Oral Presentation Guidelines  Assessment

 “Framing statement”  If Dx unknown: 2-3 item DDx; most likely,

  Chief concern / ID / “One Liner” reasoning
o “This is a 60 year old F with a history of (up to 3 relevant  If Dx known: assess if better, worse, same
things) who presents [from where? If relevant] with  Plan:
shortness of breath, admitted for CHF exacerbation”  Workup (for each item on DDx)
 Treatment plan
 HPI (include relevant ROS, PMHx, etc. here) o “Problem #2 - _______”
o Baseline / USOH – describe status of PMH items from CC o For problems, remember social issues, functional
o Now: pt was in this state until ___ ago, when they developed status, dispo
____ The follow-up presentation:
1. 8-10 word “headline” – reminder of who the patient is
  Past History (or one-liner)
o PMHx / PSurgHx 2. Problem list
 List new items; give state / severity (last FEV1, uses 2L a. “Problem #1: _______”
O2 for COPD) i. Overnight events / updates
 For writeup; list previously mentioned items w/o ii. Current PE
description too iii. Assessment / Plan
o Meds (doses, indications, etc) b. “Problem #2: _______”
o Allergies / Intolerance (describe rxn)
o FamHx The Interview, Clinical Reasoning, DDx
o SocHx – incl. functional status (ADLs / IADLs) and  Start by getting a “full” list of concerns
cognitive status
 Frame the situation – what’s important
 ROS (relevant)
 Keep a running DDx / questions to ask / PE exam
maneuvers to do
  “Physical Exam”
o VITAMIN C
o Vital Signs (with ranges as needed)
o Most common
o General Appearance – give a good descriptive picture of
o Worst-case scenario
the patient
o Rest of exam by system
VITAMIN C:
 Labs / Data: CBC, BMP CMP, LFTs, U/A, micro,  Imaging
(simple  complex)  Vascular
o Group related (e.g. WBC & diff, Hbg / MCV, Na/Cl/bicarb & AG  Infection
 Trauma
  “Assessment / Plan”  Autoimmune
o Summary: CC + “p/w SOB, found to have (hx, PE, Data),  Metabolic / Medications
admitted…”  Idiopathic
o “Problem #1 - _______”  Neoplastic
 Subjective / Objective – brief summary to set  Congenital
up for…