A Practical Guide to Clinical Medicine

A comprehensive physical examination and clinical education site for medical

students and other health care professionals

Web Site Design by Jan Thompson, Program Representative, UCSD School of Medicine.
Content and Photographs by Charlie Goldberg, M.D., UCSD School of Medicine and VA
Medical Center, San Diego, California 92093-0611.
Send Comments to: Charlie Goldberg, M.D.
Introduction Breast Exam Write Ups
History of Present Illness The Pelvic Examination The Oral Presentation
The Rest of the History Male Genital/Rectal Exam Outpatient Clinics
Review of Systems The Upper Extremities Inpatient Medicine
Vital Signs The Lower Extremities Clinical Decision Making
The Eye Exam Musculo-Skeletal Exam Physical Exam Lecture Series
Head and Neck Exam The Mental Status Exam A Few Thoughts
The Lung Exam The Neurological Exam Commonly Used Abbreviations
Cardiovascular Exam Physical Exam Check Lists References
Exam of the Abdomen Medical Links

The "daVinci Anatomy Icon" denotes a link to related gross anatomy pictures.
Daily Presentations During The New Patient The Holdover Admission Outpatient Clinic
Work Rounds Presentation Presentation Presentations

Overview and General Information about Oral

Presentation
The goal of any oral presentation is to pass along the “right amount” of patient information to a specific
audience in an efficient fashion. When done well, this enables the listener to quickly understand the patient’s
issues and generate an appropriate plan of action. As with any skill, it can be learned, although this takes time
and practice. In addition, the world of medicine presents some additional challenges, including:

The structure of presentations varies from service to service (e.g. medicine vs. surgery), amongst
subspecialties, and between environments (inpatient vs. outpatient). Applying the correct style to the right
setting requires that the presenter seek guidance from the listeners at the outset.
Time available for presenting is rather short, which makes the experience more stressful.
Individual supervisors (residents, faculty) often have their own (sometimes quirky) preferences regarding
presentation styles, adding another layer of variability that the presenter has to manage.
Students are evaluated/judged on the way in which they present, with faculty using this as one way of
gauging a student’s clinical knowledge.
Done well, presentations promote efficient, excellent care. Done poorly, they promote tedium, low morale,
and inefficiency.

General Tips:
 Practice, Practice, Practice! Do this on your own, with colleagues, and/or with anyone who will listen (and
offer helpful commentary) before you actually present in front of other clinicians. Speaking "on-the-fly" is
difficult, as rapidly organizing and delivering information in a clear and concise fashion is not a naturally
occurring skill.

Immediately following your presentations, seek feedback from your listeners. Ask for specifics about what
was done well and what could have been done better – always with an eye towards gaining information
that you can apply to improve your performance the next time.

Listen to presentations that are done well – ask yourself, “Why was it good?” Then try to incorporate
those elements into your own presentations.

Listen to presentations that go poorly – identify the specific things that made it ineffective and avoid those
pitfalls when you present.

Effective presentations require that you have thought through the case beforehand and understand the
rationale for your conclusions and plan. This, in turn, requires that you have a good grasp of physiology,
pathology, clinical reasoning and decision-making - pushing you to read, pay attention, and in general
acquire more knowledge.

Think about the clinical situation in which you are presenting so that you can provide a summary that is
consistent with the expectations of your audience. Work rounds, for example, are clearly different from
conferences and therefore mandate a different style of presentation.

Presentations are the way in which we tell medical stories to one another. When you present, ask yourself
if you’ve described the story in an accurate way. Will the listener be able to “see” the patient the same way
that you do? Can they come to the correct conclusions? If not, re-calibrate.

It's O.K. to use notes, though the oral presentation should not simply be reduced to reading the admission
note – rather, it requires appropriate editing/shortening.

In general, try to give your presentations on a particular service using the same order and style for each
patient, every day. Following a specific format makes it easier for the listener to follow, as they know
what’s coming and when they can expect to hear particular information. Additionally, following a
standardized approach makes it easier for you to stay organized, develop a rhythm, and lessens the chance
that you’ll omit elements.

