How do you present patients in medical school? Presenting in front of attendings often makes medical students tense up. It’s very uncomfortable to attempt to sound competent, concise, and thoughtful to a likely evaluator.
But what if I told you that the whole process could be stress-free and easy?
In this post, I’ll break down, step-by-step, exactly how to present patients in medical school to your attendings/residents. This will include the dos and the do not’s of presenting!
If you prefer a video format, check out the following video and more on my YouTube channel!
Tell a Story When Presenting Your Patient:
This is how I learned to present, and I believe it’s the best way to present patients.
Tell a story.
You know how easily we mentally check out during a boring lecture. They often just read off their slides. It becomes a bullet point presentation – just fact after fact.
Medical students are often the boring lecturer when they present. We become so worried about telling all the facts. But we suck at tying it all together.
Think about it; we don’t talk about patient experiences with our peers the way we present. We’re much more casual and hit the high points, Now no I’m not arguing that you should be too casual but learn how to tell a story without hitting unnecessary info.
I’ll break down exactly how I tell my patient’s medical story. Just remember that you want to be interesting and concise.
What Would I Want To Hear?
Imagine yourself as the attending. What would you want to hear?
You certainly wouldn’t want to hear your medical students telling you about lung sounds in a patient with a broken finger.
Ask yourself if a piece of info is important for your patient. You get better over time on identifying what’s important. I discuss some things you should always mention later in the post.
Write Out Your Presentation in Bullet Format
Too often I see my peers reading their typed notes word for word. They rarely look up and don’t even pretend like they’re not just regurgitating their progress note.
I get that it’s hard to memorize a presentation. It’s as scary as actually having to do one.
So use a bullet point outline.
Here’s what I do.
On the first bullet, I’ll often write a shrunk version of my one-liner. I’ll talk about mastering this later in the post.
The next few bullets I’ll break down symptoms, timeline, important features, etc. that I want to discuss when I’m telling my patient’s story.
In the next bullet points, I’ll write the vital ranges and underline anything I want to mention. I’ll also include physical exam findings and labs which are pertinent.
Finally, I’ll include a list of problems with Ddx and suggestions for the plan.
Here’s an example of what this would look like.
Honestly, this is probably more than I’d write down. I have created my abbreviations which tends to cut my bullet point to half what’s shown above.
Unless I’m lost,I don’t have to look down. Thus I’m always making eye contact with my attending – demanding attention.. This makes the presentation seem much more natural. You’re having a discussion with your attending.
Don’t read your note that they can read on their own.
Step-By-Step Approach To Presenting Patients in Medical School Master the One-Liner.
Your one-liner will tell the resident if they should take your presentation seriously or not. The same way a great singer grabs your attention with their first note, you have to impress with a solid one-liner.
Here’s how to do it.
Who are they?
Include their name, age, and demographics.
Why predisposes them to these symptoms/disease?
What comorbidities do they have? Which are important for their current chief complaint?
Provide some insight into severity here. Do they have HF? If so what’s their ejection fraction?
Do they have diabetes? What’s their A1C?
I discuss other examples later in the post.
Why are they here?
Their chief complaint is the most important part of your one-liner. Here are things you must include.
What caused them to come into the hospital/clinic?
Patients usually come in with symptoms, not diagnoses. So your patient comes in with a chief complaint of chest pain, not a heart attack.
Sometimes a patient may come in for one thing but are getting worked up for a different symptom altogether. You can state, “patient is being evaluated for (insert symptom) that was identified in the emergency room/clinic”. You can include in your HPI what the patient originally came in for to paint the full picture.
Master Your PHI (Present History of Illness)
I remember presenting once in the pediatric emergency room to an attending. My patient was a 6-year old girl with a cat scratch to her eye. It was my first rotation, and I had no idea what I was doing (Maybe I should have looked for such a post back then).
I began with a killer one-liner. But then, instead of talking about her eye, I began to talk about her flu-like symptoms. The attending immediately stopped me and said, “I don’t care! Tell me about her eye!”.
So learn from my mistake. Don’t talk about the flu on a patient with a scratched eye.
Keep your story to the point.
After you understand this important lesson, the next step is to begin to form the order of your story. Often this begins with how the long the symptoms are going and how they first presented. Then provide a chronological order of how the symptoms worsened/improved over time.
Make sure to include why the patient finally came to see a doctor. Why now instead of two days ago when the symptoms first started?
This is also where you include the rest of your PHI. There are several acronyms people use that I haven’t cared to remember. But here are the important details to discuss (if applicable).
How long have the symptoms lasted?
