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Format for Focused Presentation of Patients
A focused presentation is both a means of conveying information and a tool of the intellect. A critical aim of the presentation is to focus in a chronological and medical logical manner on the development of illness in the patient. Focus means editing the presentation to include that which is significant, and excluding that which is not helpful. Deciding which is which is an art that grows over the course of a career. However, practicing this art and studying how to present effectively can accelerate your learning curve. Finally, a focused and succinct presentation keeps the attention of all the listeners and allows time for substantive discussions.
HISTORY
Chief Complaint:
- Patient age/sex/ethnicity (if relevant), complaint, and duration.
e.g. : “Mr. Jones is a 63-year old male who presents with chest pain for 3 days.”
History of the Present Illness:
- This is the most important part of the presentation. It should be organized in a linear fashion, A—B—C—D. Begin with the earliest antecedent event for the present illness and move in a strictly chronological manner to the present.
- For all relevant symptoms, describe them fully; the WIDOW mnemonic helps:
- W Where is symptom, which side, where radiating?
- I Intensity mild, severe, sharp, dull?
- D Duration how long? How long is each episode? Interval?
- O Onset gradual, sudden, progressing in intensity, diminishing?
- W What makes better; nitroglycerine, eating, rest, position, aspirin?
- Note that prior hospitalizations, medical encounters and lab results related to this illness are part of your HPI.
- Include only positive findings and very few of the most pertinent negatives.
e.g.: “The HPI begins at age 17, when Mr. Jones began to smoke, which has been for a total of 118 pack-years and continues to the present. At age 25, patient began working in a shipyard and had extensive asbestos exposure for the next 20 years. About 10 years ago, the patient developed a cough that he characterized us occurring almost every morning, productive of about a teaspoon of greenish sputum, without any change, or any blood. When the patient takes antibiotics for any reason he notes that his sputum becomes clearer and decreases in volume. Over the past six months, patient noted a 25-pound weight loss, without trying to lose weight. Appetite has not changed. Two months ago, patient noted occasional flecks of blood in his sputum, but no change in his chronic cough. Over the past 2 weeks, sputum production has increased to 3 teaspoons and now is blood-streaked. Three days prior to admission, patient noted a sharp pain in his right chest. Pain came on gradually, does not radiate, but is worsened by taking a deep breath. He denies fever, but for the last 2 nights, he soaked his sheets with sweat. This morning, he saw his private doctor, who said that his chest x-ray was “abnormal.” The doctor also reported that his white blood count was elevated, and recommended that he come to the ER, where he arrived at 1 pm. Because of his abnormal CXR, the ER admitted him directly to the medical service with no further evaluation or treatment.” [Note that this history includes information relevant to this chest problem beginning at age 17 (he now is 63) and progresses to the time of presentation to you.]
Other History:
PMH, FH, ROS. Take a complete history but only report findings not related to the HPI (if you believe it is related, it will already have been mentioned in the HPI – do not repeat). List and fully describe each. Otherwise state: “PMH, FH, ROS are non- contributory.” It always is relevant to present social and occupational history (e.g.: “Patient was a skilled industrial worker for 40 years – shipyards, shoe factory – and has been retired for the past 5 years. He lives in Brooklyn with his wife, who accompanied him to the hospital. He drinks 5 cans of beer a week on average”). Again, if parts of the other history have been stated in the HPI, do not repeat.
PHYSICAL EXAM
Examine the patient thoroughly from head to foot, including all systems. However, only report patient’s appearance, vital signs, and positive findings. (Some persons prefer to include pertinent negatives; this is fine, as long as they are pertinent.) Describe each finding as completely and quantitatively as possible.
e.g.: “On PE, patient was a cachectic male appearing older than his stated age, lying comfortably in bed, in no acute distress. BP 110/74 and pulse 90/regular while lying, 105/70 and pulse 96/regular while standing, respirations 24 and shallow, temperature 100.8 °F Physical exam was entirely normal except: bitemporal wasting, chest exam shows barrel-chest with hyperreasonance bilaterally, unable to take a deep breath due to guarding in right chest, dull to percussion at right base, rales, bronchial breathing, and egophany at right base, otherwise breath sounds diminished throughout. Skin-a 2x1.5 cm brown, raised, crusted, rough patch on left upper back, non-tender, non-warm, with irregular borders.”
LABORATORY
List the routine admission labs, but only report the abnormal results
e.g. : “Hematocrit 27, White blood cell count 12.8 with 79 polys, 4 bands, 13 lymphs, 4 monos. Chest X-ray shows a mass in right hilum with dense right lower lobe alveolar consolidation and blunting of right costophrenic angle. Routine chemistries, urinalysis, and EKG all were within normal limits.”
ASSESSMENT
This is the key responsibility of the physician. Use the data you have assembled to establish a problem list, create a differential diagnosis for each problem, consider the pros and cons of each diagnosis, and establish a final differential diagnosis in order of likelihood. For each diagnosis, list the points pro and con, in that patient. “Rule out” is not a diagnosis! For each problem, provide an assessment first, then a plan of action based on your assessment. For each problem, the plan should be divided into diagnostic and therapeutic possibilities.
For example, in this hypothetical patient, the problems are:
- Right pulmonary process
- Chronic cough
- Weight loss
- Anemia
- Skin lesion
The Assessment, Diagnostic Plan and Therapeutic Plan would therefore be as follows.
Pulmonary process
Assessment: CXR shows an infiltrate, patient had night sweats, chest pain, change in cough, and leukocytosis. This probably represents community-acquired pneumonia. Right lung mass could be a tumor. Thus: environmental exposures (tobacco, asbestos)—chronic bronchitis and tumor—partial obstruction of a bronchus—impaired clearance of secretions—pneumonia. Pneumonia is numbers 1 through 8 in the differential for the acute process. What is pro is the acute onset, fever, change in sputum, infiltrate on CXR. There is essentially nothing against. A remote possibility is pulmonary embolism with infarction. Against is that there is no predisposition for this, no explanation for 3-day change in sputum production. Another remote possibility is tuberculosis which could explain many of the chronic findings (including weight loss), but does not explain his acute presentation.
Diagnostic Plan: Obtain sputum for gram and AFB stains, cultures, blood cultures, CT scan of the chest to evaluate relation of infiltrate and mass, to assess for mediastinal nodes. Plant a PPD skin test. Consider V/Q scan if no response to antimicrobial agents.
Therapeutic Plan: IV hydration, and empiric broad spectrum antibiotics (e.g. vancomycin because of concern for resistant pneumococci, while awaiting stain and culture results, and erythromycin for atypical organisms), duration of course and nature of antibiotics will await evaluation of response to therapy and assessment of that mass.
Chronic cough
Assessment: Chronicity, in a smoker, purulent sputum that clears with antibiotics suggests chronic bronchitis. Barrel chest, hyperreasonance, and flattened diaphragm also suggest COPD. All other possibilities are remote.
Diagnostic Plan: Assess PFT’s to confirm diagnosis, assess extent of disease and response to bronchodilators.
Therapeutic Plan: none, at present.
Weight loss, Anemia, Skin lesion would be assessed in similar fashion.
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