Specific types of presentations

There are a number of common presentation-types, each with its own goals and formats. These include:

1. Daily presentations during work rounds for patients known to a service.

2. Newly admitted patients, where you were the clinician that performed the H&P.
3. Newly admitted patients that were “handed off” to the team in the morning, such that the H&P was
performed by others.
4. Outpatient clinic presentations, covering several common situations.

Key elements of each presentation type are described below. Examples of how these would be applied to most
situations are provided in italics. The formats are typical of presentations done for internal medicine services and
clinics.

Note that there is an acceptable range of how oral presentations can be delivered. Ultimately, your goal is to tell
the correct story, in a reasonable amount of time, so that the right care can be delivered. Nuances in the order of
presentation, what to include, what to omit, etc. are relatively small points. Don’t let the pursuit of these
elements distract you or create undue anxiety.

Daily presentations during work rounds of patients that you’re

following:
Purpose:

Organize the presenter (forces you to think things through)

Inform the listener(s) of 24 hour events and plan moving forward
Promote focused discussion amongst your listeners and supervisors
Opportunity to reassess plan, adjust as indicated
Demonstrate your knowledge and engagement in the care of the patient

Duration:

Rapid (5 min) presentation of the key facts

Key features of presentation:

Opening one liner: Describe who the patient is, number of days in hospital, and their main clinical
issue(s).
24-hour events: Highlighting changes in clinical status, procedures, consults, etc.
Subjective sense from the patient about how they’re feeling, vital signs (ranges), and key physical exam
findings (highlighting changes)
Relevant labs (highlighting changes) and imaging
Assessment and Plan: Presented by problem or organ systems(s), using as many or few as are relevant.
Early on, it’s helpful to go through the main categories in your head as a way of making sure that you’re
not missing any relevant areas. The broad organ system categories include (presented here head-to-toe):
Neurological; Psychiatric; Cardiovascular; Pulmonary; Gastrointestinal; Renal/Genitourinary;
Hematologic/Oncologic; Endocrine/Metabolic; Infectious; Tubes/lines/drains; Disposition.

Example of a daily presentation for a patient known to a team:

Opening one liner:This is Mr. Smith, a 65 year old man, Hospital Day #3, being treated for right leg
cellulitis
Events of the past 24 hours:
MRI of the leg, negative for osteomyelitis
Evaluation by Orthopedics, who I&D’d a superficial abscess in the calf, draining a moderate
amount of pus
PE remarkable for:
Patient appears well, states leg is feeling better, less painful
T Max 101 yesterday, T Current 98; Pulse range 60-80; BP 140s-160s/70-80s; O2 sat 98% Room
Air
Ins/Outs: 3L in (2 L NS, 1 L po)/Out 4L urine
Right lower extremity redness now limited to calf, well within inked lines – improved compared
with yesterday; bandage removed from the I&D site, and base had small amount of purulence; No
evidence of fluctuance or undrained infection.
Labs and imaging remarkable for:
Creatinine .8, down from 1.5 yesterday
WBC 8.7, down from 14
Blood cultures from admission still negative
Gram stain of pus from yesterday’s I&D: + PMNS and GPCs; Culture pending
MRI lower extremity as noted above – negative for osteomyelitis
 Assessment and Plan
This is a 65 yo male, hospital day 3, being treated for lower extremity cellulitis and abscess. Issues are as
follows:
Cellulitis complicated by abscess, which has now been adequately drained. Exam improved and
feels better. Likely organism is Staph, covering for MRSA until cultures back
Continue Vancomycin for today
Ortho to reassess I&D site, though looks good
Follow-up on cultures: if MRSA, will transition to PO Doxycycline; if MSSA, will use PO
Dicloxacillin
Hypertension: When admitted, outpatient anti-hypertensive medications held as blood pressure was
low due to sepsis. Now BP is climbing back to hypertensive range. No symptoms
Given AKI, will continue to hold ace-inhibitor; will likely wait until outpatient follow-up to
restart
Add back amlodipine 5mg/d today
Renal: Now back to baseline kidney function, which is normal. On admission AKI due to sepsis. All
improved as expected with control of infection. Appears euvolemic
Hep lock IV as no need for more IVF
Continue to hold ace-I as above
Disposition: Anticipate d/c tomorrow on po antibiotics – pending final culture results as above to
determine best oral med.
Wound care teaching with RNs today – wife capable and willing to assist. She’ll be in this
afternoon.
Set up follow-up with PMD to reassess wound and cellulitis within 1 week

