Patient Presentations in Emergency Medicine

welcome to your emergency medicine rotation we're glad to have you join us today we want to talk about one of the fundamental skills in emergency medicine patient presentations now you'll notice their features about the emergency department that shaped the way we present things here happen very fast a tackle patient room three now acuity is very hot drama Tea Room walk yeah now he's taking the room one I will be right there and there tend to be multiple distractions excuse me yes patients INR seven got it thank you so much absolutely I agree thank you definitely send me let's activate the cath lab right away thank you so in order to be able to function this environment we have to make sure our presentations are concise organized and focused on the emergent issues there's a presentation going on right now let's see how it's done hi dr. Mitra yeah I have a patient I'm ready to present whenever you're ready sure go ahead so I just saw mr. Ferguson he's over in room four he's a 64 year old male he has a history of osteoarthritis of the left knee anxiety high blood pressure glaucoma diabetes carpal tunnel syndrome hyperlipidemia and gout that mostly hits his right great toe his pain started a few days ago when he was drinking tea he typically drinks chamomile but he had run out got some peppermint and thought perhaps that was what was going on on social history mr. Ferguson doesn't smoke he does drink the occasional glass of dry red wine and he lives at home with two pet Chihuahua and their names are honey and bear which I thought was just kind of cute on exam mr. Ferguson is a no acute distress he has blue eyes his neck was supple there was no cervical adenopathy it's definitely not anything cardiac and he looks really really well but uh dr. dr. Mitra give a pulse doctor I need a doctor perhaps that was not the best example let's talk more about how to present an IDI presenting is not about restating all of your findings rather it should be a synthesis of your findings to help shape future medical decision making now there are different ways to conceptualize this process the one we want to share with you today is to think about presenting like telling a story now like any good story your presentation should have a beginning middle and end your beginning is your introductory statement that contains the patient demographics the pertinent past medical history and the reason for the visit the middle of your presentation is the crux it's where you developed your characters which in this context are these conditions you're considering either because they carry high probability or high risk and your ending is your differential diagnosis and management plan now it's important that your presentations do not read like a mystery novel and once your audience is completely clueless about where the story is going and what's going on instead your differential diagnosis is the focal point upon which to build your narrative in fact your listeners should be able to anticipate your differential diagnosis based on the preceding narrative your introductory statement sets the stage for the rest of the presentation by making the reason for the visit clear as well as creating a backdrop or frame for the conditions that your patient may be at risk for based on their predisposing factors so let's go back to mr. Ferguson he's a gentleman with diabetes high blood pressure high cholesterol and arthritis let's say the reason for his visit is that he was found unresponsive with a blood glucose of 20 in that scenario you want to highlight that he's a diabetic patient who's on an oral hypoglycemic agent if however the reason for his visit is that he developed severe lip swelling then the items you want to pull into your frame is that he has high blood pressure and that he's on an ACE inhibitor setting this stage for angioedema notice that neither scenario has high cholesterol and arthritis are not relevant so they do not necessarily need to be presented you're using your ending to help shape the beginning of your narrative the middle of your presentation is the crux in which you develop your characters which in this context are disease conditions you are considering either because they carry high probability or high risk general you want to think early about the life and limb threatening conditions that use them to help shape your assessment so with chest pain think about the myocardial infarction the pulmonary embolism or the or DIC dissection even before you walk into the room if it's right lower quadrant pain think about appendicitis or variant origin or a topic pregnancy the earlier you start considering these do not misdiagnosis the better you'll be looking for them and using them to shape your narrative now each of these characters also have their many stories which are the classic presentations or patterns of disease so for example with unstable angina it's the new or accelerating chest pressure that's worth it was exertion and better with rest with appendicitis it's the migratory right lower quadrant pain that's associated with fever anorexia and nausea you want to be proactive and looking for these patterns of disease early on to help organize your findings so rather than randomly present the quality of the pain the radiation of the pain or the severity of pain extract and organize them into a way that fits within the mini-stories of the disease conditions you are considering so in general and emergency medicine we don't use the headings of past medical history family history