Presenting Patients

[esklar]

Hello, hoping someone can shine some light or give some advice. So I just started my first rotation last week in the ED in a small community hospital. I love it so far. All the docs and the PA are wicked nice and helpful. Basically they let me go see the patient then I report back to them and tell them what I want to do as far as ordering meds/labs, we discuss things a bit (and what I may have missed) and then we see the patient together. I've asked for feedback and things I need to work on and mostly it's just that I need to be more systematic or organized about presenting patient's HPIs. The PA I was with on Sunday said I did much better as the day went on and I got more practice but I find that I'm struggling to organize the information into a narrative or story for them. I find that as much as I try to get all of the information making sense I'm missing things here and there and jumping around a bit. We didn't have any practice as far as presenting patients during didactic year so I feel like I'm just starting to learn. I take notes in the room and try to go through my notes in a systematic way but still find myself feeling a bit unorganized. Any suggestions or tips on how to better organize a narrative? I'm trying to go through OPQRST or 'sacred seven' but I feel like not every case fits neatly into those templates. Is it ok to feel like this? I feel like I have a high standard for myself and I really want to work on this valuable skill. 

[EMEDPA]

sounds like you are doing all right for where you are in school. try to focus in the E.D. on a directed H+P, not what happened to them in 1974. why are they there today as opposed to yesterday. learn what is important info for each complaint. sounds like you are on your way with pqrst, etc. Other things like PASTHAM helps for dyspnea, etc.

 

P – Progression, Palliation, Position, and Provocation
A – Associated signs and symptoms, and Accessory muscle use
S – Severity, Speech, and Sputum
T – Time, Treatments
H – History
A- Allergies
M – Medications

[RealWayPA]

Mr./Ms. _______ is a very pleasant ____ year old with past medical history of _______, _________, __________ who presents to us today with chief complaint of _______. Onset began __________ (length of time) prior to arrival to our facility by ________ (ambulance, car, etc.). The patient describes the _______ as _______, ________, and ________. Before arriving at our facility, the patient self-administered __________ which did ________ to the patient's complaint. The patient's allergies include ________, and the patient's home medications include _______. Current vital signs are _______, _______, _______. On physical exam, the patient had ________, ________, _______ and did not have ________, ________, ________. My differential includes ________, _______, _______ because of _______ reasons. I would like to get ________ tests in order to rule out or rule in _______, _______, _______. I would like to administer _______ to treat ________ symptoms _________, _________, _________.

 

Does that help at all? 

 

I agree with the above poster that emergency medicine is all about "attacking the problem." Start your differential with what could be most life threatening and work backwards from there. 

[RealWayPA]

EMEDPA, 

 

Thanks for "liking." Is that a satisfactory format for a PA student to use? That's the format I used when I was an EMT. How can I make it better?

[EMEDPA]

some folks talk about the ROWS concept in emergency medicine (r/o worst-case scenario). that is the job. in family medicine they start from an assumption that chest pain in a 22 yr old female is gerd, anxiety or muscle strain. in EM we start at PE, Dissection, pneumothorax, arrhythmia, and MI and work our way back to GERD, muscle strain, or anxiety as dx of exclusion. what will kill the pt right now? it's not gerd or the panic attack...

[EMEDPA]

EMEDPA, 

 

Thanks for "liking." Is that a satisfactory format for a PA student to use? That's the format I used when I was an EMT. How can I make it better?

looks good. short and to the point. I did something similar as a medic and in fact kept a cheat sheet of things to cover in every radio report.

one problem I frequently see with new students is that they spend 20 minutes taking what should be a 2 min hx. I don't care if they live with their third cousin and have 8 steps from their front door to street level. that's important(maybe) at dispo, not up front. I allow that for a pt or 2 then tell them "you have 5 minutes for the initial H+P, go". They can go back later and do a rectal exam or pelvic if we feel the need. they can ask about how the pt is getting home later. right now I want to know why they are here and what we need to do in the next 2-5 minutes.

