Presenting a Patient - Guidelines and Tips

CORE Presentation Adapted by Primary Care Associates

July 5th, 2011

Presenting a Patient Premises

Purpose: To concisely convey information to another

health care provider
Present information needed to develop a basic
understanding of the patients current state of health
This fundamental skill will be part of your professional
communications for the remainder of your career
Just as with documentation, standardized format
enhances clarity and minimizes confusion

Presenting a Patient Premises

The format of a formal Patient Presentation differs

according to:
the service (ambulatory family medicine, surgery, emergency
medicine, etc.)
the setting (hallway, exam room, rounds discussion table, etc.)
the listener (preceptor, resident, department staff, etc.)

TIP: Ask the preceptor/resident about oral case

presentation guidelines at the start of the rotation

Presenting a Patient Basics

Rule of thumb: BE BRIEF

Family history, social history and review of systems are
frequently excluded from the case presentation
Especially the acute problem presentation (ED, UC, FM)
However, ALL details should be investigated in case they are
significant

Elements of the social/family history or ROS that are

relevant to the chief complaint (e.g., homelessness, father
died of MI @ age 40, 20 pack-year smoking history, etc.)
may be included in the history of chief complaint

Presenting a Patient Basics

Patient name, age, race, gender
Chief complaint (onset, duration)
Mr. Sullivan is a 24 year-old white man who presents with a 3-day
history of a progressively worsening cough, productive of yellow
sputum, accompanied over the last 24 hours by sharp, left sided
chest pain.

History of Chief Complaint (O-P-Q-R-S-T; CODIERS)

Relevant SH/FH/ROS

Relevant PMH/PSH
Current Medications
Allergies

Presenting a Patient
Delivery Tips
Be interested and energetic
and your audience will respond

Know ALL the facts of the story

but dont automatically tell it all

Be confident
never condescending

Use notes
but dont read them

Be organized
follow a standardized pattern

Presenting a Patient
Delivery Tips
Use precise language
Positive statements are more powerful than negative
statements
Lungs are clear of wheezes or crackles is better than Lung
auscultation showed no abnormalities

Get to the bottom line as quickly as possible

remembering that this varies with the setting, audience, etc.

Presenting a Patient
Delivery Tips
Avoid redundancy
On auscultation, the lung sounds were
On physical exam, the heart was
The patient states

Avoid judgmental language

The patient is a poor historian
This 26 year-old man is a frequent flyer in the ED..

Dont editorialize
The nurse kept interrupting the interview to administer
medications, even though I asked to be left alone

Presenting a Patient
Questions?
Practice
Flexibility to accommodate preceptor preferences
Frustration is normal

Dont hesitate to contact us:

Primary Care Associates (FM Fellows)

Grosvenor 333
fellowsd@oucom.ohiou.edu
(740)593-2106

Practice Case 1:
Ambulatory Family Medicine
Leonard Harris is a 78 year-old AA male who presents with his daughter,
Jill, to the family doctors office. Leonard has no complaints. Jill has
made this appointment to express concerns re: her fathers recent absentmindedness
Student Doctor Schoeny
Student Doctor Manzanillo

Primary Care Associates (FM Fellows)

Grosvenor 333
fellowsd@oucom.ohiou.edu
(740)593-2106

Practice Case 2:
Inpatient OB/GYN
Ashlee Pranso is a 32 year-old white female presenting to
L&D reporting, Really bad pain in my belly.
Student Doctor Crye
Student Doctor Parks

Primary Care Associates (FM Fellows)

Grosvenor 333
fellowsd@oucom.ohiou.edu
(740)593-2106

Practice Case 3:
Inpatient Internal Medicine
Ms. Brittany Pierce is a 49 year-old white female presenting
with a headache 3 days ago, and since that time persistent
dizziness.
Student Doctor Kocoloski
Student Doctor Phillips

Primary Care Associates (FM Fellows)

Grosvenor 333
fellowsd@oucom.ohiou.edu
(740)593-2106