The Brand New Patient (admitted by you)

Purpose
Organize the presenter (forces you to think things through)
Provide enough information so that the listeners can understand the presentation and generate an
appropriate differential diagnosis.
Present a thoughtful assessment
Present diagnostic and therapeutic plans
Provide opportunities for senior listeners to intervene and offer input
Duration
8-10 min
Key features of presentation:
Chief concern: Reason why patient presented to hospital (symptom/event and key past history in
one sentence). It often includes a limited listing of their other medical conditions (e.g. diabetes,
hypertension, etc.) if these elements might contribute to the reason for admission.
History of present illness (HPI):
The history is presented highlighting the relevant events in chronological order.
Events are best presented as temporally oriented bullets (from the starting point of the illness
to the present moment), making it easy to follow the sequence in which things progressed.
These events are often described based on how many days ago they occurred. For example:
7 days ago, the patient began to notice vague shortness of breath.
5 days ago, the breathlessness worsened and they developed a cough productive of
green sputum.
3 days ago his short of breath worsened to the point where he was winded after walking
up a flight of stairs, accompanied by a vague right sided chest pain that was more
pronounced with inspiration.
Etc.
Enough historical information has to be provided so that the listener can understand the
reasons that lead to admission and be able to draw appropriate clinical conclusions.
 Past history that helps to shed light on the current presentation are included towards the end
of the HPI and not presented later as “PMH.” This is because knowing this “past” history is
actually critical to understanding the current complaint. For example, past cardiac
catheterization findings and/or interventions should be presented during the HPI for a patient
presenting with chest pain.
Where relevant, the patient's baseline functional status is described, allowing the listener to
understand the degree of impairment caused by the acute medical problem(s).
It should be explicitly stated if a patient is a poor historian, confused or simply unaware of all
the details related to their illness. Historical information obtained from family, friends, etc.
should be described as such.
Review of Systems (ROS): Pertinent positive and negative findings discovered during a review of
systems are generally incorporated at the end of the HPI. The listener needs this information to help
them put the story in appropriate perspective. Any positive responses to a more inclusive ROS that
covers all of the other various organ systems are then noted. If the ROS is completely negative, it is
generally acceptable to simply state, "ROS negative.”
Other Past Medical and Surgical History (PMH/PSH): Past history that relates to the issues that
lead to admission are typically mentioned in the HPI and do not have to be repeated here. That said,
selective redundancy (i.e. if it’s really important) is OK. Other PMH/PSH are presented here if
relevant to the current issues and/or likely to affect the patient’s hospitalization in some way.
Unrelated PMH and PSH can be omitted (e.g. if the patient had their gall bladder removed 10y ago
and this has no bearing on the admission, then it would be appropriate to leave it out). If the listener
really wants to know peripheral details, they can read the admission note, ask the patient
themselves, or inquire at the end of the presentation.
Medications and Allergies: Typically all meds are described, as there’s high potential for adverse
reactions or drug-drug interactions.
Family History: Emphasis is placed on the identification of illnesses within the family (particularly
among first degree relatives) that are known to be genetically based and therefore potentially
heritable by the patient. This would include: coronary artery disease, diabetes, certain cancers and
autoimmune disorders, etc. If the family history is non-contributory, it’s fine to say so.
Social History, Habits, other → as relates to/informs the presentation or hospitalization. Includes
education, work, exposures, hobbies, smoking, alcohol or other substance use/abuse.
Sexual history if it relates to the active problems.
Physical Exam
Vital signs and relevant findings (or their absence) are provided. As your team develops trust
in your ability to identify and report on key problems, it may become acceptable to say “Vital
signs stable.”
Note: Some listeners expect students (and other junior clinicians) to describe what they find
in every organ system and will not allow the presenter to say “normal.” The only way to know
what to include or omit is to ask beforehand.
Key labs and imaging: Abnormal findings are highlighted as well as changes from baseline.
Summary, assessment & plan(s) Presented by problem or organ systems(s), using as many or few
as are relevant. Early on, it’s helpful to go through the main categories in your head as a way of
making sure that you’re not missing any relevant areas. The broad organ system categories include
(presented here head-to-toe): Neurological; Psychiatric; Cardiovascular; Pulmonary;
Gastrointestinal; Renal/Genitourinary; Hematologic/Oncologic; Endocrine/Metabolic; Infectious;
Tubes/lines/drains; Disposition.
The assessment and plan typically concludes by mentioning appropriate prophylactic considerations
(e.g. DVT prevention), code status and disposition.

