What is the best way to present a patient?

From the Guidelines

The best way to present a patient is to use a structured format that includes pertinent information while remaining concise, as recommended by the most recent and highest quality study 1. When presenting a patient, it is essential to prioritize relevant information over exhaustive details, maintain a logical flow, and adjust the presentation length based on the clinical context and audience. The presentation should begin with a brief one-liner that summarizes the patient's demographics, chief complaint, and most relevant history, followed by a systematic presentation covering:

• Subjective information, including history of present illness, past medical history, medications, allergies, social history, and family history
• Objective data, including vital signs, physical exam findings, laboratory results, and imaging studies
• Assessment, including differential diagnosis and most likely diagnosis
• Plan, including diagnostic workup, treatment recommendations, and follow-up It is also crucial to communicate effectively with the patient, providing education and information about their condition and management options, as suggested by 1. Additionally, clinicians should engage in behaviors that actively foster trust, confidence, and collaboration, and provide information that is timely and oriented to the patient's concerns and preferences, as recommended by 1 and 1. By following this structured approach and prioritizing effective communication, clinicians can ensure that they communicate all essential information efficiently, demonstrate clinical reasoning skills, and facilitate appropriate decision-making for patient care. Some key strategies for effective communication include:
• Avoiding unnecessary delays in providing information
• Communicating with consultants and others involved in the patient's care to provide coherent recommendations and information
• Using simple language tailored to the patient's educational level
• Avoiding jargon and explaining medical terminology in lay language
• Providing information in small doses and checking for comprehension
• Assuring the patient that they are available to answer questions in the future, as suggested by 1 and 1.

From the Research

Presenting a Patient

To present a patient effectively, several key elements should be considered:

• The chief complaint is a crucial part of the medical history, as noted in 2, where it was observed that house officers and medical students often failed to include this essential information in their presentations.
• A focused medical history can be achieved by using a chief complaint-directed differential diagnosis, as proposed in 3, which suggests that this approach can help teach clinical expertise and improve diagnostic ability in student physicians.
• When presenting a patient, it is also important to consider the patient's information needs, as discussed in 4, which highlights the challenges of keeping up with new medical findings and developments, and proposes a method for automatically formulating patient-related information needs.

Key Components of a Patient Presentation

Some key components to include when presenting a patient are:

• Chief complaint: as emphasized in 2 and 3, this is a critical part of the medical history.
• Relevant medical history: including any previous illnesses, allergies, or medications, as well as any relevant family history.
• Current symptoms and treatment: including any current medications, therapies, or interventions, as well as any recent test results or medical procedures.
• Patient demographics and personal medical information: as discussed in 5, this can include information such as age, sex, medical history, and current health status.

Assessing Patient Condition

When assessing a patient's condition, it is also important to consider other factors, such as:

• Oxygen saturation levels: as discussed in 6, oxygen saturation can be a reliable screening test for predicting respiratory failure in patients with acute asthma.
• Other vital signs: including heart rate, blood pressure, and temperature, which can provide important clues about the patient's overall condition.