In em you frequently need to take the hx and do the PE as tx and interventions are being started. this is a very different mind set than in the clinic. If an 80 yr old guy comes in sweaty with chest pain I want him on the monitor, IV in, on 02, ekg ordered, cxr ordered, and getting ready to chew aspirin and take his first nitro within 2 minutes of the time he hits the door as I cover the H+P around nurses and techs getting him ready for his workup. in clinics there is a progression of H+P then tests and interventions. In the ED they all occur at the same time.

[RealWayPA]

Sounds exactly right - although I'm still an ER tech and not a PA student, that's the approach the ER docs and PAs use in our shop. I kind of chuckle when I see the IM residents presenting patients to their attendings after doing a 45 minute physical and history. Most of our good ER providers can compress exam, diagnosis and treatment decisions into less than 30 seconds in a true emergency. That sort of thinking is what has molded my view of what is and isn't important when practicing emergency medicine.

[EMEDPA]

Sounds exactly right - although I'm still an ER tech and not a PA student, that's the approach the ER docs and PAs use in our shop. I kind of chuckle when I see the IM residents presenting patients to their attendings after doing a 45 minute physical and history. Most of our good ER providers can compress exam, diagnosis and treatment decisions into less than 30 seconds in a true emergency. That sort of thinking is what has molded my view of what is and isn't important when practicing emergency medicine.

sounds like you are ready for a career in EM.

[RealWayPA]

EMEDPA,

 

Thanks for the compliment. My dream job: critical access hospital work in rural area of Pacific Northwest, mountain state, or backwoods New England. Equal mix of family medicine clinic work and ER coverage, plus maybe some inpatient medicine far down the road once I learn the ropes. My grandpa was a family physician who operated with the small town mentality - "give me two chickens and I'll treat your kid." Needless to say, it's had a huge influence on me. Since I spent half of my life interacting with Native Americans on reservations, I feel really strongly about the work that critical access hospitals do. Plus, I think I'll enjoy being able to build long-term relationships with patients through the family practice work.

[EMEDPA]

those types of jobs typically are not for new grads. get 5 yrs of experience at some busy places that allow for a high degree of autonomy and you will be ready to take the step to small town/solo coverage type situations. when you are ready, send me a PM and I can recommend some practices on both costs that meet your requirements. Several folks here on the forum (me, boatswain, GeoBrothers) work at least part time in these settings. I currently do 9 shifts/mo at an inner city dept and 4-7 shifts/mo at the rural places(often 24 hr shifts). I hope to transition to full time rural practice as soon as positions become available. seeing 36 pts/night with 2-3 being appropriate for an ED is getting old. I would really rather see 12 who are actually sick at the rural sites.

[RealWayPA]

What type of rural job is appropriate for a new grad? Full-time ED with good SP oversight? I definitely want to work mostly (preferably only) in a rural area, so what should I look for in my first job?

[EMEDPA]

What type of rural job is appropriate for a new grad? Full-time ED with good SP oversight? I definitely want to work mostly (preferably only) in a rural area, so what should I look for in my first job?

yup, that would be fine. just make sure you are ready for solo coverage before you make that leap. sometimes places try to force folks into it who know they are not ready yet just to have an easier schedule for senior staff members...make sure you can manage an airway, a trauma, a medical arrest, sepsis, difficult access situations, anaphylaxis, etc BY YOURSELF without a doc around before you even consider working alone. start with knowing acls/atls/pals material down cold then work on the procedural stuff. study the stuff that scares you. I used to be terrified of really bad OB situations so I took the ALSO (adv. lfe support in obstetrics) course. It's a great 2 day course which is scenario based. they push babies at you sideways, make you deal with seizing pregnant pts and crash c-sections, etc. now I know I could handle a shoulder dystocia, breech, post partum hemorrhage, perimortem c-section, etc alone if I had to. The week after taking the class I did a precipitous delivery solo in the middle of the night on a teenager who thought she had a kidney stone and didn't even know she was pregnant. went fine.

[Joelseff]

Suggestions above are great. I did it kind of short and sweet. Describe the patient, HPI, pert pos, pert negs, Vitals, Pert Labs, Pert Exam Findings (pos and neg) my assessment with a ddx and then my suggested TX plan.