Example of a New Admission Presentation:

Chief Concern: Mr. H is a 50 year old male with AIDS, on HAART, with preserved CD4 count and
undetectable viral load, who presents for the evaluation of fever, chills and a cough over the past 7
days.
HPI: Mr. H has been known to be HIV + since 2000
 Until 1 week ago, he had been quite active, walking up to 2 miles a day without feeling short
of breath.
Approximately 1 week ago, he began to feel dyspneic with moderate activity.
3 days ago, he began to develop subjective fevers and chills along with a cough productive of
red-green sputum.
1 day ago, he was breathless after walking up a single flight of stairs and spent most of the
last 24 hours in bed.
Past HIV history is remarkable for:
Diagnosed with HIV in 2000, done as a screening test when found to have gonococcal
urethritis
Was not treated with HAART at that time due to concomitant alcohol abuse and non-
adherence.
Diagnosed and treated for PJP pneumonia 2006
Diagnosed and treated for CMV retinitis 2007
Became sober in 2008, at which time interested in HAART. Started on Atripla, a
combination pill containing: Efavirenz, Tonofovir, and Emtricitabine. He’s taken it ever
since, with no adverse effects or issues with adherence. Receives care thru Dr. Smiley at
the University HIV clinic.
CD4 count 3 months ago was 400 and viral load was undetectable.
He is homosexual though he is currently not sexually active. He has never used
intravenous drugs.
He has no history of asthma, COPD or chronic cardiac or pulmonary condition. No known
liver disease. Hepatitis B and C negative. His current problem seems different to him then his
past episode of PJP.
Review of systems: negative for headache, photophobia, stiff neck, focal weakness, chest pain,
abdominal pain, diarrhea, nausea, vomiting, urinary symptoms, leg swelling, or other complaints.
Other PMH/PSH:
Hypertension x 5 years, no other known vascular disease
GERD
Gonorrhea as above
Alcohol abuse above and now sober – no known liver disease
No relevant surgeries
MEDS and Allergies:
Atripla, 1 po qd
Omeprazole 20 mg, 1 PO, qd
Lisinopril 20mg, qd
Naprosyn 250 mg, 1-2, PO, BID PRN
No allergies
Family History
Both of the patient's parents are alive and well (his mother is 78 and father 80). He has 2
brothers, one 45 and the other 55, who are also healthy. There is no family history of heart
disease or cancer.
Social history, habits
Patient works as an accountant for a large firm in San Diego. He lives alone in an apartment
in the city.
Smokes 1 pack of cigarettes per day and has done so for 20 years.
No current alcohol use. Denies any drug use.
Sexual History as noted above; has sex exclusively with men, last partner 6 months ago.
Physical Exam notable for:
Seated on a gurney in the ER, breathing through a face-mask oxygen delivery system.
Breathing was labored and accessory muscles were in use. Able to speak in brief sentences,
limited by shortness of breath
Vital signs: Temp 102 F, Pulse 90, BP 150/90, Respiratory Rate 26, O2 Sat (on 40% Face
Mask) 95%
 HEENT: No thrush, No adenopathy
Lungs: Crackles and Bronchial breath sounds noted at right base. E to A changes present. No
wheezing or other abnormal sounds noted over any other area of the lung. Dullness to
percussion was also appreciated at the right base.
Cardiac: JVP less than 5 cm; Rhythm was regular. Normal S1 and S2. No murmurs or extra
heart sounds noted.
Abdomen and Genital exams: normal
Extremities: No clubbing, cyanosis or edema; distal pulses 2+ and equal bilaterally.
Skin: no eruptions noted.
Neurological exam: normal
Labs and Imaging notable for:
WBC 18 thousand with 10% bands;
Normal Chem 7 and LFTs.
Room air blood gas: pH of 7.47/ PO2 of 55/PCO2 of 30.
Sputum gram stain remarkable for an abundance of polys along with gram positive
diplococci.
CXR remarkable for dense right lower lobe infiltrate without effusion.
Assessment and Plan:
Acute community acquired pneumonia: Mr. H is an HIV + male with preserved CD 4 count
and undetectable viral load while on HAART, who presents with an acute pulmonary process.
The rapid progression, focality of findings on lung exam and chest x-ray, along with the
sputum gram stain suggest a bacterial infection, in particular Streptococcal Pneumoniae.
Other pathogens to consider include influenza, H Flu and Legionella. His presentation,
compliance with PJP prophylaxis, reasonably intact immune system and statement that his
