Presentations

One of the keys to success on your EM rotation is to perfect your patient presentations. 

Keys to a good patient presentation

  • Precise 
  • Contains all the key information
  • Speaks like a story

Outline

  • Patient age, sex, with pertinent past medical history presents with a chief complaint
  • Few sentences regarding HPI (onset, quality, duration, location, severity, alleviating or exacerbating factors, associated symptoms)
  • If pertinent, include 
    • Allergies, medications, surgical history, social history, travel, immunizations
  • Pertinent negatives
  • Vital signs and pertinent positive and negative physical exam findings
  • Differential diagnoses
  • Plan
    • Medications
    • Labs
    • Imaging
    • Consults
    • Disposition: discharge vs admission

Special Considerations:

  • Pregnant patient: Always inquire about gravida para status, gestational age, current OBGYN, how current pregnancy was confirmed (home pregnancy test vs US), if taking prenatal vitamins, previous pregnancies with associated comorbidities, next OBGYN appointment
  • Psychiatric or patient that has overdosed: time of overdose, what medications (dosage, quantity), substances or weapons available in the home, any co-ingestions (tylenol, aspirin, EtOH), history of prior SI/inpatient hospitalizations, drug abuse history, psych history. If you ever feel uncomfortable during a patient interview, step out of the room immediately. 
  • Pediatric patients: Birth history (complications, gestational age at birth), vaccinations, oral intake, number of wet diapers per day, who they live with, any second hand smoke exposure
  • Non-English speaking patient: We do have MAARTI translation available via iPad. Familiarize yourself with this and you can help your team by getting this set up prior to the patient evaluation. These evaluations take time, so your resident may choose to do the interview with you to save time. 
  • Elderly or nursing home patient: Often, nursing home patients are unable to answer our questions regarding why they have arrived at the ER. You can offer to try to call their facility to get valuable information for your resident/attending, such as what brought them in, medications, code status, POA contact information, etc. 

Resources: 

Note Writing

It is not a requirement to write notes in the EMR on your patients during your rotation at Doctor’s Hospital ED. However, it is a very valuable skill and may be a requirement on your other ED rotations. The resident you work with may have you practice writing a note. If you have down time, you can write a note (even on paper if there are no computers available) and ask a resident for feedback. The link below is an extremely valuable guide in note writing.

Resources: