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Oral Presentation
The goal of any oral presentation is to pass along the “right amount” of patient
information to a specific audience in an efficient fashion. When done well, this
enables the listener to quickly understand the patient’s issues and generate an
appropriate plan of action. As with any skill, it can be learned, although this takes
time and practice. In addition, the world of medicine presents some additional
challenges, including:
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.
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.
There are a number of common presentation-types, each with its own goals and
formats. These include:
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:
o MRI of the leg, negative for osteomyelitis
o Evaluation by Orthopedics, who I&D’d a superficial abscess in the calf,
draining a moderate amount of pus
PE remarkable for:
o Patient appears well, states leg is feeling better, less painful
o T Max 101 yesterday, T Current 98; Pulse range 60-80; BP 140s-
160s/70-80s; O2 sat 98% Room Air
o Ins/Outs: 3L in (2 L NS, 1 L po)/Out 4L urine
o 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:
o Creatinine .8, down from 1.5 yesterday
o WBC 8.7, down from 14
o Blood cultures from admission still negative
o Gram stain of pus from yesterday’s I&D: + PMNS and GPCs; Culture
pending
o 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:
o 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
o 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
o 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
o 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
o Chief Concern: Mr. H is a 50 year old male with AIDS, on HAART, with
preserved CD4 count and undetectable viral load, who presents for the
evaluation of fever, chills and a cough over the past 7 days.
o HPI: Mr. H has been known to be HIV + since 2000
Until 1 week ago, he had been quite active, walking up to 2 miles
a day without feeling short of breath.
Approximately 1 week ago, he began to feel dyspneic with
moderate activity.
3 days ago, he began to develop subjective fevers and chills along
with a cough productive of red-green sputum.
1 day ago, he was breathless after walking up a single flight of
stairs and spent most of the last 24 hours in bed.
Past HIV history is remarkable for:
Diagnosed with HIV in 2000, done as a screening test when
found to have gonococcal urethritis
Was not treated with HAART at that time due to
concomitant alcohol abuse and non-adherence.
Diagnosed and treated for PJP pneumonia 2006
Diagnosed and treated for CMV retinitis 2007
Became sober in 2008, at which time interested in HAART.
Started on Atripla, a combination pill containing:
Efavirenz, Tonofovir, and Emtricitabine. He’s taken it ever
since, with no adverse effects or issues with adherence.
Receives care thru Dr. Smiley at the University HIV clinic.
CD4 count 3 months ago was 400 and viral load was
undetectable.
He is homosexual though he is currently not sexually
active. He has never used intravenous drugs.
He has no history of asthma, COPD or chronic cardiac or
pulmonary condition. No known liver disease. Hepatitis B and C
negative. His current problem seems different to him then his past
episode of PJP.
o Review of systems: negative for headache, photophobia, stiff neck, focal
weakness, chest pain, abdominal pain, diarrhea, nausea, vomiting,
urinary symptoms, leg swelling, or other complaints.
o Other PMH/PSH:
Hypertension x 5 years, no other known vascular disease
GERD
Gonorrhea as above
Alcohol abuse above and now sober – no known liver disease
No relevant surgeries
o MEDS and Allergies:
Atripla, 1 po qd
Omeprazole 20 mg, 1 PO, qd
Lisinopril 20mg, qd
Naprosyn 250 mg, 1-2, PO, BID PRN
No allergies
o Family History
Both of the patient's parents are alive and well (his mother is 78
and father 80). He has 2 brothers, one 45 and the other 55, who
are also healthy. There is no family history of heart disease or
cancer.
o Social history, habits
Patient works as an accountant for a large firm in San Diego. He
lives alone in an apartment in the city.
Smokes 1 pack of cigarettes per day and has done so for 20 years.
No current alcohol use. Denies any drug use.
o Sexual History as noted above; has sex exclusively with men, last
partner 6 months ago.
o Physical Exam notable for:
Seated on a gurney in the ER, breathing through a face-mask
oxygen delivery system. Breathing was labored and accessory
muscles were in use. Able to speak in brief sentences, limited by
shortness of breath
Vital signs: Temp 102 F, Pulse 90, BP 150/90, Respiratory Rate
26, O2 Sat (on 40% Face Mask) 95%
HEENT: No thrush, No adenopathy
Lungs: Crackles and Bronchial breath sounds noted at right base.
E to A changes present. No wheezing or other abnormal sounds
noted over any other area of the lung. Dullness to percussion was
also appreciated at the right base.
Cardiac: JVP less than 5 cm; Rhythm was regular. Normal S1
and S2. No murmurs or extra heart sounds noted.
Abdomen and Genital exams: normal
Extremities: No clubbing, cyanosis or edema; distal pulses 2+
and equal bilaterally.
Skin: no eruptions noted.
Neurological exam: normal
o Labs and Imaging notable for:
WBC 18 thousand with 10% bands;
Normal Chem 7 and LFTs.
Room air blood gas: pH of 7.47/ PO2 of 55/PCO2 of 30.
Sputum gram stain remarkable for an abundance of polys along
with gram positive diplococci.
CXR remarkable for dense right lower lobe infiltrate without
effusion.
o Assessment and Plan:
Acute community acquired pneumonia: Mr. H is an HIV + male
with preserved CD 4 count and undetectable viral load while on
HAART, who presents with an acute pulmonary process. The
rapid progression, focality of findings on lung exam and chest x-
ray, along with the sputum gram stain suggest a bacterial
infection, in particular Streptococcal Pneumoniae. Other
pathogens to consider include influenza, H Flu and Legionella.
