Presenting a Patient Already Admitted to the Hospital
Presentations are the abridged versions of your notes. They outline your understanding of the patient’s case and your management plan. The difficulty in mastering presentations is that every listener has a preferred style of presenting and has expectations for presentations. This article describes the basic structure I recommend medical students follow when they are just beginning their clinical rotations.
You typically present or “round on” a patient who is already admitted to the hospital. For these patients, presentations are organized like a “SOAP” or progress note for the patient. SOAP stands for the four main components of the presentation: Subjective, Objective, Assessment, and Plan. We will focus on SOAP presentations as these are more common on the hospital wards. In a separate article, we will discuss presentations for newly admitted patients.
The two main things to consider with any presentation:
1. Your audience
Other team members, including the attending, may not know the patient well, depending on how long they have been on service. I encourage you to ask senior team members to clarify their presentation expectations. Some may want you to add additional details and briefly summarize the patient’s hospital course.
2. The setting in which you are presenting
The structure of rounds themselves is chosen by senior team members. You may present in the workroom (known as table rounds), outside the patient’s room with a mobile computer workstation, or even at the patient’s bedside. The information you will have available is limited in the latter two scenarios. If you know you will not be able to read off your own computer, prepare by writing out data ahead of time.
I recommend a presentation organization as follows:
1. Start with a one-liner
With every presentation, I recommend you should start with the one-liner for the patient. The one-liner orients the listener to the patient you are talking about. It can be the traditional one-liner: “Mr. ZZZ is a ##-year-old man with [insert list of relevant past medical conditions] who presented with [chief complaint].” The one-liner can also be as simple as “Ms. ZZZ is the woman who presented with [chief complaint].” The goal is for the listener to have a broader overview of who the patient is so that they can frame what they listen for in the rest of the presentation.
2. 24-hour events
Briefly state the important parts of the action plan from the prior day. Started a new medication, underwent a procedure, developed a complication, had a family meeting, etc. Try to mention the relevant changes, not every change, so that the listener can understand the trajectory of the patient’s care.
3. Subjective
Describe how the patient is feeling – are they experiencing the same symptoms they initially presented with or have those symptoms resolved? Have they developed new or worsening symptoms? The key is to ask the patient about all the symptoms but present only the ones that are relevant for their hospital stay and the important positives and negatives on review of symptoms. There is no need to list symptoms the patient isn’t experiencing.
4. Objective
This section includes the patient’s vitals, physical exam, labs, imaging, and other studies. I recommend clarifying the expectations for this section due to the sheer volume that you may have to state. Some may want you to say every piece of information (the full physical exam, all lab values, medications), and some may want you only to say the pertinent exam findings and the relevant lab values. As you get further in your training, you should mention data that serve as evidence that support or rule out different diagnoses for the patient’s presentation.
5. Assessment
This is your interpretation of the patient’s case based on the information you just presented. It is like the one-liner, but rather than restating the chief complaint, mention the key elements of the subjective and objective to support a possible diagnosis (i.e., Pt XYZ w/PMHx 1,2,3 who presented with dyspnea, productive cough, fever, leukocytosis and consolidation on chest x-ray most concerning for pneumonia). If the patient has already been diagnosed, no need to rehash their presentation and instead, briefly describe the management (i.e., Pt XYZ w/PMHx 1,2,3 who presented with pneumonia, currently being treated with IV antibiotics). Take time to form a thoughtful assessment because this part shows the listeners your ability to synthesize the information from the case into a diagnosis.
6. Plan
The plan details your management plan for each medical issue. There are two types of plans: the focused problem-based plan and the more comprehensive organization by body system. There are advantages and disadvantages to both. Ultimately, specialties and teams tend toward one or the other, so they should let you know which organization to use but remember to ask if they don’t specify.
The problem-based plan is composed of the symptoms or medical diagnoses compiled as a prioritized list of active and/or relevant issues. For the above example, this could include problems such as “dyspnea,” “acute hypoxic respiratory failure,” “pneumonia,” and “COPD.” You do not have to mention all the chronic medical issues in your oral presentation, though you should write about them in your progress note.
For systems-based, the easiest approach is head to toe. This list does not include all possible systems, because as you can imagine, there are conditions that overlap between sections. The advantage of systems-based is being thorough in addressing all the patient’s medical issues.
Neurological/Psychiatric (i.e., pain, analgesia, sedation, encephalopathy or altered mental status)
Cardiovascular (i.e., shock, pressors, acute coronary syndrome/elevated troponin, heart failure)
Respiratory (i.e., respiratory failure, ventilation, COPD, pneumonia)
Gastroenterology (i.e., GI bleeding, hepatitis, cirrhosis)
Genitourinary/Renal (i.e., fluids/electrolytes, acid-base problems, acute kidney injury)
Infectious disease (i.e., active or chronic infections)
Hematology/Oncology (i.e., anemia, thrombocytopenia, coagulopathies, thrombosis/VTE)
Endocrine (i.e., diabetes, adrenal insufficiency, thyroid dysfunction)
The presentation format of the plan is similar regardless of organization style. If the problem is an undifferentiated sign or symptom, start with brief summary of the signs and symptoms. Then describe a differential: the diagnosis and the supporting information for your leading diagnosis and include why you reject other diagnoses if relevant. Follow with your management plan: what studies do you want to get to further characterize the issue (specific physical exam maneuvers, labs, imaging) and what interventions do you want in the meantime (start new medications, procedures, consults, continue home medications)? Chronic and non-contributory medical issues do not always need to be expanded upon.
The following is an example for an undifferentiated problem:
#Dyspnea
The patient initially developed with subacute cough, congestion, then presented acute dyspnea, leukocytosis and consolidation on CXR. Acute dyspnea most likely due to bacterial pneumonia based on infectious signs and symptoms as well as imaging findings. Viral pharyngitis is also possible given the infectious signs and symptoms. Unlikely ACS/MI as troponin was negative, EKG did not show changes c/w ischemia. PE also less likely given no hypoxia, tachycardia, hypotension but this cannot be ruled out without definitive imaging. Also cannot rule out a lung malignancy particularly given significant reported weight loss and consolidation on CXR.
Dx (Diagnostics)
- Respiratory culture
- Respiratory viral panel to evaluate for viral URI
- CTPA to rule out PE
Tx (therapeutics)
- Decongestants, cough syrup, and oxygen (O2) supplementation as needed (PRN)
- Albuterol nebulizer q2hrs PRN
- Empiric CTX for CAP (community-acquired PNA)
When you begin to present patients, it is easy to feel intimidated. If you struggle in the beginning, do not be discouraged! You will hone your presentations throughout your training and with time, you will feel more comfortable. Good luck!