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Introduction Breast Exam Write Ups
History of Present Illness The Pelvic Examination The Oral Presentation
The Rest of the History Male Genital/Rectal Exam Outpatient Clinics
Review of Systems The Upper Extremities Inpatient Medicine
Vital Signs The Lower Extremities Clinical Decision Making
The Eye Exam Musculo-Skeletal Exam Physical Exam Lecture Series
Head and Neck Exam The Mental Status Exam A Few Thoughts
The Lung Exam The Neurological Exam Commonly Used Abbreviations
Cardiovascular Exam Physical Exam Check Lists References
Exam of the Abdomen Medical Links
The "daVinci Anatomy Icon" denotes a link to related gross anatomy pictures.
Daily Presentations During The New Patient The Holdover Admission Outpatient Clinic
Work Rounds Presentation Presentation Presentations
The structure of presentations varies from service to service (e.g. medicine vs. surgery), amongst
subspecialties, and between environments (inpatient vs. outpatient). Applying the correct style to the right
setting requires that the presenter seek guidance from the listeners at the outset.
Time available for presenting is rather short, which makes the experience more stressful.
Individual supervisors (residents, faculty) often have their own (sometimes quirky) preferences regarding
presentation styles, adding another layer of variability that the presenter has to manage.
Students are evaluated/judged on the way in which they present, with faculty using this as one way of
gauging a student’s clinical knowledge.
Done well, presentations promote efficient, excellent care. Done poorly, they promote tedium, low morale,
and inefficiency.
General Tips:
Practice, Practice, Practice! Do this on your own, with colleagues, and/or with anyone who will listen (and
offer helpful commentary) before you actually present in front of other clinicians. Speaking "on-the-fly" is
difficult, as rapidly organizing and delivering information in a clear and concise fashion is not a naturally
occurring skill.
Immediately following your presentations, seek feedback from your listeners. Ask for specifics about what
was done well and what could have been done better – always with an eye towards gaining information
that you can apply to improve your performance the next time.
Listen to presentations that are done well – ask yourself, “Why was it good?” Then try to incorporate
those elements into your own presentations.
Listen to presentations that go poorly – identify the specific things that made it ineffective and avoid those
pitfalls when you present.
Effective presentations require that you have thought through the case beforehand and understand the
rationale for your conclusions and plan. This, in turn, requires that you have a good grasp of physiology,
pathology, clinical reasoning and decision-making - pushing you to read, pay attention, and in general
acquire more knowledge.
Think about the clinical situation in which you are presenting so that you can provide a summary that is
consistent with the expectations of your audience. Work rounds, for example, are clearly different from
conferences and therefore mandate a different style of presentation.
Presentations are the way in which we tell medical stories to one another. When you present, ask yourself
if you’ve described the story in an accurate way. Will the listener be able to “see” the patient the same way
that you do? Can they come to the correct conclusions? If not, re-calibrate.
It's O.K. to use notes, though the oral presentation should not simply be reduced to reading the admission
note – rather, it requires appropriate editing/shortening.
In general, try to give your presentations on a particular service using the same order and style for each
patient, every day. Following a specific format makes it easier for the listener to follow, as they know
what’s coming and when they can expect to hear particular information. Additionally, following a
standardized approach makes it easier for you to stay organized, develop a rhythm, and lessens the chance
that you’ll omit elements.
Key elements of each presentation type are described below. Examples of how these would be applied to most
situations are provided in italics. The formats are typical of presentations done for internal medicine services and
clinics.
Note that there is an acceptable range of how oral presentations can be delivered. Ultimately, your goal is to tell
the correct story, in a reasonable amount of time, so that the right care can be delivered. Nuances in the order of
presentation, what to include, what to omit, etc. are relatively small points. Don’t let the pursuit of these
elements distract you or create undue anxiety.
Duration:
Opening one liner: Describe who the patient is, number of days in hospital, and their main clinical
issue(s).
24-hour events: Highlighting changes in clinical status, procedures, consults, etc.
Subjective sense from the patient about how they’re feeling, vital signs (ranges), and key physical exam
findings (highlighting changes)
Relevant labs (highlighting changes) and imaging
Assessment and Plan: Presented by problem or organ systems(s), using as many or few as are relevant.
Early on, it’s helpful to go through the main categories in your head as a way of making sure that you’re
not missing any relevant areas. The broad organ system categories include (presented here head-to-toe):
Neurological; Psychiatric; Cardiovascular; Pulmonary; Gastrointestinal; Renal/Genitourinary;
Hematologic/Oncologic; Endocrine/Metabolic; Infectious; Tubes/lines/drains; Disposition.
