5-Minute New Patient Oral Presentation

PCP: Note name of PCP and whether or not they are in regular care

ID/ Chief Complaint: include age, gender, language (if not English) and geographic ancestry, as well as what led the patient to seek medical attention. Identify whether the patient has decision-making capacity and if not who the decision-maker is.

History Of Present Illness: Includes all details pertinent to patient’s presenting complaint, including pertinent ROS, relevant PMH and any ancillary information obtained from family/eyewitnesses/nursing home staff.

Past Medical History: List most relevant history first, including both past medical/surgical/psych history. Include chart review and details of significant past studies. For Peds include birth/ immunizations/ developmental history. For Ob-Gyn include pregnancies, birth hx. For primary care include health care maintenance (immunizations, cancer screening, cholesterol).

Medicines: Complete list and dosing of patient’s current outpatient medications including OTC drugs and supplements. Use generic names of drugs.

Social: Include tobacco/alcohol/drug use, home situation, previous/current employment. Include sexual history, work exposures, and travel history when relevant

Family: Pertinent or unusual family history, particularly those with a genetic basis
ROS: Any complaints that were not included in HPI.

Exam: Include vitals (may include ER + Floor findings for hospitalized patients if significant differences noted) and a general description of patient’s appearance. Initial exam should be comprehensive, but presentation should include only pertinent positives/negatives.

Labs/Studies: Significant positives/negatives from both blood work and diagnostic imaging. Include past labs if helpful to follow trends.

Assessment/Plan: Briefly Summarize case, touching on pertinent points from chief complaint/HPI/past/ social history, significant physical and diagnostic findings. Then, outline what you think is going on to explain the above, Narrowing your differential to the 2-3 most likely diagnoses. Analyze the differential by comparing and contrasting the possibilities- using key features of the problem and evidence. Describe your Plan for management including treatments or further diagnostic work-up. After the chief complaint/problem has been dealt with, then address other issues in order of importance.

Questions: Probe the attending/ resident by asking questions about uncertainties or difficulties. Be prepared to answer questions from other team members, including multidisciplinary members (PCP, RN, Case Manager, Pharmacist, etc)

Select: Choose a case-related issue for your self-study and be prepared to discuss what you learned the following day.

5- Minute Follow-Up Presentation

Events: Report any clinical events over past 24 hours-include procedures, key new test results, and input from consult services, SW, PT/OT. Talk to the patient, nurses and cross-cover intern. Review chart for orders/ notes from cross-cover and consultants/ ancillary services.

Status of Previous Symptoms/ New Symptoms: Update on previous symptoms and new symptoms over the last 24 hours.

Vital Signs: Report trends as well as current values for T, P, BP, RR, SaO2 I&O: Report totals as well as relevant breakdown for both intake and output. Report weight and trends in net fluid balance over preceding days.

Physical Exam: State important new physical findings, and status of previous findings. Give level of invasion (Foley, IV, ETT, etc.) and number of days for each. Be prepared to defend the appliances and to make the case that no iatrogenic complication has occurred (infection, thrombosis, pneumoTx, etc).

Medication List: Run the generic drug list daily (taken from MAR) to avoid inappropriate dosing and reduce polypharmacy as soon as possible. Are doses and intervals appropriate for renal/hepatic function? If it takes too long to run the drug list, the drug list is probably too long.

New Lab/Imaging Results: Report new lab data including status of crucial lab tests (i.e. collected but not run yet). If a lab is not important enough to report, it probably was not important enough to get.

Assessment and Plan: Summarize the patient’s medical problems and then present a prioritized problem focused discussion of the major issues. The diagnostic aspect of the problem should be stated first including a Narrowed differential diagnosis if relevant, Analysis of what you think is going on and why, followed by the diagnostic and treatment Plan. Disposition must be included as a problem, as well as any relevant social, discharge, follow-up and end-of-life care issues. Multi-disciplinary Input (RN, Pharmacist, etc.) should be included in all relevant aspects of the assessment and plan.

Patient Involvement/Education: Does the patient and/or family understand and agree (Informed Consent)?

Questions: Probe the attending/ resident for any additional information that you require to help fill in the blanks and address your learning needs. Plan to answer questions other team members have.

Select: Choose a case-related issue for your self-study and be prepared to discuss what you learned the following day.

Click here for a pdf form of the New Patient Presentation and the Follow-up Presentation

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