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Professional Standards
Each patient is an opportunity to sharpen your history and exam skills. Ask someone more senior to verify your
findings if youre uncertain. Practice will make you better! Here are some things to remember about professionalism:
Basic Principles
Presentation Tips
An oral case presentation is not a simple recitation of the case write-up; it is a concise, edited presentation of the
most essential information. A case presentation should be memorized as much as possible by third year
rotations. Notes may be utilized during the presentation, but should not be read out loud directly.
Length
Lengths of presentations vary depending on the service. A full medicine presentation in attending rounds should
be under 5 minutes. A presentation in the hallway on medicine walk rounds should take no more than 3
minutes; surgery is often less than 1 or 2 minutes.
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Coherent
Oral presentations should be coherent; they should strive for an organized format and follow a ritual scheme.
Coherent presentations help you to develop an organized clinical thought process and help the listener process the
data.
Concise
Present the pertinent and relevant information; leave out the non-essential information. You will learn this through
experience and feedback. Your write up should be complete and include full details of each of the components of
the medical history and physical exam; however, your case presentations should include only relevant details. You
will gradually learn what is relevant.
To keep the presentation concise, focus on: chronologic history (the patients story only, not your interpretation),
vital signs, general description of the patients clinical appearance, and pertinent physical exam findings. Dont
editorialize. In the first two years of On Doctoring, students find it hard to remember to keep patient history in the
history section and physical exam findings in the physical exam section of the presentation. Try consciously to do
this every time you present a case.
Complete
Your oral presentation should be complete; ask yourself, is any important information missing? Have you
described enough detail of the physical exam based on the chief complaint? For example, in a patient with a rash
did you describe the rash fully? In a patient with left shoulder paindid you examine the left shoulder?
It is really important to get into the habit of starting your physical exam with the vital signs and a general
description of the patient (i.e. does the patient look ill? In distress? Anxious?), the latter is a learned skill and will
come with time and clinical experience.
Compelling
The oral presentation should be compelling; at the end of year two, this means you must: know your patients
history by asking in-depth questions, have confidence in your assessment and plan, be specific with your plan, and
highlight your clinical reasoning process and the rationale for your plan! The assessment is your chance to interpret,
clinically reason and explain why you think the patient has a particular diagnosis, what were the other possibilities
you considered, and why you discarded them. The plan includes your suggestions for diagnostic tests and
treatment.
Basic Structure
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issues only)
The complete ROS should not be presented in oral presentations
Physical examination (pertinent findings only)
One-line summary statement
Assessment and plan
Organization
You want to flesh out the bare bones enough to make your presentation engage and give the listener a feel for the
patient as a person.
Structure
Mr./Mrs./Ms. is a _____ year-old man/woman who (one of the following below):
presents with a chief complaint of _____.
was electively admitted for evaluation of ______ .
comes in to clinic for follow up of _____.
Mr. J is a 55 year old man with a history of heart disease, s/p coronary bypass 2 years ago now presenting with a
6 hour history of substernal chest pain.
Mrs. S is a 77 year old woman with history of diabetes, dementia, congestive heart failure in clinic today with a 2
day history of fever along with swelling and redness of the right lower leg.
Include the race or ethnicity of the patient only if it is relevant and will make your listener weigh diagnostic
possibilities differently. To orient your listener, the identifying information should include the patient's relevant
active medical problems, of which there are usually no more than four. You will list these problems here, by
diagnosis only, and will elaborate on them later in the HPI or other medical problems/PMH. Your small group
facilitator should help you identify which problems are relevant when it is not obvious. Include habits
(tobacco/alcohol/substance use) when relevant.
Good Examples
Mr. Smith is a 65-year-old smoker with a long history of diabetes mellitus, cirrhosis, and chronic obstructive
lung disease, who presents with a chief complaint of fever and productive cough
Jessica is a 9-year-old girl, otherwise healthy, who presents with left leg pain and inability to walk. She was in
her normal state of health until
Mr. Jones is a 58-year-old man whose active problems include coronary artery disease, diabetes mellitus, and
chronic obstructive lung disease
Avoid presentation of distracting information such as an overly detailed discussion of the patient's medical
problems in your introductory remarks, as the presenter does in the next example:
Bad Example
Format for Oral Presentations
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Mr. Jones is a 58-year-old man whose problem list includes coronary artery disease - myocardial infarction x
2, the last in 1996, multiple negative rule-outs since, ejection fraction equaled 35% in 1994; diabetes mellitus x
10 years, insulin requiring for five years, complicated by retinopathy; chronic obstructive lung disease - with
a FEV 1 of 1.2 liters and steroid dependence
In the bad example, the listener will forget the chief complaint by the time the HPI is reached. The good example
is concise and does not interrupt the listener's train of thought between the chief complaint and the HPI.
