How To Present Your Case In The ED

how to present your case in the ED

As a medical student, presenting history and physical exam of a patient to the attending can be nerve-wracking. In the ED, physicians typically prefer an even more succinct presentation than usual, ideally less than 3 min. Case presentations are a great opportunity to show that you understand what the pertinent positives and negatives for the patient’s presenting complaint are and that you can summarize a large amount of information collected in an organized manner. Case presentations are your opportunity to impress your preceptor, so it is an important skill to master. It will also be the mode of communicating with the rest of the healthcare team throughout your career in medicine. Better communication = better patient care!

Ask

Before we get started, it is important to recognize that every physician may have their own preference for how they would like case presentations organized. Some prefer more details, and some prefer a specific order. Therefore, it is always a smart idea to ask your preceptor at the beginning of your ED shift if they have a preference for how they like cases to be presented.

The One Liner

State the patient’s name, age, sex, chief complaint, and any pertinent medical history. E.g., John Doe is a 16-year-old male with a history of eczema presenting with wheezing.

History of Presenting Illness (HPI)

include the details of the chief complaint, as well as any pertinent positives and negatives.
  1. Why did this patient present to the ED today?
  2. What are the details of the chief complaint? I.e. Onset, Duration, Progression, Alleviating and Aggravating Factors, Causes/Triggers, Changes with Position, etc.
    • For pain, it is helpful to describe OPQRSTU – Onset, Position, Quality, Radiation, Severity, Temporal, déjà vU (has it ever happened before).
  3. Any associated symptoms
  4. Any risk factors?
    • Any relevant past medical history (e.g. chronic conditions, hospitalizations, surgeries, etc.), family history, or social history (e.g. habits, living situation, alcohol consumption, smoking history, illicit drug usage)?

Review of Systems

Describe any other symptoms here.

  • Note that some ED physicians may not want a review of systems included in the oral case presentation if it does not include any additional pertinent information, but a review of systems should always be included in your written patient note. 

Medications

Allergies

if the patient states that they do not have any allergies, this can be recorded and/or stated as “NKDA” which stands for No Known Drug Allergies.

Physical Exam Findings

  1. Start off by stating the most updated set of vitals.
  2. Next, state the patient’s general appearance as this helps decide between sick vs. not sick. E.g., patient is alert, oriented, and in no apparent respiratory distress.
  3. Then, delve into the pertinent details of the physical exam. E.g. for a cardiac complaint, it is important to include the specific details of the cardiovascular exam and respiratory exam, but not of all the other systems.
  4. A brief overview of the other systems that a physical exam was conducted for can be useful, but be as concise as possible, and organize information in a head-to-toe fashion if needed. If there were no other findings, you can state that the remainder of the physical exam was unremarkable. 

Summary

In 2-3 sentences, gather the main findings of your history and physical exam. Be sure to restate the initial one-liner sentence, other pertinent positives and negatives, and any important test results so far.

Impression/Assessment

State your differential diagnosis for each problem.

  • Start off by stating what you think the most likely diagnosis is, and why you think it is the most likely.
  • Then, state any other likely diagnoses you are suspecting.
  • Lastly, state the deadly diagnoses that could be possible with this patient’s chief complaint. In some cases, this can be the first thing you may want to say. It is important to specify why you do or do not feel confident in ruling these out. E.g., in a baby presenting with fever of unknown origin, it is important to state why you are not (or are) suspecting meningitis, encephalitis, malignancy, or autoimmune conditions.
  • Many medical students will shy away from stating their impression of what could be going on in terms of differential diagnosis, but this is an important thing to attempt. Preceptors will appreciate your effort in synthesizing what could be going on and be impressed by it, even if your impression is incorrect. This is often what sets apart students that “meet expectations” vs. students that are considered “outstanding”.

Plan

What do you want to do next?

  • Plan includes anything from the tests you want to order (including repeat vitals, bloodwork, and imaging), immediate treatment (including analgesics and fluids), and referrals you want to make (including consults, admission/discharge plan, and referral to allied health professionals such as social work, speech-language pathology, occupational therapy, and physiotherapy).  
  • Do not forget to take the patient’s social history into account when deciding what to do next.

