The major challenge as a trainee presenting to a supervising attending is that every attending is different, wants different things, has a different approach, which makes your job impossible. You will do better to have a system. Here’s one system.
Before presenting the case at hand, provide an update on what’s going on with your other patients. How are they doing? What are they waiting on? Now you’re ready to start in with the present case.
Frame First. Open up with a very brief one-sentence summary of the case, with your conclusion. This frames everything else you’re about to say.
“I think Ms. Jones has pneumonia.”
“I think Mr. Smith will need a CT scan for rule out appendicitis.”
“I think Mr. Lee will need a workup for chest pain, but if negative can be managed as an outpatient.”
Next is the chief complaint.
“Mr. Jones is a 34 year old male with abdominal pain.”
Past medical history follows, most important first.
“He had a kidney transplant in 2004 for polycystic kidney disease. He is also known for diabetes and hypertension.”
Notable medications, especially important are recent changes in medications or noncompliance, and relevant allergies to medications.
“He’s on cyclosporin and mycophenolate, as well as glyburide, amlodipine, and hydrochlorothiazide. His amlodipine dose was recently doubled. He reports a penicillin allergy, which gives him a rash.”
Pertinent social situation follows, as it pertains to the situation. This is often omitted, but social situation plays an important role in admit/discharge decisions; how can you discharge a patient without knowing the environment you are discharging to?
Who does the patient live with? (alone / with family / with spouse, who also has advanced dementia)
What sort of living environment does the patient reside in? (apartment / group home / nursing home / homeless)
What does the patient do during the day? (works as an administrator / is a left-handed pianist / is unemployed / is a student)
What is the patient’s level of function? (fully functional / able to do some but not all ADLs / fully dependent)
How much help does the patient have at home? (24/7 home health aide / home health aide twice per week for 6 hours / visiting nursing every day)
Bad habits? (drugs, alcohol, cigarettes. history of withdrawal)
Does he have physicians looking after him? If the patient was referred to the ED by a physician, this is particularly important. If there are clinicians who play a particularly relevant role in the present concern, report this. Taking care of patients is a team sport.
Does the patient have any advanced directives? What are the goals of care?
“He lives with wife, works as a bus driver. Denies bad habits. Is supposed to follow with Dr. Green in the renal transplant service at Heartbreak Hospital, but hasn’t seen Dr. Green in six months.”
Next is a good place to comment on prior visits to the ED.
“He’s never been to this department.”
“He has 48 similar visits to this department, has been extensively worked up dozens of times.”
Next is the history of present illness. This should start with “[The patient] was in his usual state of health until…” and then provide a chronological sequence of events that led up to the present visit; the first part of the HPI should report all the patients complaints, which were elicited with open ended questions, and end with the complaints that led to his coming to the ED, and then what complaints he has at this moment. The next part of the HPI is the focused review of systems, which you can delineate from what the patient offers up without prompting by using phrases like, ‘on questioning,” ‘endorses,’ and ‘denies.’ This is not a complete review of systems, but a focused review of systems with pertinent positives followed by pertinent negatives. A good way to end the HPI is to comment on prior episodes.
“Mr. Jones was in his usual state of health until 3 days ago, when he developed dull periumbilical pain that was intermittent but progressive until this morning, when he developed vomiting and the pain became constant, sharper, and moved to the right lower quadrant. He went to see his family physician, who referred him to the emergency department. At the moment he complains of severe right lower quadrant pain and nausea. On questioning, he endorses diarrhea and chills, but denies mucus or blood in the stool, recent travel or antibiotics, urinary or testicular complaints, shortness of breath, and rash. He had a similar, much less severe episode a few months ago that resolved in one day by itself.”
After the HPI comes the physical exam, which should always start with general appearance and vital signs, and then proceed from head to toe, with a level of detail appropriate for your level of training. I think it is best to leave the area of interest for last.
“Mr Jones is well appearing, calm, and mildly uncomfortable in abdominal pain. His vitals are normal except for a heart rate of 106. His head to toe exam demonstrates no findings about the head, neck, heart, lungs, and extremities. His abdomen is moderately tender in the right lower quadrant, without signs of peritonitis. His GU exam is normal.”
Now you’ve finished the H&P, and the next question is what has been done for the patient already, if anything, and results.
“He was treated with 4 mg of IV morphine and 4 mg of IV ondansetron, and a CBC, chemistry, LFTs and lipase were sent, as well as a urine analysis, according to the abdominal pain nursing protocol. He was uncomfortable when I saw him, so I ordered another 4 mg of IV morphine. The UA has been resulted and shows trace blood, all other studies are pending.”
And now your assessment and plan. I think the best way to provide a summary of the key features of the case, and then answer these questions:
- What do you think the patient has?
- What dangerous conditions or complications could be causing or associated with this patient’s symptoms?
- What tests are indicated to rule out or rule in these dangerous conditions?
- What therapies or symptom relief measures are needed?
- If the tests that you order are negative, what is the plan for the patient?
“Mr. Jones is a healthy young man with abdominal pain, diarrhea, and fever for 36 hours, his exam is reassuring but he has mild lower abdominal tenderness. Most likely, Mr. Jones has a self-limited GI illness, but I’m concerned about appendicitis. Bowel obstruction and perforated ulcer are unlikely given the relatively benign abdomen. Given a normal GU exam, I don’t think we need to further pursue a lesion there; his abdominal tenderness makes thoracic causes of abdominal pain like pneumonia or cardiac etiologies very unlikely. If his labs show no diagnostic abnormalities, I think he needs a CT scan of the abdomen with IV contrast to rule out appendicitis. If that’s negative, I think he’s safe to be discharged with a nonspecific diagnosis and followup. He’s comfortable right now but I’ll continue to treat for symptoms as needed, and I’ll also give him a liter of fluid.”
The most important way that this system differs from the most common presenting style is that the HPI is presented after the patient’s background information is presented. Most attendings will want to hear the HPI first; I believe that in a stable patient, the HPI can only be properly interpreted in the larger context of the patient’s medical history, social history, etc.
How much detail you present depends on the complexity of the case and how senior you are as a trainee. If you’re about to graduate your residency, your attending may not want to hear anything else than, “Mr. Jones is a healthy 34 year old with a flu-like syndrome, I discharged him with follow up.”
Send thoughts, comments, suggestions, objections, additions to firstname.lastname@example.org
Trainee worksheet, with specific guidance on how to succeed during an EM shift. Designed to fit on one page, front and back.
List of ways that I might practice differently than other attendings, to save residents some trouble.
Older, detailed guide to patient assessment.
Update: 1. facts 2. opinions 3. questions