screen showing my heart rate above 100. I casually silenced my watch and also my head so that I could stop being so nervous.

At the door, we were greeted by my patient’s nurse and saw Dr. Lezinsky for the first time. He was a legend at the hospital and was also the neurology residency program director. I’ve heard stories of him being one of the best attendings you’ll ever have the pleasure of listening and learning from, but that he was also hard on students.

Without many words, he said, “Which medical student has the first patient?”

“That would be me.”

“What year?”

“First-year, sir.”

“Let’s hear the story.”

I have a bad habit of overly relying on handwritten or printed notes if I have them on hand. I remembered most of the beginning of the presentation, but slowly started to read off of my paper so that I wouldn’t say anything out of order or incorrectly.

About halfway through, I quickly glanced at my resident. Catherine gave me the look of, “What are you literally doing? Didn’t we rehearse?” In stark contrast, Dr. Lezinsky was devoid of emotion and instead nodded his head every so often. But was that an affirmative nod? Or a nod that meant, “Not right, but we’ll talk about it once you’re done presenting.”

In what seemed like an eternity with my palms now clammy, I concluded the presentation with the one-liner, my differential as to my thoughts on what could be causing David’s symptoms, and my proposed management plan.

“Is that all, T.J.?”

“I believe so, sir.”

“OK, Catherine, anything else to add?”

“Only that he is up to date with all of his vaccinations, and that he and his family only speak Cantonese.”

“T.J., can you get the … oh great! You have the tablet. I’ll let you introduce the team to the family, and we’ll have the interpreter join us to help.”

The team met David and his parents, and it was smooth sailing from there. Myasthenia gravis is what we thought he had because of his weakness worsening as the day progressed along with slurred speech in the evenings. Immunosuppressive treatment was soon started and David’s condition improved.

As we entered the elevator to the next patient floor, it was Dr. Lezinsky at the front and me right behind him. As the door closed, Dr. Lezinsky turned his body towards me.

“Was this your first time presenting?”

“Yes, it was.”

“That was really good. Over time, you’ll find yourself not referring to your notes, but relying more on your understanding of the patient’s history and possible disease etiology.”

“Thank you so much, Dr. Lezinsky. That really means a lot.”

Looking back to my first presentation, I’ve improved since then. After you do something so many times over, you start creating your own personal style. Yet, I know that there is always room to improve and the way you present a patient varies tremendously depending on the environment and the status of the patient. It all boils down to this: If you can give an effective and memorable presentation, you’re a better advocate for your patient.

Ton La, Jr. is a medical student and can be reached on  LinkedIn .

Image credit:  Shutterstock.com

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A medical student’s first patient presentation 3 comments

Comments are moderated before they are published. Please read the comment policy .

Verbal Patient Presentations: A Practical Guide for Medical Students

In the hospital and clinic, medical student verbal patient presentations convey important information to the team. Time is of the essence, so concise and logical presentations of the relevant information will set students apart. The overall format for the verbal presentation is similar to the written note, but is usually more concise. Being able to select the pertinent information and present it in an efficient manner takes organization and practice, but it is a skill that can be learned. This resource is practical guide for medical student verbal patient presentations to the healthcare team along with a sample verbal patient presentation. Our institution has used this with M1 and M2 students in clinical skills, but we have also used it for verbal presentations of case patients in small-group case-based learning. This guide reflects my preferences as a family medicine physician. There are many ways to present, so students will need to be ready to adjust to the preferences of other attending physicians throughout medical school. #Communication #education #medicine #training

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Mark Almont 05-05-2021 03:44

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Well-Being Programs: The Hidden Gems of Medical Education

New section.

Well-being programs are the hidden gems of 21st century medical education.

Daryl H. Thorne, EdD, MEd, LCPC, NCC, ACS

The challenging and rigorous learning that typically characterizes medical school can lead to stress, anxiety, and burnout for the learner if deliberate measures are not taken to mediate these potential impacts. This is not new information for the medical community. And because of the ongoing concern for, and research on, mental health and burnout in the medical community (inclusive of students), medical education programs are tasked with establishing wellness/well- being programs and/or wellness-related initiatives, at a minimum.

The broad topic of “mental health” is now widely accepted as being important enough to broach openly. While society continues to struggle with accepting overt signs of mental illness – active psychotic delusions (Le Glaz et al., 2022) and death by suicide (Zivanovic et al., 2018) - there appears to be less stigma around depression and anxiety. In fact, scholarship on anxiety and depression among medical students is burgeoning. From brief literature reviews (Mirza et al., 2021) to empirical research (Manago & Krendl, 2023; Alvi, et al., 2010; Vitaliano, et al. 1984) interest in medical student mental health and well-being have been evident for quite some time; thus, leading the Liaison Committee for Medical Education (LCME) to include element 12.3 in their accreditation Standards. Element 12.3 states, “[a] medical school has in place an effective system of counseling services for its medical students that includes programs to promote their well-being and to facilitate their adjustment to the physical and emotional demands of medical education.” This LCME requirement mandates medical education programs to devote resources to support the well-being of their learners along the continuum of the curriculum. It is important to note that wellness programs vary from university to university, and from program to program. Given the variability and scope of wellness programming, it may not be a stretch to suggest that  the breadth and depth of offerings/initiatives within medical education programs reflect their prioritization of student well-being.

