How to present a case to a preceptor

[frozenarbitor]

What is a good way to present a patient case to a preceptor during clerkship? Any insight from clerks or resident or staffs would be very helpful. Thanks!

Here's a good article on this subject, any additional thoughts?

http://www.medaholic.com/clerkship-pearls-how-to-present-a-patient-case-effectively/

[Jochi1543]

I'd say start with a 1-2-sentence summary, e.g. "This is a 56-yo quadriplegic male with a history of recurrent sacral ulcers who presented with spinal osteomyelitis 1 week ago. Since then, he has developed bacteremia and acute kidney injury with a creatinine of 800." Mention significant investigations, e.g. "Blood culture grew coagulase-negative staph; urinalysis was clear" and the current meds - focus on the relevant ones. E.g., in this scenario, it'd be important to say he's on IV Cloxacillin q6h for 2 days now with the tentative end date of January 20th, but the fact that he's on ASA and Senokot can probably be omitted.

 

By this point, you will likely have been interrupted approximately 37608765 times, but on the odd chance you haven't, relish it and present a plan, e.g.

"Issues and plan: 1) acute kidney injury - dialyze 2) bacteremia - continue with Clox, repeat blood culture in 3 days 3) osteomyelitis - bone scan, consult ortho/spine for debridement."

[Renin]

I would also start with whether or not the patient is stable, especially if you're presenting on call.

 

Depending on your level, the staff may also want to know from the start whether or not you want to admit the patient (if it's a consult).

[medaholic]

Thanks for the mention OP.

 

It all depends on what rotation you're on and who you're presenting to. Knowing your audience and how they want it done, is 90% of giving a good presentation.

 

For example - Surgery should be brief, succinct, action oriented.

- 26 year old man, RLQ pain for 6 hrs, likely appendicitis, confirmed on CT, started antibiotics and needs to go to OR

 

Psychiatry - social hx and mental status exam are key. Always ending with axis diagnosis and plan.

 

OBGYN - LMP - bleeding, cramps, etc, previous pregnancies, sexual history are very important.

 

Speaking now from a resident's perspective - I think the part medical students can improve on is 1) being thorough with their history/physical or 2) including only relevant info in their presentation.

 

Too many times I've seen medical students miss pertinent details, and then go on and on about irrelevant details. Ideally, you should know everything you can about your patient but you don't have to present everything, only what's important.

[rogerroger]

Thanks for the mention OP.

 

It all depends on what rotation you're on and who you're presenting to. Knowing your audience and how they want it done, is 90% of giving a good presentation.

 

For example - Surgery should be brief, succinct, action oriented.

- 26 year old man, RLQ pain for 6 hrs, likely appendicitis, confirmed on CT, started antibiotics and needs to go to OR

 

Psychiatry - social hx and mental status exam are key. Always ending with axis diagnosis and plan.

 

OBGYN - LMP - bleeding, cramps, etc, previous pregnancies, sexual history are very important.

 

Speaking now from a resident's perspective - I think the part medical students can improve on is 1) being thorough with their history/physical or 2) including only relevant info in their presentation.

 

Too many times I've seen medical students miss pertinent details, and then go on and on about irrelevant details. Ideally, you should know everything you can about your patient but you don't have to present everything, only what's important.

 

 

 

This is good advice.

 

I also suggest paying close attention to the way junior residents present their cases to staff. The style will vary depending on the service, but these presentation will give you a snap shot of what you should aim for.

 

I would not try to emulate the senior residents. They have already well proven to staff long ago that they know what the positives and negatives are. Many will have presentations which are very succinct and brief and that as a clerk you would never get away with.

[medaholic]

Found two other posts that related more to Emerg Med

 

http://academiclifeinem.blogspot.ca/2012/08/the-3-minute-em-student-presentation.html

 

http://academiclifeinem.blogspot.ca/2012/11/the-secret-to-patient-presentations.html

[frozenarbitor]

Thanks guys! Good to see you on the forum, medaholic! Your blog has been very helpful.

[Satsuma]

My suggestion is to start with your diagnosis (I know as a clerk you may not be sure, but at least you can show you have thought about what it likely is) and then go one with relevant PMhx, and PE findings.

 

So, for example, "A 58 yo F presents with CHF, PMHx significant for MI, HTN, DM and a 40 pack year hx of smoking. She c/o SOB x 3 days with increased swelling in both her legs, no fever, etc. On exam VSS (say what they are), mild increased WOB, reduced AE both bases with diffuse crackles etc. My plan is blah blah blah".

 

When you present within a framework of a diagnosis it is much easier for the person you are reviewing with. Especially since as clerks you are likely to collect a non-focuses (or less focused) history then the person you are reviewing with would have. So if you start of with their hx/PE it is harder to follow than if you start off with what you think the dx is. Thinking of the dx beforehand also helps you focus on pertinent negatives and pertinent positives.

[Lactic Folly]

Just be sure to consider all the data and multiple possibilities before settling on that diagnosis, to avoid confirmation bias...

[frozenarbitor]

Just be sure to consider all the data and multiple possibilities before settling on that diagnosis, to avoid confirmation bias...

 

Very true. Being through and consider as many DDx as possible is definitely important. Uncertainty is a big part of clinical medicine.

[NLengr]

Very true. Being through and consider as many DDx as possible is definitely important. Uncertainty is a big part of clinical medicine.

 

Just be sure you say something like:

The most likely diagnosis is X. Other possibilities include: A,B,C,D....

 

Nothing is worse than hearing all the zebras before getting to the horses.

[frozenarbitor]

Just be sure you say something like:

The most likely diagnosis is X. Other possibilities include: A,B,C,D....

 

Nothing is worse than hearing all the zebras before getting to the horses.

 

Good point. Common things are common.