EM Clerkship’s 10 Step Patient Presentation

* Demographics (Age, Gender, Pertinent Medical/Surgical History, Chief Complaint)* At Least 4 Descriptors (Location, Quality, Severity, Duration, Timing, Context, Modifying Factors)* Red Flags/Pertinent Positives and Negatives* Vital Signs* Focused Physical Exam of the Complaint* Suspected Diagnosis* Can’t Miss Diagnosis* Testing Plan* Treatment Plan* (If Asked) Anticipated Disposition

Demographics (Age, Gender, Pertinent Medical/Surgical History, Chief Complaint)

“I have a 48 year old, FEMALE with a past medical history of INSULIN DEPENDENT DIABETES, AND NO HISTORY OF ABDOMINAL SURGERY, who presents with ABDOMINAL PAIN“a Typical demographics statement

Age

The reason age is so important (especially with abdominal pain) is because it adds additional (frequently forgotten) items to your basic differential. For example…

* Pediatric Patients* Intussusception* Necrotizing Enterocolitis* Henoch Schonlein Purpura* Testicular and Ovarian Torsion* Geriatric Patients* Abdominal Aortic Aneurysm* Mesenteric Ischemia* Volvulus* Myocardial Infarction

Interesting Fact: In some studies, geriatric abdominal pain has a mortality of almost 10%!!!

Gender

The reason gender is so important (especially with abdominal pain) is because ECTOPIC PREGNANCY is the most important life threatening diagnosis in women of child bearing age.

Pertinent Past Medical and Surgical History

This is the only place in your presentation when the patient’s medical and surgical history is included. Keep it focused on the most important items.

* Always include previous abdominal surgeries (or say “no history of abdominal surgery”)* Always include an overview of previous GI workups* Diabetes, immunosuppression, active cancer, and blood thinners are almost always pertinent medical conditions regardless of chief complaint* Obvious GI diagnoses should be included such as inflammatory bowel disease, peptic ulcers, cirrhosis, etc

At Least 4 Descriptors (Location, Quality, Severity, Duration, Timing, Context, Modifying Factors)

“She describes it as a SEVERE, GENERALIZED, abdominal pain that STARTED LAST NIGHT and has been GRADUALLY WORSENING since then”An example of giving 4 Descriptors

Most attendings think about (and document) the history of present illness as a list of descriptors. This is for billing reasons. A “level 5” chart requires 4 “HPI Elements” to be documented.

Red Flags/Pertinent Positives and Negatives

“She has had some subjective FEVERS but NO HISTORY OF AFIB, and NO VOMTING, DARK TARRY STOOLS, URINARY SYMPTOMS, or VAGINAL BLEEDING OR DISCHARGEAn example of Giving red flags and pertinent positives/negatives

Abdominal pain is not typically a complaint known for having a big list of “red flags” that need to be asked. In my opinion, examples of true red flags with abdominal pain would potentially be the following…

* History of Atrial Fibrillation* History of Bariatric Surgery

However, it is generally expected that you give a thorough list of pertinent positives as well.

* Fever, Chills, Malaise* Chest Pain, Shortness of Breath* Nausea, Vomiting, Diarrhea* Vaginal Bleeding/Discharge* Dysuria, Urinary Frequency/Urgency, Hematuria* Melena

Additional Reading