Students at nearly every medical school in the United States have access to mental and medical health services, but this may not be enough to help students adjust to medical school or to promote their overall sense of well-being. Wellness programs and offerings may vary  depending upon the school’s resources and how they conceptualize ‘well-being’ beyond the LCME’s accreditation directive. Programs that offer a holistic approach to well-being - addressing more than just the mental and physical domains - help students, and physicians of the future, expand the boundaries of what to consider as important to their wellness. This paradigm shift opens the creative space for medical students and physicians in training to attend to their wellness in unexpected ways throughout their careers.

A culture of wellness is the goal. The ideal well-being program becomes part of the culture of the university, not just the medical education program. As mentioned earlier, every program is different. Each should meet the needs of its student-body and reflect the values of the university. I am fortunate to work in the school of medicine at a university that shows its commitment to the well-being of its students and its staff and faculty, as part of its evolving culture. Uniformed Services University of the Health Sciences (USUHS) is a unique institution in that it trains health providers and scientists as its primary mission for the military. Given its uniqueness, USUHS embodies multiple cultures throughout the institution – medical, military, civilian, science, nursing, academic, and etcetera. The culture of the military is shaped by the “mission” and the mission of USUHS is “Learning to Care for Those in Harm’s Way”. The medical students at USUHS are responsible for learning medical and military curricula, which is overwhelming and not typical for most medical education programs. This is precisely why the  intention of the well-being program is holistic by design. As the scope of this article is limited, I will note that our Well-Being Program is informed by the Student Wellness Advisory Board (SWAB), which consists of elected student well-being representatives across the university, along with faculty and campus partners to ensure oversight of wellness activities. The inclusive representation contributes to the cultural integration of the well-being program within the University. The annual wellness fair is the event that makes obvious that there is a culture of wellness at USUHS. This year’s fair was held on 22 March.

The purpose of the wellness fair was to bring a host of wellness-related resources, interactive sessions, and activities to campus for the university-stakeholders that included students, staff, faculty, family members, and contracted-workers. There was something there for everyone – relaxation chairs, sleep lab simulations, Reiki, yoga, painting, music, blood pressure checks, counseling information, a burpee station, acupuncture demonstrations, healthy foods, therapy dogs, and additional wellness resources. There were people in attendance who shared that they looked forward to this annual event so that they could get information (or engage in new experiences) that they may not have otherwise considered if left to their own devices. One of the most surprising highlights of the fair was the introduction of Reiki to the campus and seeing students, faculty, and even exhibitors take advantage of a 15-minute session. For those unfamiliar with Reiki, it is an energy-healing modality that can help ease symptoms of anxiety (Lipinski et al., 2020) by promoting relaxation at a deep level without the practitioner touching the client/patient. I am a Reiki practitioner and a licensed counselor, but my role at USUHS is the assistant dean for the well-being program, so it is important for me to have access to a variety of wellness resources to share with my university-community to assist in the amelioration of burnout.

Balancing the demands of medical school with self-care can feel overwhelming to students. Medical education programs that incorporate wellness into the culture help students to normalize help seeking and to attend to their own well-being, making these behaviors integral to their developments as health professionals. To this end, well-being programs are the gems of medical education programs, and their value must not be hidden from students.

Author's Note : Daryl H. Thorne, EdD, MEd, LCPC, NCC, ACS is the Assistant Dean for Well-Being Program and Assistant Professor in the Department of Family Medicine. There are no conflicts of interest. The opinions and assertions expressed herein are those of the author(s) and do not reflect the official policy or position of the Uniformed Services University of the Health Sciences or the Department of Defense.

References:

Le Glaz, A., Lemey, C., Berrouiguet, S., Walter, M., Lemonge, C., & Flahault, C. (2022).  Physicians’ and medical students’ belief and attitudes toward psychotic disorders: A systematic review. Journal of Psychosomatic Research, 163, 1-17 . https://doi.org/10.1016/j.jpsychores.2022.111054 .