HPI
Introduction
The HPI is a very important component that should be presented in a chronological story. Define the nature of the
complaint clearly, the duration of symptoms, progression of symptoms, significant treatments (OLDCARTS). Be
interested and get a complete story from the patient.
"Mr./Mrs./Ms. _____ was in his/her usual state of _____ (i.e. excellent health/poor health) until _____ (i.e.
three days prior to admission) when he/she developed the _____ (acute/gradual) onset of _____.
Don't mention that an event occurred "on Saturday"; refer to the time relative to the day of admission; i.e. 3
days prior to admission.
Review of Systems
Mention only significant positives and negatives. DO NOT report out each system review!
Review of systems is positive for occasional nosebleeds and frequent heartburn after meals. He has chronic
longstanding constipation.
Good Examples
Mr. Smith is a 63-year-old former 30 pack/year smoker who has a long history of chronic obstructive lung
disease characterized by two block dyspnea on exertion, FEVI of 1.0 liter, and home oxygen therapy. He was in
this usual state of health until three days prior to admission when he developed the gradual worsening of his
shortness of breath, associated with a cough productive of yellow sputum and a fever of 102.
Tommy is a 5-year-old boy who has a history of congenital heart disease due to tetralogy of fallot s/p reparative
surgery in 2007. He was in his usual state of health, until the weekend prior to admission he began having
dizziness, and the night of admission, he developed syncope while getting ready for bed.
PMH
Give a brief summary of the current ongoing issues (diabetes, HTN, etc.), major past illnesses, surgeries, current
medications, and allergies. Specifically characterize the major presenting symptoms, including patient attributions
(what the patient thinks is causing the symptoms), any prior episodes, and complications and the relevant ROS
questions. Relevant ROS include those related to the major and adjacent organ systems, constitutional complaints such
as fever and weight loss and epidemiological risk factors or exposures. If there were any evaluation of the chief
complaint prior to hospital admission, such evaluation should be included though it should be presented in a
summarized fashion (e.g. One week ago, John was seen by his primary provider for his cough and was diagnosed
with pneumonia and prescribed amoxicillin).
Use the OLDCARTS mnemonic to make sure all those bases are covered.
Format for Oral Presentations
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Bad Example (poorly characterized and too brief of an HPI)
Mr. Brown is an 83-year-old man admitted for evaluation of chest pain. He was well until three weeks prior to
admission when he began to feel chest heaviness whenever he exerted himself. He saw his local doctor who
prescribed antacids with little benefit. The pain woke him last night so he came into the emergency room for
evaluation. His other problems include
Good Examples
The past medical history is significant for hyptertension and diabetes. He is s/p appendectomy and inguinal
herniorraphy. Medications include metformin, lisinopril, and glyburide. He has no allergies.
Mr. Brown is a 33-year-old current intranasal cocaine user, admitted for evaluation of chest pain. He was in
his usual state of excellent health until 1 day prior to admission when he developed a second episode of
sudden onset of chest pain, characterized as a sharp, radiating to his left shoulder, lasting several hours.
The pain was aggravated by exertion and relieved by rest. Associated with the pain were shortness of breath
and nausea. One week prior to admission he was seen in the emergency from for a similar episode of pain and
without other testing was diagnosed w ith gastritis and prescribed antacids without benefit. There was no
history of cough, heartburn, weight loss, fever, chills, or sweats. (Relevant ROS) The patient has no known
risk factors for coronary artery disease. He has no history of high blood pressure, hyperlipidemia, or
diabetes, and has never smoked cigarettes. He has no known FH of early coronary heart disease. (Pertinent risk
factors for coronary artery disease and pertinent FH/PMH). He has been using intranasal cocaine for the past 3
years, several times a week. Last use was an hour prior to the onset of his chest pain. He does not use any other
drugs, nor does he inject cocaine (pertinent habits).
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to you at your level of training and also improves with your clinical experience. Consultation with your
facilitator and preceptor will help you make this determination; i.e. "gonorrhea in 1945, malaria in 1940,
cataract extraction in 1972, and tinea pedis" are probably not relevant during presentation of a patient with
diabetes for his/her new onset chest pain.