 

Just don't jump from one section to the next then back again. It was always painful witness a team member getting pimped and they do that. It's like when your parents are scolding your little brother and you know he's about to get snacked and he is sitting RIGHT NEXT TO YOU! It makes you want to jump out of the window.

[gbrothers98]

Hello, hoping someone can shine some light or give some advice. So I just started my first rotation last week in the ED in a small community hospital. I love it so far. All the docs and the PA are wicked nice and helpful. Basically they let me go see the patient then I report back to them and tell them what I want to do as far as ordering meds/labs, we discuss things a bit (and what I may have missed) and then we see the patient together. I've asked for feedback and things I need to work on and mostly it's just that I need to be more systematic or organized about presenting patient's HPIs. The PA I was with on Sunday said I did much better as the day went on and I got more practice but I find that I'm struggling to organize the information into a narrative or story for them. I find that as much as I try to get all of the information making sense I'm missing things here and there and jumping around a bit. We didn't have any practice as far as presenting patients during didactic year so I feel like I'm just starting to learn. I take notes in the room and try to go through my notes in a systematic way but still find myself feeling a bit unorganized. Any suggestions or tips on how to better organize a narrative? I'm trying to go through OPQRST or 'sacred seven' but I feel like not every case fits neatly into those templates. Is it ok to feel like this? I feel like I have a high standard for myself and I really want to work on this valuable skill. 

Several things.

First you will get better at this through the year. Having the ED as your first rotation is tough cause it is different medicine than what you are taught in didactic year. The focus is on symptom control and getting to the heart of the matter which is to exclude life and limb threatening illness, decide if the pt can go home, needs the OR, needs an inpatient bed or needs a higher level of care and consultation.

Presenting a pt is difficult because you are taking a situation you understand and trying to get another individual to understand the same thing. Except the person you are doing this with has more experience and a more in depth knowledge base than you do. 

It can be like the donkey chasing the carrot. Sometimes you get a little bite but more often you just keep chasing something just a little bit out of reach. 

Retrench your goals, you wont be perfect on your first rotation, you wont come out of ~6 weeks in the ED being perfect. Your goal is steady improvement with hopefully some flashes of introspection and success.

You were given an example of a script to use above which is pretty decent but basic and straightforward. You will eventually understand that not everything can fit easily in that framework. But that is a start, you just have to be prepared to do the heavy lifting that the script will not afford you as you progress.

Finally, you point out something that I see as a major deficit during your didactic phase. Everyone presents patients. Students, residents, attendings, everyone. I hope your program has a feedback mechanism that can be utilized to inform them that presenting patients should be an integral part of the curriculum and that this was missing from your experience during clinical year. 

Good luck. 

G Brothers PA-C

[esklar]

Thank you everyone for the great advice. I have tried using the script which helped a bit. I also found that if I take 30 seconds after the patient encounter to organize myself and my notes that helps. I just need to remember to go through things the same way every time which I hope will come with more experience. I'm feeling more and more comfortable every day with just general H&Ps so hopefully this will come too. 

 

G Brothers, I completely agree about not having the opportunity to practice during didactic year and it's something I brought up last year and will bring up again when I see the faculty this year. We had so many opportunities where we could have practiced but didn't for one reason or another. 

 

Anyways, thank you all again! Just need to practice, practice, practice.

[greenmood]

You mentioned a notepad and notes so I will share my experience from my ED rotation. I had a notepad and took lots of notes to help me present the patient. About two weeks into my rotation, after continuing to struggle to get all the right information across to the doc or PA, one of the ED physicians grabbed my notepad and said I was no longer allowed to use it.

 

I never had a problem again.  YMMV.

[EMEDPA]

You mentioned a notepad and notes so I will share my experience from my ED rotation. I had a notepad and took lots of notes to help me present the patient. About two weeks into my rotation, after continuing to struggle to get all the right information across to the doc or PA, one of the ED physicians grabbed my notepad and said I was no longer allowed to use it.

 

I never had a problem again.  YMMV.

agree. most of the info you need you can get from a brief H+P and a review of the pts prior meds and hx.

[esklar]

You mentioned a notepad and notes so I will share my experience from my ED rotation. I had a notepad and took lots of notes to help me present the patient. About two weeks into my rotation, after continuing to struggle to get all the right information across to the doc or PA, one of the ED physicians grabbed my notepad and said I was no longer allowed to use it.

