What is the best approach to present a patient's case during rounds, considering their age, sex, chief complaint, history of present illness, past medical history, and relevant laboratory results?

How to Present a Case During Rounds

Begin with a one-sentence opening that includes the patient's age, sex, and chief complaint, followed immediately by a structured presentation covering history of present illness, past medical history, physical examination findings, and relevant laboratory results. 1

Opening Statement Structure

• Start with: "[Age]-year-old [sex] presenting with [chief complaint]" 1, 2
• The chief complaint must be stated in the patient's own words when possible, as this is frequently omitted but critical for framing the presentation 2
• Include relevant demographic information such as ethnicity/race if pertinent to the differential diagnosis 1

History of Present Illness

• Present the chronology of symptoms systematically: onset, location, quality, severity, duration, context, and modifying factors 1
• Document pertinent negatives to demonstrate thoroughness - explicitly state what symptoms are absent that would support alternative diagnoses 1
• For acute presentations like chest pain, include associated symptoms: dyspnea, nausea/vomiting, diaphoresis, and radiation patterns 3, 4
• Avoid gender assumptions in language - use neutral terms like "partner" or "spouse" rather than "wife" or "husband" 3

Past Medical History

• List active medical conditions with disease-specific details when relevant (e.g., for chronic conditions, include date of diagnosis and current disease control) 1
• Include prior surgeries and their dates, particularly recent procedures that may impact current presentation 3
• Document all medications: prescription drugs with names, dosages, and frequencies, plus over-the-counter medications, supplements, and herbal remedies 1
• State medication allergies and specific adverse reactions 1

Social and Family History

• Document substance use: tobacco (pack-years), alcohol (drinks per week), and recreational drugs 1
• Include occupation and relevant environmental exposures 1
• For family history, focus on first-degree relatives with conditions relevant to the presentation, particularly early coronary disease and hereditary conditions 1

Physical Examination

• Begin with vital signs: temperature, heart rate, blood pressure, respiratory rate, and oxygen saturation 3
• Present findings in anatomical order: general appearance, HEENT, cardiovascular, respiratory, abdominal, extremities, neurologic 1
• For cardiac presentations, specifically note: jugular venous pressure, heart sounds, presence/absence of murmurs or gallops, peripheral pulses, and edema 3
• Include pertinent negatives in the physical exam (e.g., "lungs clear to auscultation, no wheezes or crackles") 1

Laboratory and Diagnostic Results

• Present results in logical groupings: complete blood count, basic metabolic panel, cardiac biomarkers, imaging studies 3
• For ECG findings, systematically describe: rate, rhythm, axis, intervals, ST-segment changes, T-wave abnormalities 3
• Highlight abnormal values and their clinical significance rather than listing all normal values 3

Assessment and Plan

• State your working diagnosis or differential diagnosis with supporting evidence from the presentation 3
• Outline the management plan organized by problem or system 3
• For surgical cases, include: type of intervention, rationale for choosing this approach, anticipated complications, and postoperative care requirements 3

Critical Pitfalls to Avoid

• Never assume gender identity matches appearance - use the patient's stated name and pronouns, which should be documented before the presentation begins 3
• Do not dismiss atypical presentations in women and elderly patients - women present more frequently with atypical symptoms like jaw pain, shoulder pain, or epigastric discomfort rather than classic chest pain for acute coronary syndrome 4, 5
• Avoid using the patient's legal name if it differs from their affirmed name - this "dead naming" creates distress and undermines trust 3
• Do not omit the chief complaint - this occurs in approximately 50% of presentations but is essential for proper case framing 2

Special Population Considerations

• For transgender and gender-diverse patients, complete an organ inventory rather than making assumptions based on gender presentation, as this informs appropriate screening and treatment options 3
• For adolescent patients, assess safety concerns including threats from perpetrators, fear of specific individuals, and access to weapons when relevant 3
• For diabetic patients presenting with pain syndromes, maintain heightened suspicion for atypical presentations of serious conditions due to autonomic dysfunction 3, 4

Presentation Length and Style

• Formal presentations should be comprehensive but concise, typically 3-5 minutes for routine cases 6
• Informal presentations (such as quick updates) can be abbreviated but must still include age, sex, chief complaint, key findings, and current plan 6
• Organize information logically rather than chronologically when the timeline is complex 3