social history or review systems rather we incorporate the relevant items from each of these topics into one big historical narrative so the pertinent past medical history gets incorporated into the introductory statement the relevant items from the review systems becomes part of the many stories for the disease conditions that you are considering for medications and allergies you should always obtain them in review with your patient however there may be some practice variation about whether you should represent them in total or review them together in front of the electronic health record for physical exam vital signs should always be presented and you should highlight abnormalities or otherwise you can globally refer to them with terms such as unremarkable be sure to describe the general appearance of your patient and for the remainder of your exam you can use the reason for the visit as well as the differential diagnosis to decide what is pertinent and what is non-contributory and can be excluded if there's any available data such as EKG labs or radiographic studies you can present these as well but once again focusing on items that inform you differential diagnosis your ending is your differential diagnosis and management plan in other words what do you think is going on with the patient and how do you want to manage their care it's important that your differential diagnosis is not a random list of diagnostic considerations but rather should be stratified on probability and risk of harm so one such classification scheme is to start with first what do you think is the most likely diagnosis or especially with critical care patients what is the imminent diagnosis that must be readily addressed secondly present the high-risk or do not miss conditions that may not necessarily be the most likely but still need to be excluded thirdly are they do not miss diagnoses that you have considered but yet you feel have been excluded this time based on your history physical exam and initial data it's important that you at least consider these diagnoses otherwise you run the risk of missing them so you should always regard the conditions that pose risk to life limb or reproductive ability in your differential diagnosis lastly you have the option of presenting conditions that pose low risk and are also of low to moderate probability your management plan can be divided into diagnostics therapeutics and disposition so different institutions may have nuances in terms of how they like things being presented but this concept of thinking about your presentations is telling a story will help you make them more concise and a synthesized version of your findings that prioritizes the identification and exclusion of do not miss diagnosis I think our doctor has been revived and our students going to try again applying these concepts let's go see how it goes this time around hey dr. mantra' yes I'm ready to present a patient whenever you are I learned a lot from last time meet Kate oh okay so mr. Ferguson is a 64 year old male with a history of diabetes hypertension and hyperlipidemia who comes in with a chief complaint of chest pain for the last three days he described it as a substernal burning he gets about five days in episodes a day he first noticed it after he's drinking some tea but then he's also had multiple unprovoked episodes as well the pain is neither exertional nor the pleuritic and it doesn't radiate to his back or anywhere else he does get some shortness of breath with the pain but he doesn't have any nausea vomiting or diaphoresis he doesn't have any leg swelling fevers cough or abdominal neither mr. Ferguson takes glyburide lisinopril and Zima statin he doesn't have any drug allergies and he doesn't smoke on physical exam mr. Ferguson's vital signs were unremarkable he's comfortable and well appearing he doesn't have any jvd his lungs were clear his heart exam was with a regular rate and rhythm without any murmurs gallops rubs his abdominal exam was benign and he did have an intact in symmetric distal pulses without any lower extremity edema or tenderness his EKG is here I looked at it looked like it was in normal sinus rhythm without any acute ischemic changes for my assessment and plan mr. Ferguson is a 64 year old gentleman who comes in with multiple cardiac risk factors with the chief complaint of substernal chest pain for my differential the fact that the pain is burning and he notices it mostly after tea makes me think of something gee I like reflux as the most probable diagnosis but he does have multiple cardiac risk factors and he has had the spontaneous episodes of pain as well which make me concerned enough that we should rule out the acute coronary syndrome he doesn't have any pleuritic pain or any signs or symptoms of DVT to make me strongly suspect a PE he doesn't have any tearing pain he's normotensive and he doesn't have any post evidence to make me strongly suspect i section either for my plan I'd like to get a CBC a BMP I said a cardiac biomarkers a chest x-ray and give him aspirin currently he's chest pain free and we can reassess the need for further analgesia later for disposition mr. Ferguson if his first set of enzymes comes back negative I'd still like to ring them in to our chest pain observation center to complete a rule out and get a functional study in the morning great assessment and good plan thank you there you have it there's nothing like a great story and a well-crafted concise presentation thank you for joining us you


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