Congrats – you have now completed your oral case presentation! This is a skill you will continue to develop with practice, so do not worry and keep working at it. It is also a good idea to always ask your preceptor for feedback on your case presentation once it is complete, as that will help you identify your strengths and weaknesses.

References and Further Reading

Cite this article as: Sheza Qayyum, Canada, "How To Present Your Case In The ED," in International Emergency Medicine Education Project, December 7, 2020, https://iem-student.org/2020/12/07/how-to-present-your-case-in-the-ed/, date accessed: December 3, 2022

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As face masks become ubiquitous in our health-care practice due to the COVID-19 pandemic, communication between the patient and health-care provider has become harder than ever before. The challenges posed by COVID-19 have highlighted various areas of deficiencies in the health care industry as well as heightened anxiety among health-care providers as well as patients. Communication with patients has become particularly challenging and ever so more important than before.

Imagine the plight of a patient struggling to breathe, being greeted by someone in full PPE, struggling to understand your muffled speech through the mask amidst the background noise of oxygen hissing through a breathing mask. Earlier, your smile would have worked to ease some of the anxiety by coming across as approachable and friendly; however, your face mask has cost you a brave soldier in your battle of gaining trust. The situation is worse in the elderly, frail, and cognitively impaired patients who may rely on lip-reading and facial expressions to communicate.

Health care workers are forced to have difficult conversations of do-not-resuscitate orders, advance care planning, and break bad news while wearing a face mask and PPE, creating a barrier for effective communication with patients and their family members.

If you have previously relied on a firm handshake and a smile to lessen the anxiety of patients but are now finding it challenging to have clear communication, here are few ways to improve communication with patients.

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Cite this article as: Neha Hudlikar, UAE, "Unmasking communication during COVID-19," in International Emergency Medicine Education Project, August 10, 2020, https://iem-student.org/2020/08/10/unmasking-communication-during-covid-19/, date accessed: December 3, 2022

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The emergency room constantly presents challenges, and physicians always have to act with urgency. Patients, on the other hand, fear diagnoses they will hear, being unprepared to deal with the consequences, let alone mustering the strength to inform their loved ones. In this chaotic and busy environment of the emergency department, healthcare professionals often overlook a core value: to facilitate healing beyond medicine.

Physicians strive to express compassion when faced with life and death matters, but doctors are human too! They suffer from many emotions their patients go through, sometimes more than their hearts can contain. On top of that, they are expected to provide care continuously, so they may reach a threshold where dying patients and crying family members seem to not affect them. The danger is physicians’ becoming “machines” lacking human emotions, consideration or care.

The importance of not losing our humanity cannot be overemphasized. Physicians are not only healthcare providers but they are leaders and health advocates. When conventional medicine fails to provide treatment, physicians have a responsibility to assure patients that they will be with them every step of the way. We are responsible for our patients’ lives from the day we take care of them. Let’s not mistake this for disregarding patient autonomy. Patients are entitled to decide for themselves, but a caring practitioner -one that listens and engages in conversation- will make the difference. Our responsibility is to make patients feel empowered. We can make a clinical difference by touching our patients beyond the physical.

Physicians must expand their perspective to see beyond emergency medicine. Conventional medicine has taught us to observe the patient for signs and symptoms but deemphasized patients’ expressions, feelings, ambitions, and dreams. Why should we see patients from just one lens? Medical students, physicians, and other healthcare professionals in the emergency department should remind themselves of perceiving a more subjective but meaningful aspect of patient care, which lies beyond the physical. True healing requires a multidisciplinary effort, including familial, environmental, and socio-economical aspects of care.

Social aspects of medicine play a crucial role and should never be neglected. Our utmost responsibility is to foster solidarity, peace, and humaneness in this world. Compassion must be the center of our every action as we concentrate on understanding the patient as a human, rather than the diseases. Physicians that mind the interconnections between medicine, emotions, and humans, make a difference.

Cite this article as: Leah Sarah Peer, Canada, "A Lens Beyond Emergency Medicine," in International Emergency Medicine Education Project, April 10, 2020, https://iem-student.org/2020/04/10/a-lens-beyond-emergency-medicine/, date accessed: December 3, 2022