What are the key points to review for each patient's condition and treatment plan in preparation for rounds tomorrow, considering their respective medical histories and potential complications?

Structured Approach to Patient Review for Rounds

Essential Pre-Round Preparation

Before entering any patient room, mentally prepare by reviewing the medical chart for documentation of previous discussions, anticipating patient emotional responses, and organizing your presentation framework. 1, 2

Core Information to Review for Each Patient

• Diagnosis confirmation: Pathologic or clinical confirmation status, stage of disease, molecular profile (RAS/BRAF, MMR/MSI status for oncology patients) 1, 3
• Current treatment regimen: All medications, adherence patterns, barriers to adherence, previous treatment responses with documented A1C or tumor markers 1
• Comorbidity assessment: Number and severity of conditions (≥3 conditions triggers intensified monitoring), organ-specific function including renal (CrCl), hepatic, and cardiac status 1, 3, 4
• Recent clinical events: Hospital admissions, ED visits, ICU stays, functional status decline, disease progression 1
• Social determinants: Food security, housing stability, transportation access, financial security, documented health care proxy 1, 2

Bedside Discussion Structure (5-7 minutes per patient)

Opening (30 seconds)

• Address patient by name and greeting to establish rapport 5, 2
• Ask permission before sharing new medical information, including test results or treatment changes 1

Information Gathering (2 minutes)

Ask patients what they understand about their current medical situation before providing any new information. 1

• Interval symptoms: Changes since last assessment, focusing on organ systems relevant to their condition 5
• Medication-taking behavior: Actual adherence, side effects, barriers 1, 4
• Functional status: Mobility, self-care ability, falls, confusion 1
• Pain and symptom burden: Severity, impact on daily activities 1

Physical Assessment Priorities (1-2 minutes)

• Vital signs review: Blood pressure (including orthostatic if indicated), temperature, respiratory rate 1, 5
• System-specific examination:
  • Respiratory: Oxygen requirements, ventilation parameters if applicable 5
  • Cardiovascular: Volume status, perfusion 5
  • Neurological: Mental status, focal deficits 5
  • Skin: Injection sites for lipohypertrophy/nodules (diabetes patients), pressure areas 1, 4
  • Feet: Comprehensive foot exam for diabetes patients (10-g monofilament, pulses, skin integrity) 1

Critical Safety Checks (Use Checklist Approach)

Systematically verify these items for every patient, every day to prevent adverse events: 6, 7

• VTE prophylaxis: Documented risk assessment and appropriate prophylaxis prescribed 6, 7
• Antibiotic stewardship: Indication documented, duration specified, culture results reviewed 6, 7
• Medication reconciliation: Drug interactions assessed, renal dosing verified (especially for exenatide/GLP-1 agonists with CrCl <50 mL/min) 3, 4
• Code status documentation: Current advance directive, surrogate decision maker identified 1

Information Delivery (1-2 minutes)

Provide information in small amounts using language appropriate to the patient's health literacy level, checking understanding frequently. 1

• Frame updates in context of patient's stated goals rather than your clinical preferences 1, 2
• Use teach-back technique: "To make sure I explained this clearly, can you tell me in your own words what we discussed?" (improves medication understanding OR 1.84 and behavioral instruction understanding OR 1.83) 8
• Explicitly encourage patient questions: Only 54% of physicians do this despite most patients wanting active participation 8

Emotional Response Management

When patients display emotion, respond empathically rather than minimizing concerns or changing the subject. 1, 2

• Acknowledge emotions explicitly: "I can see this is concerning for you" 1
• Explore underlying concerns: "What are you most worried about?" 2
• Affirm commitment: "I want you to know we will support you regardless of which treatment option you choose" 1, 2

Critical Decision Points Requiring Immediate Action

Treatment Efficacy Assessment

Persist with treatments for sufficient duration (4-8 weeks for medications, 8-12 weeks for other therapies) before determining efficacy; cease therapies that fail to demonstrate benefit after adequate trial. 3

Triggers for End-of-Life Care Discussions

Initiate advance care planning conversations within one month of terminal diagnosis and reassess at these sentinel events: 1

• Cancer progression on imaging or clinical exam 1
• Functional status decline (new mobility limitations, ADL dependence) 1
• Multiple ED visits or hospitalizations 1
• Consideration of new chemotherapy line after progression 1
• Consideration of high-burden interventions (dialysis, feeding tube, palliative surgery) 1
• Patient/family request for discussion 1

Peri-Operative Medication Management

Hold Byetta (exenatide) on the day of any procedure requiring anesthesia due to delayed gastric emptying and aspiration risk. 4

Documentation Requirements

Document these elements in the medical record after each encounter: 1, 2

• Patient's understanding of their condition (in their words) 1
• Goals of care discussions, including what matters most to patient 1
• Advance directive status and surrogate decision maker 1
• Medication changes with rationale 1
• Safety checklist completion (VTE, antibiotics, code status) 6, 7

Team Communication Strategy

Conduct brief pre-room discussion with team before entering patient room (improves team satisfaction 78.0 vs 68.3 on VAS, allows discussion of sensitive topics 84.3 vs 59.3, reduces patient confusion from medical jargon 13.7 vs 21.3) 8

Pre-Room Huddle Content:

• Overnight events and new data 5, 8
• Anticipated difficult conversations 8
• Teaching points for trainees 9, 8
• Delegation of tasks (who presents, who documents, who is "checker") 6

Common Pitfalls to Avoid

• Interruptions: Limit to urgent clinical decisions only (83% of interruptions are non-urgent) 5
• Missing information: Proactively check microbiology results (missing 10% of time) and recent procedures (missing 6% of time) before rounds 5
• Abandoning patients: Never imply abandonment; explicitly state ongoing support regardless of treatment choices 1, 2
• Assumption-based care: Avoid stereotyping end-of-life preferences based on race, ethnicity, or religion; use open-ended questions 1
• Premature treatment changes: Allow adequate trial duration before declaring treatment failure 3