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Presentation Skills and Pocket Cheat Sheet - Appendix 4

Presentation Skills and Pocket Cheat Sheet

How to Present a Patient to your Attending Physician or Team Members

Appendix #4:

New Patient H&P or Hospital Admit or New Consult

  • Pt identification/intro: “Pt is a 62 y/o white male alcoholic who presents with acute abdominal pain.
  • CC + HPI: OLD CARPS. Onset, location, duration, character, aggravating, relieving, temporal (pert pos/neg), severity
  • “T” in carts is amplified for pertinent positives and negatives from the hx + medical records review + ROS
  • MASH: Medications, Allergies, Surgeries, Hospital Admissions/Major Medical Diagnoses
  • FISH; Family Hx. Immunizations and Preventative (Females ask LMP/contraception/GPAL; children ask development).
  • Social (HEEADSSS as approp). Habits (Drugs/Tob/ETOH).
  • ROS, as pertinent (some were asked in #3 above). There are a maximum of 14 systems
  • Vital Signs, followed by Physical Exam
  • LABS.  Imaging Studies. Consultation opinions/procedures
  • Assessments, by number (= problems + DDx + supportive logic). Keep them numbered the same every day.
  • Plan. Each individual assessment gets an individual plan.

Daily Hospital Rounds

  • Pt ID/intro: “Pt is a 62 y/o white male with the following problem list: (example: pancreatitis, acute alcohol withdrawal syndrome, HTN, guaiac + stool, Leukocytosis, elevated transaminases, elevated lipase.
  • Brief summation of prior days, with current hx of the past 24 hours.
  • Pertinent positives and negatives of the hx, but only if pertinent (Able to pass gas, No chills or SOB)
  • ROS only as pertinent (generally done with pert+ and Pert-)
  • Vital Signs, followed by Physical Exam
  • New Labs, imaging, and consultation opinions/procedures, contrasting values with old data
  • Assessment (=problems list + DDx + supportive logic)
  • Plan. You will list your plan after each individual assessment.

Clinic Visit of an existing patient

  • Pt ID and chief complaint (CC)
  • OLD CARPS
  • Pertinent pos and neg (the “P” = “T” in OLD CARTS), which = pertinent ROS!
  • MASH only if it adds to the presentation
  • FISH only if it adds to the presentation
  • VS, Physical Exam, directed to the complaint and appropriate regions
  • Assessment of the CC, with DDx and supportive logic. Add other A’s only if pertinent or active
  • Plan for the CC. Add other P’s for other pertinent A’s.

These 3 styles of presentation depend upon the situation: new patient, existing hospital patient on daily rounds, or an outpatient follow-up visit. These are summarized in chart form below. At the very bottom is a summarized summary, suitable for laminating, folding, and putting into your pocket. You will find it makes you look like an honors student on rounds.

Element of Presentation

New Patient H&P

BRIEF EXAMPLE

Hosp Round, not new

Clinic, not new

Pt Ident

62 y/o cauc male

Same

Same

Chief Complaint & HPI (OLD CARPS),

P =pert+ and pert-

Abd pain x 1 week, worse c…

Problem List + CC +

Interval Hx

CC + HPI (OLDCARPS). Problem List if pertinent

Don’t forget: Pert+, Pert- from HPI and old medical records

Hematemesis, wt loss, nausea

Only if pertinent

Only if pertinent

MASH: Meds, Allergy, Surg, Hospital admissions & major medical problems

ASA 81mg,,old appy, pancreatitis x 3

Only Meds

Only as Pertinent

F: Fam Hx

I: +/- Gyn, GPAL, LMP, Iz, BC/Estrg, +/- peds Birth, Devel, Iz’s, Mammo/Colon

S: +/- psych (HEADSS)  

H: drugs/cigs/ETOH

Parents a/well. No job x 3 yrs, Recent MVA. 6 beers /day, no drugs, +2ppd x 30yrs.

Only as pertinent

Only as pertinent

ROS: 12 systems

+migraine, COPD, HTN, 25 lb wt loss, tingling toes. No melena

Only as pertinent

Only as pertinent

VS + PE

T=37, 120/80, 80, 14. Alert, oriented, …

Same

Same

Labs + Imaging + Consults

Hg10, was 12. Lipase = 1100. Abd u/s = +ascites, nl liver

New labs, imaging studies, and consults, compare as pertinent

New labs, imaging studies, and consults, compare as pertinent

Assess (problem list)

Pancreatits, UGI bleed, anemia, ascites, alcoholism at risk for withdrawal sx

Same

Same

Plan

Serial lipase, Ca++, Hg, CMP. Thiamine (banana bag) IV. Ativan PO q6, GI consult for EGD, I/O’s, NPO, IV NS @ 150/hr x XX hours

Same

Same

Hospital H & P Hospital Rounds Clinic Rounds
  1. Pt Intro +/- problems
  2. HPI
  3. Pert+ Pert-
  4. MASH
  5. FISH
  6. ROS
  7. VS, PE
  8. Labs/Radiol/Consults
  9. Assessments, in order
  10. Plans (orders) for each Assessment
    MASH = Meds, Allergies, Surgeries, Hospitalizations/other med problems
  1. Pt Intro + active problems
  2. Brief Sum of new events
  3. Pert+, Pert-
  4. Meds
  5. VS + PE
  6. New Labs, Imaging, Consults  
  7. Assessment of each problem
  8. Plan (orders) for ea prob
    FISH=Fam, Iz’s/prev, Soc, Habits
  1. Pt Intro + CC
  2. OLD CARPS
  3. MASH, if pertinent
  4. FISH, if pertinent
  5. VS + PE
  6. Assess of the presenting complaint(s)
  7. Plan for each active problem encountered