 

I never had a problem again.  YMMV.

 

Just wanted to say thanks for this suggestion! I stopped using pen and paper and went without yesterday and today and felt like I was able to give much more succinct reports. Still working on keeping everything in order when I present (not skipping from HPI to physical exam findings and then back) but I'm still working on it and trying to practice. Could also be a tad bit due to my ADHD as I have trouble organizing my thoughts on a regular basis, not just when presenting patients. But I'm hoping with more experience I'll get more comfortable. I'm already leaps and bounds from where I was 2 weeks ago. Thank you!!

[winterallsummer]

Use SOAP for your presentations.

 

 

(((S)))

Begin like this: Pt is a __ y/o white/black/Hispanic/etc.. male/female presenting with CHIEF COMPLAINT (eg chest pain) x 1d/2d/6 hrs/etc.  His PMH includes (quickly relavent diseases and surgeries).

 

Next. give OPQRST of the chief complaint.  Here is an example:

 

Pt is a 65 y/o AA male presenting w/ CP x 1d.  PMH includes NIDDM, hyperlipidemia, HTN, gout.  The CP (chest pain) began at 1300 today while he was walking his dog.  CP was sudden in onset, and improved after 10 minutes of sitting down and resting.  Described as a "achy pain".  It radiates to the L arm.  Pain was 10/10 at onset, in ED the pain is 3/10, but still present.  It was a/w (associated with) naeseu but no emesis, SOB, but not a/w pallor, presyncope, diaphoresis.

 

 

... now quickly mention pertinent positives or negatives... eg this pt denies fever/chills, abd pain, LE pain.  He also admits to some DOE in the past 2-3d which is unusal for him.  He denies prior episodes of CP.  He has never been stented, CABG, had an MI or had a stress test.

 

((O))

Start w/ vitals and general appearance.  Then quickly list pertinent exam positives & negatives, eg...

CP is non-reproducible.  Lungs CTA, heart RRR w/o M, G.  Abd soft, NT.  LE NT and without edema. 

 

((A/P))

List your DDx.  Start with "what can kill this guy right now" in the ED, and then list common causes.

Then your plan.  eg I want to begin MONA, then stat cardiac enzymes and EKG (should've been done already but just an example here), telemetry, NPO, etc etc. 

 

Sometimes even early on before you have labs/imaging/etc, you can say what you think the pt is headed for.

eg this pt will likely need admission to medicine for serial troponins if his ED workup is negative.

 

---

 

So here would be a quick presentation of a simple case.

 

A 20 y/o white female presents c/o sore throat and fever w/o cough x 2d.  She has no PMH and takes no birth control, never has been hospitalized, LMP 2 wk ago.

 

Her sore throat began 2d ago and is getting worse.  There is no cough or dyspnea or CP.  She took her temp at home orally over the past 2d and Tmax was 102.4.  She tried motrin once and it did not help.  The pain is scratchy, constant, worse with talking and swallowing.  No recent travel.  Her sister at home is sick for past 3-4d with similar sx.  She is still eating the same.  Denies abd pain, N/V/D, dysuria, LE pain, dyspnea.

 

Her temp in ED is 101.4, she is a little tachy at 104, RR 16, BP in 120s.  She is in NAD and sitting comfortably texting throughout my H&P.

 

The pt has tender anterior cervical adenopathy, pharyngeal erythema, tonsillar exudates.  Her lungs are CTA, heart auscultation is unremarkable besides tachycardia.  Abd NT, ND, soft.  LE NT, no edema. 

 

I think this pt has strep vs viral illness.  I suggest go ahead and tx this pt, or we could get a rapid strep and cx.  I was thinking amox - as she has NKDA - and one dose of steroids to help w/ the pain.  I do not think we need any imaging or blood work.

 

--

 

With time it gets easier.  What is tough is everyone wants it different.  Some preceptor may want the above, somewhat lengthy presentation.  Another may want a more thorough one.  The other may just want to hear "looks like strep, febrile w/ classic findings, I would tx w/ amox and steroids".  YOu will get there with time!!