Know all of the patient's problems and include them in your write-up, but presentation of problems that are not
relevant to the currently active problems only distracts your listener.
Medications/Allergies
Provide a list of all prescribed medications and a list of any relevant non-prescription medications. Report any
relevant drug allergies and the type of reaction.
Example
"The patient developed a skin rash approximately 20 years ago after receiving penicillin and carries
the diagnosis of penicillin allergy."
Habits
Habits (tobacco/alcohol/substance use) when not mentioned in the HPI (for example in a patient who presents with a
urinary tract infection) should always be presented here as these issues are always important to address in the
assessment and plan. Any opportunity to counsel for cessation of these habits must be taken when a patient presents for
a medical encounter.
Good Example
The patient is a retired welder. He is married and has 2 grown children. He has never used tobacco. He enjoys
1-2 beers on weekends only.
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Physical Exam
General description: describe the clinical appearance of the patient; be descriptive, allowing the listener to visualize
the patient. "The patient was short of breath" is inferior to "the patient was sitting on the edge of the bed, leaning
forward with his hands on his knees, breathing with difficulty."
Vital signs should always be mentioned, including postural changes if relevant. Mention only the relevant positive
findings and relevant negative findings going from head to toe direction ending with the neurological exam. An
example of the latter includes in, for example, the dyspneic patient: "the exam is remarkable for clear lungs
bilaterally." Use concise but complete descriptions of positive findings.
Summary Statement
The Summary Statement is an important component of both your oral presentation and your write up. It is a short, crisp
paragraph that summarizes the key findings in the history and physical exam using descriptors reviewed during the
clinical reasoning session in spring of Year 1. These descriptors are important because with practice they help you and
the listeners come up with a distinctly different set or different likelihoods of differential diagnoses.
Example
33 year old current intranasal cocaine user with recurrent sharp chest pain aggravated by exertion, relieved by
rest, and associated with shortness of breath (SOB) and nausea. He has no prior h/o hypertension (HTN),
hyperlipidemia, diabetes, smoking or FH of early coronary artery disease (CAD). His exam was notable for
elevated blood pressure, tachycardia, diaphoresis and a perforated bleeding intranasal septum.
In this case, the fact that he used intranasal cocaine and that his pain was sharp and recurrent, that he had no FH of
early coronary disease or usual risk factors for coronary artery disease, and that he had a perforated bleeding nasal
septum, would make one think of cocaine induced coronary vasoconstriction rather than primary atherosclerotic
disease as the leading diagnoses. This does not mean you do not have to think of coronary artery disease in your
differential, only that you would not think of it as the most likely diagnosis.
Plan
The plan should include both diagnostics (tests you want to order) and therapeutics (your treatment suggestions).
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Examples
"The patient's major presenting problem is chest pain (avoid statements like rule-out myocardial
infarction). The differential diagnosis includes cocaine induced vasospasm, pericarditis, or early onset
coronary artery disease (CAD). The diagnosis of cocaine induced vasosconstriction appears to be the most
likely of these because _____.
"The patient's main problem of acute chest pain, could be due to a myocardial infarction, a dissecting
aortic aneurysm, pericarditis, and a variety of other diagnoses such as pneumonia, pulmonary embolus, or
esophageal disease. MI seems most likely because his description of chest pain is classic for angina and
because his ECG reveals a new injury current in the inferior leads.
Common Mistakes
Things to Avoid
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better than "the patient's problem is rule-out pneumonia."
Repetition
Vary your sentence structure. An overly repetitious presentation is monotonous for the listener. "On pulmonary
exam, the lungs were normal. On cardiac exam, the heart sounds were ____. On lymph node exam, there were
no cervical nodesetc." is difficult to listen to and unnecessary; your listener knows that S1 and S2 are part of
the cardiac exam! Use brief descriptive sentences: "an S3 gallop was heard at the left lower sternal border."
Disorganization
This problem is a result of lack of rehearsal. Stopping at the end of the HPI to say, "Oh, I can't believe I forgot to
tell you this" will kill a presentation. Or "in summary, this patient, wait, I forgot to tell you the most
important thing" You need to be aware that disorganization can happen even with careful preparation. The
best advice when you forget something crucial to your presentation is to work it in as soon as possible and don't
make it a big deal.
Source: Adapted in part from University of Washington School of Medicine thanks to Dr. Steve McGee and parts modified from
Dr. Richard Simons Oral Case Presentations PowerPoint.
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