A few pearls for adapting oral case presentations to different clinical settings... feel free to comment with your ideas and suggestions!
Post-call (5-10 min, depends on patient and clinical service)
- ID/CC (brief, but paint a picture)
- HPI (tell it like a story, chronologically), including pertinent ROS
- PMH / PSH - major items only
- Medications (include doses / frequencies if pertinent)
- Family history (only pertinent)
- Habits (esp if tobacco, heavy etoh, illicits)
- Social history (include a nugget about who this person is, supports, stressors, PCP?)
- PE – relevant positives/negatives
- Labs/Studies
- Assessment/Plan – 1-2 sentence summary, then A/P by problem
Pearls
- Stay organized
- Avoid redundancy
- Don’t editorialize
- Practice (e.g. with intern or senior resident before rounds)
Daily Work Rounds (<5 min)
- Brief ID/CC (1 sentence)
- 24 hr events & nursing reports
- New studies / labs
- S ubjective (“this morning, Ms.Henry is feeling…”)
- O bjective (your exam)
- A ssessment and
- P lan by problem
Pearls
- At bedside and with nurse present, if possible
- Introduce the team to the patient (and others in the room)
- Don’t say, “the patient”; instead, “Ms.Henry had an episode of…”
- Avoid medical jargon (or, interpret so pt can follow)
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Outpatient clinic, new patient (adapt for new outpatient consultation)
- ID / CC
- Referring MD?
- HPI (this may be more general for an annual exam)
- Positive ROS
- PMH / PSH (include degree of control of chronic issues, include Ob history for women)
- Childhood illness, if pertinent
- Primary care / screening / vaccinations
- Medications (include doses / frequencies)
- Primary care / screening / vaccinations
- Medications (include doses / frequencies)
- Family history
- Habits
- Social history
- PE – positives / negatives
- Recent labs/studies
- Assessment and Plan (recommendations) by problem
Outpatient clinic, established patient
- Brief ID/CC
- S ubjective
- O bjective (your exam, relevant labs and studies)
- A ssessment and
- P lan by problem
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Requesting a Consult (<2 min)
Requesting a Consult (<2 min)
- State your name, position, team
- Specific reason for consult. “We have a patient admitted this morning with an upper GI bleed, and we’d greatly appreciate your consultation to consider upper endoscopy.” (or, ask: would you be willing to consult? etc)
- Patient’s name and ID number, age and gender
- Very focused history, exam and studies relevant to consultant
- Your impression: “We are concerned about recurrence of his gastric ulcer”
- Define urgency of consult
Pearls
- Be courteous
- Be concise
If your patient is confused / delirious, report this objectively with your physical exam (e.g."Mr.E was oriented to self but not to location, situation, or date")
If you are presenting at the bedside, don't state the obvious that could be offensive (don't say, "morbidly obese female in no apparent distress", or "disheveled", or "appears older than stated age") - try to think about this from your patient's perspective.
Handling sensitive issues at the bedside:
If your patient is confused / delirious, report this objectively with your physical exam (e.g."Mr.E was oriented to self but not to location, situation, or date")
If you are presenting at the bedside, don't state the obvious that could be offensive (don't say, "morbidly obese female in no apparent distress", or "disheveled", or "appears older than stated age") - try to think about this from your patient's perspective.
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