current illness seems different then past PJP infection would argue against this as the
etiologic agent. Mycobacterial infection also seems unlikely. Viral infections and neoplastic
processes like CMV or Kaposi's Sarcoma of the lung do not typically give this clinical
presentation nor should they occur given his level of immune function. In addition, he
received a flu vaccine 2 months ago. The data does not support the existence of either a
primary cardiac or noninfectious pulmonary process. The current plan for his pneumonia is
as follows:
Continue Ceftriaxone and Azithromycin started in the ED for acute CAP
Follow up on cultures of sputum and blood; will try to narrow coverage based on final
cultures.
Obtain rapid flu test
Continue Atripla
Continue O2, with goal to keep sats greater then 92%
IV fluid replacement with Normal Saline at 125cc/H for next 24 hours to correct mild
hypovolemia, with plan to reassess volume status at that time
If patient does not show improvement (or worsens) and cultures are unrevealing,
consider bronchoscopy as a means of making more definitive diagnosis.
Monitored care unit, with vigilance for clinical deterioration.
Hypertension: given significant pneumonia and unclear clinical direction, will hold lisinopril.
If BP > 180 and or if clear not developing sepsis, will consider restarting.
DVT Prophylaxis: immobile and ill, which makes him high risk
Low molecular weight heparin
Code Status: Wishes to be full code full care, including intubation and ICU stay if necessary.
Has good quality of life and hopes to return to that functional level. Wishes to reconsider if
situation ever becomes hopeless. Older brother Tom is surrogate decision maker if the patient
can’t speak for himself. Tom lives in San Diego and we have his contact info. He is aware that
patient is in the hospital and plans on visiting later today or tomorrow.
Expected duration of hospitalization unclear – will know more based on response to treatment
over next 24 hours.
The holdover admission (presenting data that was generated by other
physicians)
Purpose
Handoff admissions are very common and present unique challenges
The accepting team has several goals:
Understand the reasons why the patient was admitted
Review key history, exam, imaging and labs to assure that they support the working
diagnostic and therapeutic plans
The presentation provides an opportunity for the accepting team to determine if the impression and
plan told to them makes sense. This requires them to carefully consider the following:
Does the data support the working diagnosis?
Do the planned tests and consults make sense?
What else should be considered (both diagnostically and therapeutically)?
This process requires that the accepting team thoughtfully review their colleagues efforts with a
critical eye – which is not disrespectful but rather constitutes one of the main jobs of the accepting
team and is a cornerstone of good care
*Note: At some point during the day (likely not during rounds), the team will need to verify all of
the data directly with the patient.
Duration
8-10 minutes
Key features of the presentation
Chief concern: Reason for admission (symptom and/or event)
History of Present Illness:
Temporally presented bullets of events leading up to the admission
Review of systems
Relevant PMH/PSH – historical information that might affect the patient during their
hospitalization.
Meds and Allergies
Family and Social History – focusing on information that helps to inform the current presentation.
Habits and exposures
Physical exam, imaging and labs that were obtained in the Emergency Department
Assessment and plan that were generated in the Emergency Department.
Overnight events (i.e. what happened in the Emergency Dept. and after the patient went to their
hospital room)? Responses to treatments, changes in symptoms?
How does the patient feel this morning? Key exam findings this morning (if seen)? Morning
labs (if available)?
Assessment and Plan, with attention as to whether there needs to be any changes in the working
differential or treatment plan. The broad organ system categories include (presented here head-to-
toe): Neurological; Psychiatric; Cardiovascular; Pulmonary; Gastrointestinal; Renal/Genitourinary;
Hematologic/Oncologic; Endocrine/Metabolic; Infectious; Tubes/lines/drains; Disposition.

