Now, we're gonna talk about presentation of patients
in the Emergency Department.
So what is the Emergency Medicine patient presentation?
it’s a style of presentation that organizes information
in the way that we think as emergency medicine physicians.
And it's important
because it’s the means by which you're gonna be talking about
all of your patients to your clinical preceptors
so you're gonna be communicating information
using this presentation style.
It's a major determinant of the care that your patient receives.
So if you pass on information that is complete,
and accurate, and thorough
and paints the right clinical picture for your colleagues,
your patients are gonna get good care.
But if you leave out important details,
they might not get the care that they really need.
And probably, most importantly for you as a medical student,
it’s a major determinant of the grades that you're gonna get.
So the better you get at presenting presentations
in the emergency medicine style,
the more impressive you're gonna to be to your preceptors
and the better your evaluations are gonna be
in the clinical area.
What’s different about the emergency medicine presentation
compared to other types of patient presentations?
One, we are always focused on one single
chief complaint or presenting problem.
Whereas other fields might focus on a larger,
more global picture of what's going on with the patient.
Two, we limit ourselves to that single chief complaint
and we only include elements of the past medical history
that are relevant to that chief complaint.
Whereas in other fields,
presentations often include a comprehensive problem list,
a complete past history that includes medications,
social history, family history, prior surgeries, etc.
For us, we pick and choose what elements
of that past history we think are important.
Three, we prioritize our differential diagnosis by severity.
I talked in the last lecture
about the differential of consequence
and that’s what we use to prioritize
our differential diagnosis in the ED.
Whereas in other settings,
the differential is typically prioritized by likelihood.
Four, our emphasis in the ED is on the immediate plan right now.
What tests are we gonna get today?
What treatments are we gonna prescribe right here in the ED,
and what’s the disposition gonna be?
Is this patient gonna be admitted?
Sent to the ICU?
Sent to the operating room?
We have to decide those things right here and now.
Whereas in other specialties,
a lot of times care is focused on more long term objectives.
So what's the overall hospital course gonna be?
What's the definitive management gonna be?
What's the final outcome gonna be for this patient
as opposed to the immediate steps
that have to take place right now?
Lastly in the ED,
we often don’t know the definitive diagnosis for our patient.
We very commonly have to make decisions
about treatment and disposition
without actually establishing what's wrong with them.
Whereas much more commonly in other specialties,
the diagnosis is established
because they have the benefit of a longer time
to get to know the patient and more elaborate test results
to get to the bottom of their problems.
So the structure of presentations in the ED
is very straightforward.
It's always gonna start off with that history of present illness
which is gonna be the story
of what brought the patient to the ED today.
From there, we're gonna move on to the relevant
past medical and surgical history.
The relevant pieces of the physical exam,
not a comprehensive head to toe exam
but the relevant maneuvers
that will help us establish a diagnosis.
Clinical data by which I mean: laboratory tests, EKGs,
imaging results, etc.
And lastly, an assessment and plan.
Those are the elements that have to be included
in every presentation, every time.
So starting off with the history of present illness.
I would just like to say,
this is the single most important part of the presentation,
and probably 80-85%
of the information that you get about the patient
that leads you to a diagnosis
is drawn from a high quality history of present illness.
So your focus in the HPI is gonna be on the chief complaint.
Why is the patient here in the emergency department today?
What brought them out of their home into the hospital
right now for this particular problem?
We always wanna generate a clear, linear illness narrative.
We wanna know what past events got them to this point,
what they're experiencing right now,
and what they're concerned about moving forward.
We wanna make sure that we include
all the pertinent positives and negatives
from the review of systems,
so we are not gonna necessarily do a comprehensive
head to toe review of systems on every patient,
but we definitely wanna get information
that’s gonna help us broaden or narrow our differential
based on the patient’s HPI.
And lastly, we always omit extraneous detail.
So if we're not certain it belongs
in our history of present illness,
we shouldn’t put it in.
Only the relevant facts, please.
When we're talking about the past medical history,
We're gonna always include
the essential elements of the past history
in the opening statement of the history of present illness.
