How to Present a Patient

In general Emergency Medicine presentations should be concise and to the point. While it is important to perform a thorough history and exam, you do not have to verbalize every bit of information that you obtained. The attending can always ask you more questions about the patient after the presentation. Ideally you should spend only a few sentences describing the patient’s chief complaint and relevant PMH, and then the relevant positive or negative review of systems. When you describe your exam and the lab values, point out relevant positive and negative findings only. You should always end with a conclusion as to what you think the patient has and what you would like to do. The summary is the most important part of the presentation and coming up with a plan will be the best way to impress your attending with your presentation.

Some Examples:

1)Mr. Hamm is a 54 year old male with a history of diabetes, hypertension, who is also a smoker who presents with 2 hours of unremitting chest pain described as crushing and radiating to his left arm. He also reports associated diaphoresis and dyspnea. He states he has never had this before and has had no cardiac stress tests or catheterizations. On exam he looks very comfortable and lung sounds and heart sounds were normal. His EKG shows T wave inversions laterally and labs are pending. I think Mr. Hamm may be having unstable angina and I would like to give him aspirin and admit him to telemetry.

2)Ms. Jackson is a 30 year old female with no PMH who presents with atraumatic lower back pain for 3 days, worse with movement. She denies fevers, chills, weakness, numbness, or incontinence. Her vitals are stable and on exam, she has no bony midline tenderness, a normal rectal exam, and good strength of all of her extremities. I think Ms. Jackson has muscular back pain and I would like to send her home with Tylenol.

Presenting a patient thoroughly but concisely can be tricky and may take some practice. Remember you can always go over the patient with a resident prior to presenting to the attending.

Kathy L. Chuang, MD 2011 (modified by @em_stevemcguire)