Typically, the discussion also includes appropriate prophylactic considerations (e.g. DVT
prevention), code status and disposition.
Example of a Hold Over Admission Presentation
Chief concern: 70 yo male who presented with 10 days of progressive shoulder pain, followed by
confusion. He was brought in by his daughter, who felt that her father was no longer able to safely
take care for himself.
HPI:
10 days ago, Mr. X developed left shoulder pain, first noted a few days after lifting heavy
boxes. He denies falls or direct injury to the shoulder.
1 week ago, presented to outside hospital ER for evaluation of left shoulder pain. Records
from there were notable for his being afebrile with stable vitals. Exam notable for focal pain
 anteriorly on palpation, but no obvious deformity. Right shoulder had normal range of
motion. Left shoulder reported as diminished range of motion but not otherwise quantified. X-
ray negative. Labs remarkable for wbc 8, creat 2.2 (stable). Impression was that the pain was
of musculoskeletal origin. Patient was provided with Percocet and told to see PMD in f/u
Brought to our ER last night by his daughter. Pain in shoulder worse. Also noted to be
confused and unable to care for self. Lives alone in the country, home in disarray, no food.
At baseline, patient is fully functional and able to care for himself. He has no cognitive issues.
The history is largely provided by the daughter, as patient is confused about his symptoms and the
order in which they developed.
ROS: negative for falls, prior joint or musculoskeletal problems, fevers, chills, cough, sob, chest
pain, head ache, abdominal pain, urinary or bowel symptoms, substance abuse
Relevant PMH/PSH:
Hypertension
Coronary artery disease, s/p LAD stent for angina 3 y ago, no symptoms since. Normal EF by
echo 2 y ago
Chronic kidney disease stage 3 with creatinine 1.8; felt to be secondary to atherosclerosis and
hypertension
Depression
MEDS and Allergies:
aspirin 81mg qd, atorvastatin 80mg po qd, amlodipine 10 po qd, Prozac 20
Allergies: none
Family and Social: lives alone in a rural area of the county, in contact with children every month or
so. Retired several years ago from work as truck driver. Otherwise non-contributory.
Habits: denies alcohol or other drug use.
Physical Exam in Emergency Department
Temp 98 Pulse 110 BP 100/70
Drowsy though arousable; oriented to year but not day or date; knows he’s at a hospital for
evaluation of shoulder pain, but doesn’t know the name of the hospital or city
CV: regular rate and rhythm; normal s1 and s2; no murmurs or extra heart sounds.
Lungs: CTA
Left shoulder with generalized swelling, warmth and darker coloration compared with Right;
generalized pain on palpation, very limited passive or active range of motion in all directions
due to pain. Right shoulder appearance and exam normal.
Labs and imaging in Emergency Department
CXR: normal
EKG: sr 100; nl intervals, no acute changes
WBC 13; hemoglobin 14
Na 134, k 4.6; creat 2.8 (1.8 baseline 4 m ago); bicarb 24
LFTs and UA normal
Assessment and plan in the Emergency Department and by overnight team.
Acute shoulder pain and systemic symptoms concerning for septic shoulder
Vancomycin and Zosyn for now
Orthopedics to see asap to aspirate shoulder for definitive diagnosis
If aspiration is consistent with infection, will need to go to Operating Room for wash
out.
AKI: From poor oral intake and sepsis. Given 3L NS in ER, with positive response in terms of
heart rate and BP. Also, urine output now ~50 cc/h.
IVF with NS at 125cc/h
Urine electrolytes
Follow-up on creatinine and obtain renal ultrasound if not improved
Renal dosing of meds
Strict Ins and Outs.
Confusion: Delirium from infection. Baseline cognitive function is reportedly normal.
will approach infection as above
 follow exam
obtain additional input from family to assure baseline is, in fact, normal
Over night events/response to treatments.
Since admission (6 hours) no change in shoulder pain
This morning, pleasant, easily distracted; knows he’s in the hospital, but not date or year
Key morning exam findings
T Current 101F Pulse 100 BP 140/80
Ins and Outs: IVF Normal Saline 3L/Urine output 1.5 liters
L shoulder with obvious swelling and warmth compared with right; no skin breaks; pain
limits any active or passive range of motion to less than 10 degrees in all directions
Key morning labs
Labs this morning remarkable for WBC 10 (from 13), creatinine 2 (down from 2.8)
Assessment and Plan:
Agree with assessment of over night admitting team, which is sepsis with source of infection
based in the left shoulder.
Plan:
Continue with Vancomycin and Zosyn for now
I already paged Orthopedics this morning, who are en route for aspiration of
shoulder, fluid for gram stain, cell count, culture
If aspirate consistent with infection, then likely to the OR
Renal: AKI due to hypovolemia and sepsis. Now appears volume replete
Continue IVF at 125/h, follow I/O
Repeat creatinine later today
Not on any nephrotoxins, meds renaly dosed
Delirium: related to infection as above
Continue antibiotics, evaluation for primary source as above
Discuss with family this morning to establish baseline; possible may have underlying
dementia as well
Prophylaxis:
SC Heparin for DVT prophylaxis
Code status: full code/full care.

