Resident Handbook

Inpatient Services Presentations for rounds

Outline of expected format of presentations on rounds

A. New Patient Presentations

New patient presentations will follow a formal and classical structure best epitomized by the weekly Clinico-Pathological Conference (CPC) of the New England Journal of Medicine.

1) Chief complaint/reason for admission:

2) History of present illness:

3) Past medical History:

4) Past surgical history:

5) Medications:

6) Family history:

7) Social history:

8) Physical examination:

• Vital signs

• General medical examination – appearance, pulses, heart, lungs, abdomen, skin, extremities

• Neurological examination –

  • Mental status

  • Cranial nerves

  • Motor

  • Sensory

  • Reflexes

  • Coordination

  • Gait

9) Laboratory data:

10) Imaging:

11) Other diagnostic studies:

12) Summary Statement:

13) Differential diagnosis:

14) Plan of care using systems-based approach:

15) In-Person evaluation:

16) DIDACTIC DISCUSSION:

B. Existing Patient Presentations

1) Chief complaint/reason for admission:

2) Overnight course:

3) Current status:

4) Systems-based assessment: including daily plan of care and disposition

5) In-Person evaluation:

6) Communication:

Detailed explanation and examples of presentation content

A. New Patient Presentations

1. Chief complaint/reason for admission:

• This should be succinct and if PMH is included, it should only be features that are salient to the presentation.

“This is a 67 year old man who presents with 2 days of headache and lethargy.”

OR

“This is a 67 year old man with a history of hypertension, who presents with 2 days of headache and lethargy.”

OR

“This is a 67 year old man with a history of seizures, who presents with 3 witnessed generalized tonic-clonic seizures and was admitted for evaluation and treatment of status epilepticus.”

NOT:

“This is a 67 year old man with a history of hypertension, BPH, chronic low back pain, gout, appendectomy 35 years ago, … who woke with a headache one week ago, then developed fever 3 days ago, then had a possible seizure, then ...”

2. History of present illness:

• PLEASE DO NOT SAY THE PATIENT WAS A POOR HISTORIAN. YOU ARE THE HISTORIAN, THE PATIENT IS THE HISTORY.

• Describe the salient attributes of the Chief complaint.

“Mr. Jones reported the sudden onset of headaches 2 days prior to admission. These were described by the patient as left sided, in the back of his head, and continuous in nature. They did not respond to over-the-counter medications, and were associated with nausea but no vomiting. He has felt lethargic and fatigued for the past 24 hours prior to admission. He has never had headaches like these previously.”

• Then, provide salient positives or negatives to the HPI:

“There were no associated neurological symptoms such as weakness, change in sensation, change in vision, or change in balance. He denies a stiff neck. He denies disorientation or confusion.”

• Other important pertinent positives might include – recent trauma, work exposure, recent antecedent illness.

3. Past medical History:

“The past medical history is remarkable for hypertension, depression, gout, and alcohol abuse.”

4. Past surgical history:

“The past surgical history is remarkable for a knee replacement in 2013 and excision of a basal cell skin cancer in 2014.”

5. Medications:

• Please report name of medication and correct dosage

• You should know the reason/diagnosis for each medication on the list. If you are not familiar with a medication, you are expected to have looked it up.

“His current medications include…”

6. Family history:

• Please disclose salient history of primary relatives (parents, sibs, children).

• If a genetic disease is suspected, at least 2 generations should be sought.

7. Social history:

• Education

• Work/employment (remember, a stay-at-home Mom or Dad, “works”, so consider asking “do you work outside the home?”),

• Alcohol/illicit drug use

• Tobacco in pack years

• Baseline functional status : “Lives with his daughter, baseline mRS 3”

8. Physical examination:

• Give vital signs and pertinent general exam features. Documentation should describe complete exam findings. For Presentation: if other body systems are normal, that can be noted without further detail.

• Neurologic exam: Details of exam and findings should be given in order.

  • Mental status

  • Cranial nerves

  • Motor

  • Sensory

  • Reflexes

  • Coordination

  • Gait

9. Laboratory data:

• Salient labs including complete metabolic profile, CBC, coags, ins/outs, urine output.

• If a patient has an LP, it is expected that ALL known results will be presented.

• Lab results are not to be looked up on rounds, but instead known by presenter.

10. Imaging:

• Images are to be viewed and collectively evaluated as a team.

• It is expected that presenter has already viewed the images, and both knows the preliminary/final radiology report as well as having formulated their own interpretation.

11. Other diagnostic studies:

• These are not to be looked up on rounds, but instead known by presenter.

• EEG – if a patient has been placed on continuous EEG, it is expected that a preliminary read should be known and presented.

12. Summary Statement:

• This should not be a complete restatement of the HPI, but should summarize the salient features of the history, exam, and other data.

“In summary, this is a 67 year old male with a history of hypertension, who presents with 2 days of headache and lethargy, found to have a mass lesion in the posterior fossa.”

13. Differential diagnosis: A focused differential diagnosis should be detailed by the presenter including:

• Explanation of the clinical symptoms (i.e., ischemia, seizure, increased intracranial pressure)

• Explanation of the etiopathogenesis (i.e., stroke, intracerebral hemorrhage, tumor).

• Presenter explains how the symptoms, clinical signs, and objective data support the most likely differential diagnostic choice.

14. Plan of care using systems-based or problem-based approach as appropriate:

• Neurological - The plan for the patient’s neurological care, both immediate and over the course of the hospital stay, should be articulated: diagnostic testing, monitoring, therapy, communication, and disposition.

• Then, the plan for other non-neurological problems should be similarly articulated.

• Other elements that should be included:

  • Recovery/Rehabilitation – should start at time of admission

  • Discharge Planning – should start at time of admission

  • Communication – phone or in-person with family or advocates for patient should be planned

  • Code status

15. In-Person evaluation:

The Team will greet the patient in person, and a focused exam observed by the attending will be performed by the resident or the medical students

16. DIDACTIC DISCUSSION:

The attending physician should take time out to discuss the differential diagnosis, recent or current literature, historical context for the case, current research into the disease area, and new or standard-of-care therapeutic approaches. These didactic discussions should not be “pimp sessions”, lectures, or “data dumps”, but should engage the team and create an environment of inquiry.

B. Existing Patient Presentations

1. Chief complaint/reason for admission:

“This is Mr. Jones, our 67 year old male admitted 2 days ago for evaluation of headache and lethargy.”

2. Overnight course:

• Patient’s R.N. should be present to report the overnight course including problems, changes in condition, and other salient issues.

• The R.N. should be acknowledged and thanked, and included into the discussion of the daily plan-of-care.

3. Current status:

“This morning, Mr. Jones feels better with minimal headache. He is afebrile and his vital signs are stable”

4. New results:

• Radiology, labs, other. These should be known by the presenter, not looked up on rounds.

5. Systems-based or Problem-based assessment:

• Neurological:

“Mr. Jones was seen by neurosurgery who felt that biopsy of the posterior fossa mass was indicated. This is planned for tomorrow and he will be pre-oped tonight by neurosurgery. He understands the plan as well as possible risks. He is receiving acetaminophen for pain with good control.”

• Other systems/problems

• Other elements that should be included:

  • Recovery/Rehabilitation

  • Discharge Planning

  • Communication – phone or in-person with family or advocates for patient should be planned

Last Updated: June 14, 2019