Can you provide a concise, step‑by‑step template for presenting a patient in rounds—including demographics, chief complaint, history of present illness, past medical history, medications, allergies, social and family history, focused review of systems, physical exam, key labs and imaging, prioritized assessment, and tiered management plan?

Rounds Presentation Template for Medical Learners

Use a structured, systematic approach to present patients during rounds that prioritizes assessment data, problem-based reasoning, and evidence-based management plans. 1

Core Presentation Structure

Opening Statement (15-30 seconds)

• Patient identifier: Age, sex, relevant past medical history
• Chief complaint: In patient's own words
• One-sentence summary: "This is a [age] year-old [sex] with [relevant PMH] presenting with [chief complaint] concerning for [working diagnosis]" 1

History of Present Illness (2-3 minutes maximum)

Present chronologically with pertinent positives and negatives:

• Onset: Exact timing, sudden vs. gradual 1
• Character: Quality of symptoms (pressure, sharp, burning) 1, 2
• Location and radiation: Specific anatomic locations 3, 4
• Duration: How long symptoms persist 1
• Exacerbating/relieving factors: Activity, position, medications 1, 2
• Associated symptoms: Diaphoresis, nausea, dyspnea, syncope 3, 2
• Severity: Impact on function and daily activities 1

Past Medical History (30-60 seconds)

• Active chronic conditions only—prioritize those relevant to current presentation 1
• Prior cardiovascular events: MI, PCI, CABG with dates 1
• Risk factors: Hypertension, diabetes, hyperlipidemia, smoking, family history 1, 3

Medications (30 seconds)

• Current medications with doses—emphasize guideline-directed therapies 1
• Recent changes or non-adherence 1
• High-risk medications in elderly (anticholinergics, benzodiazepines, opioids) 1

Allergies

• True allergies with reaction type—distinguish from intolerances 1

Social History (15-30 seconds)

• Tobacco, alcohol, substance use with quantification 1
• Functional status: Baseline activities of daily living 1
• Social support and living situation 1

Physical Examination (1-2 minutes)

Present only pertinent findings organized by system:

• Vital signs: Include orthostatic measurements if relevant 1
• General appearance: Distress level, mental status 1
• Cardiovascular: Heart rate/rhythm, murmurs, JVP, peripheral edema 1
• Pulmonary: Respiratory rate, work of breathing, lung sounds 1
• Extremities: Pulses, edema, cyanosis 1
• Neurologic: Cognitive function, focal deficits if relevant 1

Diagnostic Data (1 minute)

• ECG findings: ST changes, Q waves, conduction abnormalities 1, 3
• Cardiac biomarkers: Troponin with timing and trend 1, 4
• Imaging: Chest x-ray, echocardiogram findings 1
• Laboratory: Relevant abnormalities only (renal function, electrolytes, hemoglobin) 1

Assessment and Problem List

Present a prioritized problem list with your clinical reasoning for each diagnosis:

Problem #1: [Most Urgent/Life-Threatening]

• Evidence supporting: Specific findings from history, exam, diagnostics 1
• Evidence against: Alternative explanations considered 1
• Risk stratification: High/intermediate/low risk with rationale 1, 4

Problem #2-4: [Additional Active Issues]

• Use same structure as Problem #1 1

Management Plan (Tiered by Problem)

For each problem, present a specific, actionable plan:

Problem #1 Management

Immediate interventions (next 0-4 hours):

• Specific medications with doses, routes, timing 1, 3, 4
• Monitoring parameters (continuous telemetry, vital sign frequency) 1, 4
• Consultations needed with specific questions 1

Short-term goals (24-72 hours):

• Diagnostic studies pending with expected timing 1
• Medication titration plans 1
• Functional milestones (ambulation, diet advancement) 1

Discharge planning (initiated on admission):

• Anticipated length of stay 1
• Medication reconciliation needs 1
• Follow-up appointments and testing 1
• Patient education topics 1

Problem #2-4 Management

• Use same tiered structure 1

Patient-Centered Considerations

What matters most to the patient:

• Patient's stated goals: Return to work, symptom relief, specific functional targets 1
• Advance care planning status: Code status, healthcare proxy 1
• Barriers to care: Financial, transportation, health literacy 1
• Social determinants: Housing stability, caregiver support, medication access 1

Key Pitfalls to Avoid

• Never dismiss atypical presentations in women, elderly, or diabetic patients—they frequently present without classic symptoms 3, 4, 2
• Never delay ECG beyond 10 minutes for suspected acute coronary syndrome 1, 3, 4
• Never assume epigastric or jaw pain is non-cardiac without excluding ACS first 3, 2
• Never present medication lists without doses—this demonstrates incomplete knowledge 1
• Never present all historical details—select only information relevant to current clinical reasoning 1, 5
• Never forget to reconcile medications including over-the-counter and supplements 1

Practical Tips for Sounding Confident

• Keep presentations under 5 minutes for established patients, under 10 minutes for new admissions 6
• Use precise medical terminology but avoid jargon when discussing patient's subjective experience 5
• State your assessment confidently even if uncertain—phrase as "most likely diagnosis is X, though Y remains on differential" 1
• Anticipate questions: Know the patient's renal function before proposing contrast studies, know medication formulary status before suggesting expensive drugs 1
• Connect your plan to guidelines: "Per ACC/AHA guidelines, this patient meets criteria for..." 1, 3