Presentation Tips

General Guideline

Example

Present your child to the team by giving the patient name, age, gender and chief complaint or working diagnosis / reason for being in the hospital

"Juan Medina is a seven year old boy who presented with a chief complaint of difficulty breathing."

Provide subjective data about the patient's current status, including any events that have occurred since the last time the team rounded

"He had an uneventful night and says he's breathing a little easier this morning, but he still has some retractions. He doesn't complain of any further fever or rhinorrhea."

Provide objective data, including temperature (maximum and current), current blood pressure, heart rate, respirations, and ins and outs.

"He was afebrile overnight with a Tmax and current temp of 98.6. BP is 90/60, pulse is 90, respirations 28. Intake was 1.5 liters (750 IV, 750 po) and output was 500 cc's urine."

Describe findings from your most recent physical exam.

"Physical exam notable for retractions, an inspiratory:expiratory ratio of 1:2, with scattered wheezes on auscultation just before his neb treatment. Heart was regular rate and rhythm no murmurs rubs or gallops. Abdomen benign. The rest of his exam is benign, unchanged from admission."

Describe any recent labs

"His only lab from yesterday was an aminophylline level of 16.4."

Assess the patient by problems and provide treatment plans for each, explaining your rationale for any change.

Alternatively, your resident may prefer assessment by organ system. Clarify with your resident on the first day.

"So by problems:

Reactive Airways -- he continues on Proventil nebs q4 hours, the aminophylline drip at 1.0 mg/kg/hr and day 2 of IV solumedrol at 1.0 mg/kg q6h with some improvement.

Plan is to continue the current regimen since he's still somewhat uncomfortable. He's taking good pos, so I'd like to d/c the aminophylline drip and switch to po at 20 mg/kg/day divided q8 and then recheck the blood level to make sure it hasn't drifted up or down. If he deteriorates I'm not sure what to add, as he's already on a beta agonist, an anti-inflammatory and a phosphodiesterase inhibitor to cover both the early and late phase of asthma. I'll check him again at noon. If his exam continues to improve, we can heplock the IV an switch him to po steroids.

URI-- he defervesced yesterday afternoon. That with his rhinorrhea and lymphocytosis on initial CBC suggest a viral URI. Plan is to follow his temperature curve and treat the fever symptomatically if it recurs.

Disposition -- I also plan to contact his regular provider to discuss long term follow-up.