Liaison Committee on Medical Education (2023, October). Functions and structure of a medical school: Standards for accreditation of medical education programs leading to the md degree. https://lcme.org/publications/

Lipinski, K., & Van De Velde, J. (2020). Reiki: Defining a healing practice for nursing. Nursing Clinics, 55 (4), 521-536. https://doi.org/10.1016/j.cnur.2020.06.017

Manago, B. & Krendl, A. C. (2023). Cultivating contact: How social norms can reduce mental illness stigma in college populations. Stigma and Health, 8 (1), 61-71. https://doi.org/10.1037/sah0000363.supp

Mirza, A.A., Baig, M., Beyari, G. M., Halawani, M.A., & Mirza, A. A. (2021). Depression and anxiety among medical students: A brief overview. Advances in Medical Education and Practice, (12) 393-398. https://doi.org/10.2147/AMEP.S302897

Vitaliano, P.P., Russo, J., Carr, J.E., Heerwagen, J.H. (1984). Medical school pressures and their relationship to anxiety. The Journal of Nervous and Mental Disease, 172 (12), 730-736.

Zivanovic, R., McMillan, J., Lovato, C., & Roston, C. (2018). Death by suicide among Canadian medical students: A national survey-based study. The Canadian Journal of Psychiatry, 63 (3), 178-181. https://doi : 10.1177/0706743717746663

The views and opinions expressed in this collection are those of the authors and do not necessarily reflect the positions of the Association of American Medical Colleges.

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• Published: 27 May 2024

How medical schools can prepare students for new technologies

• Chantal Mathieu 1  

Nature Medicine ( 2024 ) Cite this article

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• Type 1 diabetes
• Type 2 diabetes

Patient educators and nurses can demonstrate the real-life use of health technologies.

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Technologies are changing the face of medicine. In my specialty of diabetes care, continuous glucose monitoring, decision-assisting apps and hybrid closed-loop insulin delivery systems have been introduced for people living with type 1 diabetes and are now being used by people living with other forms of diabetes as part of their treatment. The role of technology in diabetes is evolving rapidly, with new hardware, concepts and terminology around glucose control being introduced at a rapid pace. These technologies require multidisciplinary teams to support those living with diabetes.

Education and training of medical students and doctors on these new technologies and concepts is crucial. The time allotted for diabetes training in many medical curricula has remained constant as this brave new world of technology has been introduced. Many of us who teach these courses feel that simply introducing the available technologies does not do justice to the new treatment tools. We need teaching tools and techniques that help students see the new face of diabetes and understand why concepts such as ‘time in range’ are often more relevant than hemoglobin A1c. Simply showing students new hardware will not necessarily help them, as these technologies will probably already be obsolete by the time they graduate.

The answer to this challenge may well lie with patients. Introducing students to the lives of those affected by the disease can illustrate the impact of technology on daily life. Those who use these technologies can introduce their benefits and undesired aspects, leading to more effective learning. Sharing the experiences of people living with disease should be an effective way to make a long-lasting impression on our young students. During the COVID-19 pandemic in-person teaching stopped and students missed out on direct interactions that could illustrate lived experiences. However, creative virtual solutions also emerged during the pandemic, and these are now available for medical education and are almost as valuable as in-person teaching for bringing the voices of those living with disease to students.

Many medical schools already work with patient experts in teaching, particularly for diseases where clinical signs and symptoms are essential for diagnosis and where patients can more clearly illustrate them to students than any picture could. The role of patients in medical education is increasingly recognized — for example, through the ‘Where’s the Patient’s Voice in Health’ conference.

As well as patients, other members of the multidisciplinary team, such as diabetes educator nurses, dieticians or psychologists could also have a prime role in teaching medical students about the role of technology. These health professionals can teach students how new technologies work and illustrate metrics that matter to clinicians and to the people using the technologies. This will illustrate how technologies impact the daily lives of people living with diabetes, such as how they sleep with hybrid closed loop systems, how they handle these technologies during exercise, how apps function if the patient is offline, the pros and cons of specific types of hardware (such as comparing a patch pump to a catheter pump), and the use of software features (such as whether alarms should beep or not beep when glucose values are high or whether food apps are useful for vegans).

Bringing members of the team and those living with the technologies to medical courses will also demonstrate to student doctors the need for continuing medical education and how treatment varies from person to person, illustrating the need for personalization of therapeutic approaches. Such a discussion should also include societal, financial and access issues, which will vary depending on location.

Most importantly, this multi-faceted approach to teaching will amplify the voices of the people who live with these technologies and use them daily, whose voices are at least as important in the treatment of the disease as that of the doctor.

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Chantal Mathieu

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C.M. serves or has served on advisory panels for Novo Nordisk, Sanofi, Eli Lilly and Company, Novartis, Boehringer Ingelheim, Roche, Medtronic, Imcyse, Insulet, Biomea Fusion and Vertex, with financial compensation received by KU Leuven. KU Leuven has also received research support from Medtronic, Imcyse, Novo Nordisk, Sanofi and ActoBio Therapeutics. C.M. serves or has served on the speakers bureau for Novo Nordisk, Sanofi, Eli Lilly and Company, Medtronic and Boehringer Ingelheim, with financial compensation received by KU Leuven. C.M. is president of the European Association for the Study of Diabetes .

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Mathieu, C. How medical schools can prepare students for new technologies. Nat Med (2024). https://doi.org/10.1038/s41591-024-03041-3

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