A Guide to Patient Presentations in the Emergency Department
One of the most fundamental skills to have in a hectic emergency department is to be able to concisely relay information. Many emergency physicians are self-selected to have short attention spans. The ED patient presentation is unique in the house of medicine for its brevity, as well as its ability to convey information about the patient.
ED patient presentations can also convey a lot about the learner. The presentation is a synthesis of the questions the learner thought were important to ask, the disease processes considered by the learner, the learner’s ability to make decisions, and much more. It will be one of the primary ways a learner is assessed. Thus, it is imperative to master this skill. Mastery turns learners from simple information hunter-gatherers to information interpreters.
EMRA and CDEM produced a video about patient presentations based on Davenport’s “The 3-Minute Emergency Medicine Medical Student Presentation: A Variation on a Theme.” This article will expand on that theme as well as give my experience and tips/tricks I have learned.
Different attending physicians have different styles, and it is important to tailor your presentations to each. Use this general outline as a starting point for everyone:
- The Title: A one-liner stating if they're sick or not sick and why they are here
- The Journey: The story of what you think they have and why they don’t have anything else (your history of present illness and relevant past history)
- The Buildup: Your focused exam
- The Climax: Your differential diagnoses - common, life-threatening, zebras
- The Conclusion/Epilogue: What are you going to do for the patient?
This is your chance to set the scene and hook the listener. A good title makes the listener want to hear your story and prepares them for what’s coming. Use all of the information available about the patient to make the most important clinical decision - sick or not sick. Saying “This is Mr. X in bed 5. He is a well-appearing 50-year-old male with a history of alcohol coming in for abdominal pain” sets the tone and prepares the listener for what you think the patient has. For patients with multiple complaints, you can say they have multiple complaints but focus first on the medically acute complaint or the one the patient is most worried about. Only include past medical/surgical/social history if it is relevant to the complaint and if it will color the rest of your narrative.
This is the meat of the presentation, when you will convince your listeners that yours is the correct answer. The key here is to direct the story toward the final diagnosis by pruning diagnoses via pertinent positives and negatives. Beware not to blindly insert your entire review of systems, but only include decision points that change your diagnosis or management. For the previously mentioned patient with abdominal pain, I would not include ear pain but must include findings regarding to stooling, peripheral neuropathy, nausea, and vomiting. This is not to say I did not ask the patient about everything; rather, as an information interpreter, I filtered out extraneous information and only presented the relevant points. The history is reserved only for subjective things your patient or their family tells you.
This is where many attending physicians’ preferences will diverge. Some will want every system addressed at least in passing, whereas others will only want the pertinent findings. In my experience, I erred on the side of addressing each system (eg, "heart and lungs normal") with a focus on the system in question and then tailored subsequent presentations. One thing to always address first is any gross vital sign abnormalities.
This section is also where you can shine as a learner. Bedside ultrasound skills are one of the most important things for a learner to pick up during emergency medicine rotations, and being able to corroborate your exam finding with sonographic findings demonstrates initiative and technical skill.
In listing your differential, you should also include reasons why it is on your list, and then in the next section, address how you will investigate this diagnosis. In considering diagnoses, include not only likely diagnoses but also diagnoses that are life- or limb-threatening and why these are not applicable to the patient. As emergency medicine providers, we assume each and every person is dying and try to convince ourselves and each other why that is not the case. Here one shines by including clinical decisions tools such as the PERC criteria and Wells score for PE or the HEART score for chest pain.
This is your conclusion for the story. This is also where I made the most mistakes and where I learned the most. Here be sure to explain why you are ordering one test versus another. For radiological studies, the American College of Radiology has succinct guidelines for what study to order with or without contrast for each diagnosis. Before ordering any study, it is important to consider whether the results of this study will change your management of the patient and what results you EXPECT from the study.
The final section is the epilogue, and here you posit the disposition of the patient. Describe if you expect the patient to go home or be admitted if the workup is negative and who, if anyone, do we need to call for backup for this patient.
During this process, you WILL be interrupted, at least once. That is okay. The presentation is a means to start a conversation between you and your listener. The art of patient presentations will never come easy initially, and the best practice is to keep practicing. For the first few times, it may be helpful to write the outline above to organize your thoughts before presenting orally. It is always acceptable to ask for a couple of minutes to gather your thoughts - unless, of course, the patient needs emergent intervention. (In that case, you should ask for help before beginning a presentation.)
As one progresses, the goal should be to develop illness scripts. These scripts are specific for each chief complaint and built upon seeing so many patients with that chief complaint. Then, every new patient becomes a variation on the theme and each presentation becomes memorizing these distinguishing features instead of each individual detail.
Remember, this is now your patient, and your care of them does not end with the presentation. Follow up with your patient, their nurse, and the attending, and include everyone in management changes. Your care of the patient does not end until they leave the ED.
A final piece of advice is to be confident in your ability to tell a story. Do that and you will shine in the ED.