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Fourth year: presenting patients

By fourth year, you will understandably have had experience rounding on patients. So during fourth year, you are expected to know the basics -- the key to shining is knowing how to bridge the gap between gathering/presenting data vs understanding what the data may mean, having multiple differentials in mind, as well as having a plan - even if it's not exactly right.

Each program and each attending will value certain parts over others and have their own preferences, but try to have your own standardized presentation outline you can follow - then edit as you go. I did a few surgical ICU (SICU) rotations where the depth of knowledge required and the rounding were a little more intensive, so I wanted to discuss a few points below for those of you entering auditions soon.

Key points:

  • Organize prior to presenting for a focused discussion, aim for <5 min
  • Inform about 24 hour events and your plan moving forward
  • Demonstrate your knowledge and engagement in care of patient
  • Listen for adjustments to plan, and write down the changes for your note/running the list/helping the resident

Sample Presentation Outline (variable; i.e. some prefer the PE with the A&P):

  • Opening: Name, age, Hospital Day#, main clinical issue(s)
  • 24 hour events: highlighting changes in clinical status, procedures, imaging, consults, etc
  • Subjective: How patient is feeling
  • Objective: Range of vital signs (including I&Os), key physical exam findings, relevant labs (highlighting changes: i.e. BUN dropped from 2.0 to 0.8) and imaging results (official read, as well as your impression - always look at your own imaging!)
  • Assessment & Plan: Systems based for ICU. Always list existing/chronic medical problems (treatment/management/plan) along with acute (status/treatment/plan). Below are only a few examples of topics to address.
    • Neuro
      • Consider need for neuro checks, C collar clearance, AO status
    • Pulm
      • ARDS, resolved: PaO2/FiO2 (PF ratio)
      • If you expect pt to require any respiratory treatments/when to be extubated if still intubated/vent settings
    • Cardiac
      • HTN, controlled: continue home BP medication Atenolol 50mg q day. Hold if SBP<90. 
    • GI
      • Consider feeding via the gut, or TPN for those unable to eat for >7 days
      • Know indications when to start PPIs 
    • GU
      • Consider IVF/kidney function and output
    • MSK
      • Fractures
      • Consider need for PT
    • Skin
      • Wound care, check for ulcers
    • ID
      • Consider need for consult, cultures, use of antibiotics
    • Other
      • Tylenol q4-6 hours PRN pain, zofran 4mg odt q6 hours PRN nausea
    • Disposition: Whether you expect to transfer or discharge, and when expected - as well as antibiotics, wound care, follow up with PMD (length of time), any other referrals 

*I make it a habit to at least: listen to heart, lungs, abdomen (+palpation), as well as take pulses on every patient, but always make sure to check the affected body part - i.e. cellulitis of RLE? Unwrap and check it yourself, unless the nurse requests for you to wait until next dressing change*

This was just a quick run-down, but always think about the next step: admission vs discharge, but also - if they are admitted, what will they need to get home? (i.e. be able to eat, walk, stool, urinate, have PT clearance, proper follow up, nursing home arrangement, etc)

Some helpful tips I received from a mentor:

  • Think about all of the things we are doing to the patient
  • What infections/problems they can cause
  • Assess if it's possible to remove yet
  • Think about how we assess these factors

Good luck to all of those auditioning this season!

Food as Fuel

Food as Fuel

Status: Listening

Status: Listening