Medical Student Presentation Guide

This is a rather amusing if not entirely didactic guide to patient presentations

A complete History and Physical must be obtained with the resident on the floor and written up for Dr. Miller and the teaching resident.

Presentation of morning rounds must be focused and concise. Specifically:

Give a one-line introduction with: age, sex, diagnosis(es)
Brief HPI with chief complaint, length and type of symptoms, medical interventions (if any)
ER course: Vital signs, exam in ER, interventions
Floor course: Exam if different from ER, interventions
Your plan: Medical management, studies required, etc.
Concise, effective presentations are very difficult to synthesize. To help you do this, use the intern who is assigned to the patient to figure out what information is pertinent, and give a trial run of your presentation to him or her.

You should practice your presentation and time yourself. The goal is less than two minutes! Remember to include what you feel are the PERTINENT positives and negatives. Your senior resident will ask specific focused questions if they require more information. Again, let me emphasize that we realize this is a difficult task. If you feel uncomfortable or unsure, talk to one of the seniors on your team and they can guide you through your specific areas of concern.

Examples:

Bad:

This is a three year old cute little girl who has been having a hard time breathing for awhile now. She has a doctor who manages her asthma with a bunch of different medicines but things weren't going so well, so she came to the ER with her Mother, sister, and baby doll, Mrs. Bigglesworth. Apparently, she has been in the hospital before with this and mom says she misses a lot of her preschool because of her wheezing. Mom things that she is worse in the spring but she was a little fuzzy on that point. So today after ballet class mom saw that Sissy was breathing hard and they decided to go to the ER after getting Mr. Misty at the DQ on the way, by the way Sissy got blueberry which worried the ER staff who initially thought she was cyanotic. Anyway, in the ER she was breathing fast and working hard so she was given Albuterol nebs and some prednisone which she vomited twice so she was enrolled in Steve Gordon's asthma study and given Dexamethasone. She was OK on q2 nebs so she came to the floor where she is still on q2 but looking a little better. Here on the floor, she was breathing around 68 breaths per minute and was having a hard time talking but she looked otherwise well and in no distress. Her immunizations are all current but mom is not sure if she should get the new heptavalent pneumovax. Currently, mom says that she can talk in five word phrases and she easily walks up and down stairs unassisted. Her exam on the floor is as follows. HR 118, RR 50, BP 111/68, head circumference 50 cm. Today, I think we should consider spacing her nebs to q3 hours in preparation for early morning discharge tomorrow since I know we are in a bed crunch.

Good:

This is a three year old moderate-severe asthmatic female who presented to the ER at 8 pm last night after having an increased work of breathing for one day that was refractory to Albuterol q3 at home. This is her fourth hospital admission, no PICU admissions, and no intubations. Her home regiment includes Albuterol nebs PRN, Flovent 44 mcg with spacer and mask BID and PO prednisone PRN severe exacerbation. Her triggers include cats, seasonal allergies and cold weather. Her mother and brother are also sever asthmatics.

In the ER, her respiratory rate was 68 and her O2 sat 90% on room air. Her exam revealed diffuse wheezing and pan retractions but was otherwise unremarkable. She was given IM Dexamethasone as per Dr. Gordon's protocol; Albuterol with Atrovent times three then two Albuterol nebs q2. Her respiratory distress improved significantly and she was admitted to 10 South for further management.

On the floor her respiratory rate was between 35-40, O2 sat greater than 98% with 1 liter nasal cannula O2, wt=14 kg (59th %). She continues to have diffuse wheezing but now has only a little nasal flaring. She continues on Albuterol q2 but appears to be in less distress this morning.

Today, I want to continue her nebs at q2, continue her steroid regimen and get Pulmonary to consult for asthma teaching.

Day 6 and 7

First call. probably good that i can't really twitter or fb in hospital. but many observations over 30 hours lost. maybe for better?

it was quiet for trauma. the ER was mostly full of non surgical stab wounds and DTs and the like. But after 8 pm two appendicitis cases. I scrubbed in on both.

I felt dorky for admitting it-these are bread and butter surgeries and laparascopies to boot--but how can i resist being insanely excited at my first OR experience? I wore gowns, double gloved, had a mask, got yelled at by the scrub nurse--everything i dreamed of! that beep beep of vital signs, the inappropriate jokes by the anesthesiologist. I even got to suture one of the ports. However i did a terrible job and we had to steristrip it (its only a 1 cm scar, i promise!)

tried not to be irritating to the residents, but they taught a lot. got to sleep 3 hours, more than most of the other medstudents this week

prepped for presentation at GI/surg conference but a surg resident did it instead, which is good bc his was much better. i got excited and spoke up, but it felt funny, a sense of breaching hierarchy. should make note of this in future--not so much to cease as to proceed with caution.

Felt pretty shitty and out of it for rest of day. Really tired, really hungry, feet hurt, back hurt, was kind of smelly, tried to speak coherently, but felt good in a deeper way, like i was doing something really tough like travelers and military and well, surgeons, do.

Biked home. took best shower in a long ass time.

Day 6

had day off. spent previous night with bf eating frozen pizza and salad.

Day 5 examined first prison patient. Remarkable for being unremarkable. Had a lump in his butt. Officer left the room during the butt exam, which caused some distress, but distress was unfounded. In general, first time examining a real patient's butt (although not a real rectal exam). Turns out to be equally weird as examining their chest, head, etc, but not weirder. Slightly weirder trying to remove someone's orange prison pants beneath their shackles, since they are handcuffed and can't remove their own pants. patient was regular, not weird or violent, and that was helpful. Two male genital exams have both been less weird than majority of female exams, but then also less invasive. I hate pelvic exams too.

afternoon spent suture workshop, practice sutures on decomposing pig feet. gross

Day 6 maybe have a cold. Went to capoeira anyway. still really out of shape, so weird to be desperately breathless--for some reason it is so beautiful and i love it, when i think about pts with COPD or intubators, and the reason i can't breathe is because i did 30 cartwheels, not because my lungs are not viable. It is frivolous and i am so grateful for the frivolity, for my health, for breath, which can leave us anytime. we all become patients one day.