Format for Patient Presentation

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Importance of Good Patient Presentation:

One way to impress your attending physician is to do a detailed, focused patient exam and presentation as a medical student or resident. From doing countless histories, physicals and patient examinations, I have come up with this format that most attending physicians prefer. While it is true that most attending physicians have their own style of taking histories and physicals, if you're unsure about your attending, you can always use this format below. By the way, always carry a copy of Maxwell Quick Medical Reference in your pocket because my article below may be incomplete. Furthermore, your best friend will be the latest copy of Harrisons and your patient's chart. And try to avoid Wikipedia!

Chief complaint:

This is the main problem that brought your patient to the physician. This has to be in the patient's own words e.g., "I have a headache," or "I have breathing problems." The chief complaint always begins as, A 45 year old African American male presented to the ER with breathing problems. If the patient has already been in the hospital for a while, you may also add, Today is his 4th day of stay. If the patient complains of pain, you always need to ask the patient to rate the pain on a scale of 0-10 with 10 being the worst. Also ask the patient if he/she has experienced this type of complaint before, and what does the patient think about the cause of this complaint.

History of present illness:

This is the fun part because you get into the nitty gritty details. For example, in a patient with shortness of breath you might want to ask questions like: when did it start, why did it start, what were you doing when it started, what makes it worse, what makes it go away, at what time did it start, how did it start, etc. You always want to ask about pain, nausea, vomiting, diarrhea, fever, constipation, allergies. If the patient has pain, ask about location, onset, radiation, quality, progression, aggravating and alleviating factors, and intensity of the pain.

Surgical history:

Ask the patient about surgeries done on them. Also ask about automobile accidents, gun shot wounds, etc.

Family medical history:

History of paternal and maternal grandparents, siblings, children, step-children, and step-siblings.

Social history:

Family life, smoking (how much?), drinking (how much?), drug use (how much?), sexual history, etc.

General and physical exam:

Before reading this part to you physician, make sure you mention the latest vitals like blood pressure, heart rate, respiratory rate, and temperature. You then systematically examine the HEENT, neck, heart, lungs, abdomen, skin, and periphery. Make note of pertinent positives and negatives because you may get pimped on this.

Lab values:

It is always good to get print outs of the patient's latest CBC, CMP, ABG, etc. Also know the associated pathology behind an abnormal lab value because you may get pimped on this.

Report of medical procedures done and ordered:

Make a table and write down the name, time, date, location, and results of all the procedures done and pending on the patient. Also know the associated pathology behind each procedure done because you may get pimped on this.

Medication list:

Make a list of all patient medications, MOAs, doses, and the reasons why these medications are being given. Also keep a list of home medications at hand.

Patient summary:

By this time your listeners may have already zoned out because you have been speaking for 10+ minutes, so the best thing to do is to summarize the patient case by re-stating the chief complaint followed by your differential diagnosis.

Differential diagnosis:

This is the part where you get to impress your attending physician. You can read Harrisons and get a list of differential diagnoses associated with shortness of breath. Furthermore, you need to seriously read up on the signs and symptoms of your differential diagnosis list and pay attention to any lab or procedures you may want to order. Also know the corresponding pathology, pharmacology, and physiology of the listed disease processes. Know our stuff very well because you may get pimped on this.

Miscellaneous information:

Make sure you read the patient's consultant notes, nurse's notes, etc.; basically, know the patient's file inside-out.

Additional Reading:

Random USMLE Facts

1. Random USMLE Facts volume 1-1
2. Random USMLE Facts volume 2-1
3. Random USMLE Facts volume 3-1
4. Random USMLE Facts volume 4-1
5. Random USMLE Facts volume 5-1
6. Random USMLE Facts volume 6-1
7. Random USMLE Facts volume 7-1
8. Random USMLE Facts volume 8-1
9. Random USMLE Facts volume 9-1
10. Random USMLE Facts volume 10-1
11. Random USMLE Facts volume 11-1
12. Random USMLE Facts volume 12-1

General and Systemic Examinations

1. General Examination for Internal Medicine
2. Jugular Venous Distention Workup
3. ER Chest Pain Workup
4. Format for Patient Presentation
5. Pulmonary Examination for Internal Medicine
6. Cardiac Examination for Internal Medicine
7. Abdominal Examination for Internal Medicine
8. Cranial Nerve Reflexes
9. Motor System Examination
10. Random Sensory System Facts
11. Random Stroke Facts

Medical Files & Presentations

1. USMLE Flashcards [Size: 1.9 MB; Format: MS Powerpoint]
2. Otitis Media in Children [Size: 5.4 MB; Format: MS Powerpoint]
3. Irritable Bowel Syndrome [Size: 170 kB; Format: MS Powerpoint]
4. Acid-Base Disturbance: Acidotic or Alkalotic? [Size: 427 kB; Format: PDF]
5. Thrombocytopenia [Size: 2.42 MB; Format: MS Powerpoint]
6. Are Face Transplants Ethical? [Size: 70.2 kB; Format: MS Powerpoint]

USMLE Step 2 CS Videos

1. Video of Cardiology Examination in a Clinical Setting
2. Video of Neurology Examination in a Clinical Setting
3. Video of Pulmonology Examination in a Clinical Setting
4. Video of Musculoskeletal Examination in a Clinical Setting
5. Video of Abdominal Examination in a Clinical Setting
6. Video of HEENT Examination in a Clinical Setting
7. Video and Description of Rinne Hearing Test
8. Video and Description of Weber Hearing Test

USMLE Laboratory (lab) Values

1. USMLE Blood Lab Values
2. USMLE Cerebrospinal Lab Values
3. USMLE Hematologic Lab Values
4. USMLE Sweat and Urine Lab Values

Medical Images

Useful Medical Images & Diagrams (link opens in a new window)

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