Opening one liner:This is Mr. Smith, a 65 year old man, Hospital Day #3, being treated for right leg
cellulitis
Events of the past 24 hours:
MRI of the leg, negative for osteomyelitis
Evaluation by Orthopedics, who I&D’d a superficial abscess in the calf, draining a moderate
amount of pus
PE remarkable for:
Patient appears well, states leg is feeling better, less painful
T Max 101 yesterday, T Current 98; Pulse range 60-80; BP 140s-160s/70-80s; O2 sat 98% Room
Air
Ins/Outs: 3L in (2 L NS, 1 L po)/Out 4L urine
Right lower extremity redness now limited to calf, well within inked lines – improved compared
with yesterday; bandage removed from the I&D site, and base had small amount of purulence; No
evidence of fluctuance or undrained infection.
Labs and imaging remarkable for:
Creatinine .8, down from 1.5 yesterday
WBC 8.7, down from 14
Blood cultures from admission still negative
Gram stain of pus from yesterday’s I&D: + PMNS and GPCs; Culture pending
MRI lower extremity as noted above – negative for osteomyelitis
Assessment and Plan
This is a 65 yo male, hospital day 3, being treated for lower extremity cellulitis and abscess. Issues are as
follows:
Cellulitis complicated by abscess, which has now been adequately drained. Exam improved and
feels better. Likely organism is Staph, covering for MRSA until cultures back
Continue Vancomycin for today
Ortho to reassess I&D site, though looks good
Follow-up on cultures: if MRSA, will transition to PO Doxycycline; if MSSA, will use PO
Dicloxacillin
Hypertension: When admitted, outpatient anti-hypertensive medications held as blood pressure was
low due to sepsis. Now BP is climbing back to hypertensive range. No symptoms
Given AKI, will continue to hold ace-inhibitor; will likely wait until outpatient follow-up to
restart
Add back amlodipine 5mg/d today
Renal: Now back to baseline kidney function, which is normal. On admission AKI due to sepsis. All
improved as expected with control of infection. Appears euvolemic
Hep lock IV as no need for more IVF
Continue to hold ace-I as above
Disposition: Anticipate d/c tomorrow on po antibiotics – pending final culture results as above to
determine best oral med.
Wound care teaching with RNs today – wife capable and willing to assist. She’ll be in this
afternoon.
Set up follow-up with PMD to reassess wound and cellulitis within 1 week
Typically, the discussion also includes appropriate prophylactic considerations (e.g. DVT
prevention), code status and disposition.
Example of a Hold Over Admission Presentation
Chief concern: 70 yo male who presented with 10 days of progressive shoulder pain, followed by
confusion. He was brought in by his daughter, who felt that her father was no longer able to safely
take care for himself.
HPI:
10 days ago, Mr. X developed left shoulder pain, first noted a few days after lifting heavy
boxes. He denies falls or direct injury to the shoulder.
1 week ago, presented to outside hospital ER for evaluation of left shoulder pain. Records
from there were notable for his being afebrile with stable vitals. Exam notable for focal pain
anteriorly on palpation, but no obvious deformity. Right shoulder had normal range of
motion. Left shoulder reported as diminished range of motion but not otherwise quantified. X-
ray negative. Labs remarkable for wbc 8, creat 2.2 (stable). Impression was that the pain was
of musculoskeletal origin. Patient was provided with Percocet and told to see PMD in f/u
Brought to our ER last night by his daughter. Pain in shoulder worse. Also noted to be
confused and unable to care for self. Lives alone in the country, home in disarray, no food.
At baseline, patient is fully functional and able to care for himself. He has no cognitive issues.
The history is largely provided by the daughter, as patient is confused about his symptoms and the
order in which they developed.
ROS: negative for falls, prior joint or musculoskeletal problems, fevers, chills, cough, sob, chest
pain, head ache, abdominal pain, urinary or bowel symptoms, substance abuse
Relevant PMH/PSH:
Hypertension
Coronary artery disease, s/p LAD stent for angina 3 y ago, no symptoms since. Normal EF by
echo 2 y ago
Chronic kidney disease stage 3 with creatinine 1.8; felt to be secondary to atherosclerosis and
hypertension
Depression
MEDS and Allergies:
aspirin 81mg qd, atorvastatin 80mg po qd, amlodipine 10 po qd, Prozac 20
Allergies: none
Family and Social: lives alone in a rural area of the county, in contact with children every month or
so. Retired several years ago from work as truck driver. Otherwise non-contributory.
Habits: denies alcohol or other drug use.
Physical Exam in Emergency Department
Temp 98 Pulse 110 BP 100/70
Drowsy though arousable; oriented to year but not day or date; knows he’s at a hospital for
evaluation of shoulder pain, but doesn’t know the name of the hospital or city
CV: regular rate and rhythm; normal s1 and s2; no murmurs or extra heart sounds.
Lungs: CTA
Left shoulder with generalized swelling, warmth and darker coloration compared with Right;
generalized pain on palpation, very limited passive or active range of motion in all directions
due to pain. Right shoulder appearance and exam normal.