His presentation, compliance with PJP prophylaxis, reasonably
intact immune system and statement that his current illness seems
different then past PJP infection would argue against this as the
etiologic agent. Mycobacterial infection also seems unlikely. Viral
infections and neoplastic processes like CMV or Kaposi's
Sarcoma of the lung do not typically give this clinical presentation
nor should they occur given his level of immune function. In
addition, he received a flu vaccine 2 months ago. The data does
not support the existence of either a primary cardiac or
noninfectious pulmonary process. The current plan for his
pneumonia is as follows:
Continue Ceftriaxone and Azithromycin started in the ED
for acute CAP
Follow up on cultures of sputum and blood; will try to
narrow coverage based on final cultures.
Obtain rapid flu test
Continue Atripla
Continue O2, with goal to keep sats greater then 92%
IV fluid replacement with Normal Saline at 125cc/H for
next 24 hours to correct mild hypovolemia, with plan to
reassess volume status at that time
If patient does not show improvement (or worsens) and
cultures are unrevealing, consider bronchoscopy as a
means of making more definitive diagnosis.
Monitored care unit, with vigilance for clinical
deterioration.
Hypertension: given significant pneumonia and unclear clinical
direction, will hold lisinopril. If BP > 180 and or if clear not
developing sepsis, will consider restarting.
DVT Prophylaxis: immobile and ill, which makes him high risk
Low molecular weight heparin
Code Status: Wishes to be full code full care, including intubation
and ICU stay if necessary. Has good quality of life and hopes to
return to that functional level. Wishes to reconsider if situation
ever becomes hopeless. Older brother Tom is surrogate decision
maker if the patient can’t speak for himself. Tom lives in San
Diego and we have his contact info. He is aware that patient is in
the hospital and plans on visiting later today or tomorrow.
Expected duration of hospitalization unclear – will know more
based on response to treatment over next 24 hours.
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
Reason for visit: Patient is a 67 year old male presenting for first office visit
after admission for STEMI. He was referred by Dr. Goins, his PMD.
HPI:
o The patient initially presented to the ER 4 weeks ago with acute CP that
started 1 hour prior to his coming in. He was found to be in the midst of
a STEMI with ST elevations across the precordial leads.
o Taken urgently to cath, where 95% proximal LAD lesion was stented
o EF preserved by Echo; Peak troponin 10
o In-hospital labs were remarkable for normal cbc, chem; LDL 170, hdl
42, nl lfts
o Uncomplicated hospital course, sent home after 3 days.
ROS:
o Since home, he states that he feels great.
o Denies chest pain, sob, doe, pnd, edema, or other symptoms.
o No symptoms of stroke or TIA.
o No history of leg or calf pain with ambulation.
PMH/PSH:
o Prior to this admission, he had a history of hypertension which was
treated with lisinopril
o 40 pk yr smoking history, quit during hospitalization
o No known prior CAD or vascular disease elsewhere. No known diabetes,
no family history of vascular disease; He thinks his cholesterol was
always “a little high” but doesn’t know the numbers and was never
treated with meds.
o History of depression, well treated with prozac
Meds and Allergies
o Discharge meds included: aspirin, metoprolol 50 bid, lisinopril 10,
atorvastatin 80, Plavix; in addition he takes Prozac for depression
o Taking all of them as directed.
o No allergies
Social/Habits/Other
o Patient lives with his wife; they have 2 grown children who are no
longer at home
o Works as a computer programmer
o Smoking as above
o ETOH: 1 glass of wine w/dinner
o No drug use
Family history
o No known history of cardiovascular disease among 2 siblings or parents.
Physical Exam
o Well appearing; BP 130/80, Pulse 80 regular, 97% sat on Room Air,
weight 175lbs, BMI 32
o Lungs: clear to auscultation
o CV: s1 s2 no s3 s4 murmur
o No carotid bruits
o ABD: no masses
o Ext; no edema; distal pulses 2+
Labs and Imaging of note:
o Cath from 4 weeks ago: R dominant; 95% proximal LAD; 40% Cx.
o EF by TTE 1 day post PCI with mild Anterior Hypokinesis, EF 55%, no
valvular disease, moderate LVH
o Labs of note from the hospital following cath: hgb 14, plt 240; creat 1, k
4.2, lfts normal, glucose 100, LDL 170, HDL 42.
o EKG today: SR at 78; nl intervals; nl axis; normal r wave progression,
no q waves
Assessment/Plan:
1. S/P STEMI: Proximal LAD disease which was appropriately treated
with a stent. No immediate complications and now doing well. No other
critical lesions which require intervention at the moment.
Plan: aspirin 81 indefinitely, Plavix x 1y
Given nitroglycerine sublingual to have at home.
Reviewed symptoms that would indicate another MI and what to
do if occurred
2. Hypertension: now well treated with metoprolol and lisinopril. No
problems with adherence. Blood pressure on target.
Plan: continue with current dosages of meds
Chem 7 today to check k, creatinine
3. Lipids: On high potency statin. No side effects
Plan: Continue atorvastatin 80mg for life
4. Smoking cessation: Doing well since discharge without adjuvant
treatments, aware of supports.
5. Vascular Screening: Known vascular disease and history of smoking
Plan: AAA screening ultrasound