How does the patient describe their symptoms/pain? (sharp, dull, throbbing, etc.)
Where is it? Does it radiate?
How severe on a scale of 1-10 is it? Has this number gotten worse or better over time?
What makes it better and what makes it worse?
Do they have any other associated symptoms? (Fevers, weakness, headaches, chest pain, etc.)
Remember not everything is important:
Let’s go back to our bullet point outline of our presentation. When you practice it in your head, ask if that fact you plan on saying is important to the person’s story.
Ever watch a movie and wonder why a scene was even needed? Don’t include extra scenes.
The attending should understand who the patient is, why they’re here, and the important events that led them to this point.
What is considered abnormal?
If something is abnormal to a patient, explain how it differs from normal for them. If a patient can’t walk without being SOB, you must explain how far could they walk before.
If they have a headache but also have a history of migraines, then you must include how this headache is different or similar to their condition.
Indicate Pertinent Positive and Negatives on
If a patient comes in with concerns of a heart attack, including the symptoms that they have which make you worried.
It’s equally as important to include symptoms of an MI that they don’t have.
But don’t go through the whole list and indicate random symptoms that don’t matter.
Become Efficient in Telling The Past Medical
Students love to list everything the patient has. But let’s be real, I don’t care if a patient has GERD and they’re coming in for osteomyelitis.
In your PMH include big comorbidities such as diabetes, asthma/COPD, heart failure, liver disease, and kidney issues.
If they do have the above comorbidities here are some things you should include.
For diabetes always include their most recent A1C. State when this was done. Also include what form of treatment they’re on (insulin, metformin, etc.), their dose, and their compliance with their medications. Also ask about their typical blood sugars, how often the measure them, and what time of the day these readings are taken.
For heart failure include their last ejection fraction and date. Indicate what medications they’re currently taking and how compliant they are. Ask the patient how many pillows they sleep with under their head as paroxysmal nocturnal dyspnea is a common symptom. Also, ask about their baseline weight (will go up in a heart failure exacerbation) and what their diet/fluid intake is like.
For asthma, you want to identify what severity they have. Are they severe persistent, moderate intermittent, or something else? How often do they use their rescue inhaler? How many times a week do they wake up at night. Also, ask if they’ve ever had to be intubated before.
Similar to asthma, for your COPD patient also include what GOLD stage they are. You’ll learn about this on your internal medicine rotation if you haven’t already.
These are some classic examples you want to hit every time.
Start with their vitals.
Do you need to say everything? No.
Some attendings will want ranges for the heart rate and blood pressures. Others are fine if you say, “patient is afebrile, normotensive, and has a regular heart rate” or “vital signs are within normal limits”.
Regarding your physical – only say what you did. Again does everything matter? Nope.
Get away from sounding robotic. “Lungs clear to auscultation bilaterally” can just be “lungs clear bilaterally”.
If you don’t read your notes, you’ll seem more natural when presenting the physical.
What about labs? Don’t present all labs obviously. No one cares about the WBC for a patient with a broken arm.
State labs of importance such as “lytes were stable; hemoglobin was decreased to (insert value) from (insert value) yesterday. Remaining labs of patients were within normal limits”.
If, however, you did a specific lab/test to confirm/rule out a disease then make sure you state the results. A common example is a urinalysis. If a patient has suspected UTI, make sure you state their UA came back without indications for an infection.
Certains labs are important to trend. This includes Creatinine, BNP, hemoglobin/hematocrit, WBC, Platelets, Lactate, and important electrolytes.
So you finished with the easy part. You knew the story and told it. Now you get to show you know how to doctor and not just interview.
Here’s my format to present my assessment and plan.
“This is Ms. who has (insert pertinent conditions and PMH) who came in for (symptoms). Given her symptoms and (physical exam/lab evidence A, B, C) I think she could have (differential A) given that she has (x,y, and z), she could also have (differential B) because of (x,y,z) and differential C (x,y,z).
To work her up I would do test/treatment (a,b,c) and reevaluate her (insert time frame).
I expect discharge for her pending treatment/workup and hopeful discharge (give a guess if possible).”
Boom! You just rocked that patient presentation!
If your patient has multiple problems, you can break your A/P by problem. For example, you can state, “For her back pain I think she could have (X,Y, or Z). I think we should give her treatment (A or B).” Keep going down her problem list. Some attendings like a system based but the method is the same.
So there you have it. Now you can present patients in medical school like a pro!
Here are other posts you may enjoy as well.
If there is something specific, you’d like me to address in a future blog post, comment below or email me at [email protected].
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Until next time…