Labs and imaging in Emergency Department
CXR: normal
EKG: sr 100; nl intervals, no acute changes
WBC 13; hemoglobin 14
Na 134, k 4.6; creat 2.8 (1.8 baseline 4 m ago); bicarb 24
LFTs and UA normal
Assessment and plan in the Emergency Department and by overnight team.
Acute shoulder pain and systemic symptoms concerning for septic shoulder
Vancomycin and Zosyn for now
Orthopedics to see asap to aspirate shoulder for definitive diagnosis
If aspiration is consistent with infection, will need to go to Operating Room for wash
out.
AKI: From poor oral intake and sepsis. Given 3L NS in ER, with positive response in terms of
heart rate and BP. Also, urine output now ~50 cc/h.
IVF with NS at 125cc/h
Urine electrolytes
Follow-up on creatinine and obtain renal ultrasound if not improved
Renal dosing of meds
Strict Ins and Outs.
Confusion: Delirium from infection. Baseline cognitive function is reportedly normal.
will approach infection as above
follow exam
obtain additional input from family to assure baseline is, in fact, normal
Over night events/response to treatments.
Since admission (6 hours) no change in shoulder pain
This morning, pleasant, easily distracted; knows he’s in the hospital, but not date or year
Key morning exam findings
T Current 101F Pulse 100 BP 140/80
Ins and Outs: IVF Normal Saline 3L/Urine output 1.5 liters
L shoulder with obvious swelling and warmth compared with right; no skin breaks; pain
limits any active or passive range of motion to less than 10 degrees in all directions
Key morning labs
Labs this morning remarkable for WBC 10 (from 13), creatinine 2 (down from 2.8)
Assessment and Plan:
Agree with assessment of over night admitting team, which is sepsis with source of infection
based in the left shoulder.
Plan:
Continue with Vancomycin and Zosyn for now
I already paged Orthopedics this morning, who are en route for aspiration of
shoulder, fluid for gram stain, cell count, culture
If aspirate consistent with infection, then likely to the OR
Renal: AKI due to hypovolemia and sepsis. Now appears volume replete
Continue IVF at 125/h, follow I/O
Repeat creatinine later today
Not on any nephrotoxins, meds renaly dosed
Delirium: related to infection as above
Continue antibiotics, evaluation for primary source as above
Discuss with family this morning to establish baseline; possible may have underlying
dementia as well
Prophylaxis:
SC Heparin for DVT prophylaxis
Code status: full code/full care.
Outpatient-based presentations
There are 4 main types of visits that commonly occur in an outpatient continuity clinic environment, each of
which has its own presentation style and purpose. These include the following, each described in detail below.
1. The patient who is presenting for their first visit to a primary care clinic and is entirely new to the
physician.
2. The patient who is returning to primary care for a scheduled follow-up visit.
3. The patient who is presenting with an acute problem to a primary care clinic
4. The specialty clinic evaluation (new or follow-up)
It’s worth noting that Primary care clinics (Internal Medicine, Family Medicine and Pediatrics) typically take
responsibility for covering all of the patient’s issues, though the amount of energy focused on any one topic will
depend on the time available, acuity, symptoms, and whether that issue is also followed by a specialty clinic.
Duration
8-10 min
Duration
5-7 min
Reason for the visit: Follow-up for whatever the patient’s main issues are, as well as stating when the last
visit occurred
*Note: There may well not be a “chief complaint,” as patients followed in continuity at any clinic may
simply be returning for a visit as directed by their doctor.
Events since the last visit: This might include emergency room visits, input from other
clinicians/specialists, changes in medications, new symptoms, etc.
Review of Systems (ROS): Depth depends on patient’s risk factors and known illnesses. If the patient has
diabetes, then a vascular ROS would be done. On the other hand, if the patient is young and healthy, the
ROS could be rather cursory.
PMH, PSH, Social, Family, Habits are all OMITTED. This is because these facts are already known to
the listener and actionable aspects have presumably been added to the problem list (presented at the end).
That said, these elements can be restated if the patient has a new symptom or issue related to a historical
problem has emerged.
MEDS: A good idea to review these at every visit.
Physical exam: Vital signs and pertinent findings (or absence there of) are mentioned.
Lab and Imaging: The reason why these were done should be mentioned and any key findings
mentioned, highlighting changes from baseline.
Assessment and Plan: This is most clearly done by individually stating all of the conditions/problems
that are being addressed (e.g. hypertension, hypothyroidism, depression, etc.) followed by their specific
plan(s). If a new or acute issue was identified during the visit, the diagnostic and therapeutic plan for that
concern should be described.
Accurately review the historical events that lead the patient to make the appointment.
Identification of risk factors and/or other underlying medical conditions that might affect the diagnostic or
therapeutic approach to the new symptom or concern.
Generate an appropriate assessment and plan
Allow the listener to comment
Duration
5 min
Duration
5-7 minutes