And what I mean by that is,
I'm not gonna tell you a whole story
about this patient’s chest pain,
that they've had five heart attacks in the past
or seven pulmonary emboli or whatever the past history is.
So we're gonna start off saying,
this is a 64-year-old woman who has a history
of five prior myocardial infarctions
and has three coronary stents who presents with chest pain.
That’s gonna give us a much clearer picture
of who this person is
before we even launch into the history of present illness.
When I do get into the past medical history section,
I'm only gonna discuss aspects of this past history
that are pertinent to today’s visit,
so I'm not gonna give you a comprehensive history,
I'm gonna just talk about the things that are important today,
and I'm gonna omit elements that don't contribute to
understanding of the current problem today.
So for a patient who comes in with chest pain,
it probably doesn’t matter all that much
that they had sinus surgery five years ago,
that's probably not a fact that's relevant in their past history
and I'm not gonna include it in my ED presentation.
The items to include or exclude
are entirely dependent on the history of present illness,
so it's really, really important
when you think about what's relevant and what isn’t
to always focus it back on the chief complaint
and the history of present illness
because that's what's gonna determine
what information you should or you should not include.
When we do the physical exam,
we wanna examine every organ system that might be implicated
in the patients current presentation today.
So if they come in with abdominal pain,
obviously, I'm gonna examine the abdomen, right?
But if I'm worried
that it could potentially be an anginal equivalent
in an older patient,
I'm gonna do a heart and lung exam.
If I'm worried that there could be an underlying
neurologic etiology for their pain,
I'm gonna do a neuro exam.
So I'm gonna wanna make sure I cast a broad net
and examine the relevant organ systems.
I wanna describe my exam findings clearly and succinctly
so you gonna wanna work on
all of that great descriptive language
that you learned in your physical diagnosis courses.
I wanna always include descriptions of severity,
so I wanna be able to indicate whether the patient has
maybe a little bit of tenderness when I press her,
if they have an exquisitely tender abdomen,
and I wanna emphasize findings that either point towards
or away from life threatening problems.
So I'm always thinking about that differential of consequence,
and I'm trying to highlight pieces of data
that either rule in or rule out items
on that differential of consequence.
So when we present clinical data,
we wanna make sure that we describe the relevant findings
from labs, radiology studies, and the ECG.
We only wanna give specific values for key findings.
So if something is normal, it's fine to just say,
"The CBC is normal."
Where if you are concerned about one specific finding,
the hemoglobin is four,
that would be a situation where you wanna give a specific value.
You wanna always indicate if important tests are still pending
so that the listener knows that you know
that there are important pieces of data that are gonna
ultimately inform your clinical decision making,
and you don’t wanna give a laundry list of every single finding.
You wanna prioritize what's important,
get the key pieces of information out there and then stop.
If the listener wants additional pieces of information
you didn’t describe,
they can always ask,
but nobody wants to hear a litany
of 75 irrelevant test results
when there's really one or two key pieces
of clinical data that we're looking for.
So when you give your assessment and plan,
you wanna bring it all together.
So you wanna start off with a summary's data
— a summary statement
that brings together all of the key pieces of data
from your history of present illness,
your physical exam, and your ancillary testing.
And when you start talking about your differential diagnosis,
you wanna address the worst concerns first.
Your differential of consequence.
So you wanna make sure
that as you describe your assessment of the patient,
you are either supporting or refuting diagnoses
from that differential of consequence
based on what your clinical impression is.
You only wanna address your likely diagnoses
once your serious diagnoses have already been discussed
and you wanna make sure that you emphasize the plan.
A lot of times,
medical students kind of trail off
at the end of the assessment and plan
coz they really don’t know what to do.
But we wanna make sure that you give it your best shot.
Describe what you think should be done for the patient.
What further test do they need?
How do you wanna treat them?
What's their disposition gonna be?
The worst that can happen
is you know maybe you’ll be wrong
and you’ll have an opportunity to talk about why
with your preceptor,
but you wanna start practicing getting your own plan out there
and committing to a course of action for your patient
coz that's how you learn to make clinical decisions.