Outpatient-based presentations
There are 4 main types of visits that commonly occur in an outpatient continuity clinic environment, each of
which has its own presentation style and purpose. These include the following, each described in detail below.

1. The patient who is presenting for their first visit to a primary care clinic and is entirely new to the
physician.
2. The patient who is returning to primary care for a scheduled follow-up visit.
3. The patient who is presenting with an acute problem to a primary care clinic
4. The specialty clinic evaluation (new or follow-up)

It’s worth noting that Primary care clinics (Internal Medicine, Family Medicine and Pediatrics) typically take
responsibility for covering all of the patient’s issues, though the amount of energy focused on any one topic will
depend on the time available, acuity, symptoms, and whether that issue is also followed by a specialty clinic.

The Brand New Primary Care Patient

Purpose of the presentation

Organize the presenter (forces you to think things through)

Accurately review all of the patient’s history as well as any new concerns that they might have.
 Identify health related problems that need additional evaluation and/or treatment
Provide an opportunity for senior listeners to intervene and offer input

Duration

8-10 min

Key features of the presentation

Reason for the visit:

If this is truly their first visit, then one of the main reasons is typically to "establish care" with a new
doctor.
It might well include continuation of therapies and/or evaluations started elsewhere.
If the patient has other specific goals (medications, referrals, etc.), then this should be stated as well.
Note: There may well not be a "chief complaint."
Relevant acute/sub-acute history
For a new patient, this is an opportunity to highlight the main issues that might be
troubling/bothering them.
This can include chronic disorders (e.g. diabetes, congestive heart failure, etc.) which cause ongoing
symptoms (shortness of breath) and/or generate daily data (finger stick glucoses) that should be
discussed.
Sometimes, there are no specific areas that the patient wishes to discuss up-front.
Review of systems (ROS): This is typically comprehensive, covering all organ systems. If the patient is
known to have certain illnesses (e.g. diabetes), then the ROS should include the search for disorders with
high prevalence (e.g. vascular disease). There should also be some consideration for including questions
that are epidemiologically appropriate (e.g. based on age and sex).
Past Medical History (PMH): All known medical conditions (in particular those requiring ongoing
treatment) are listed, noting their duration and time of onset. If a condition is followed by a specialist or
co-managed with other clinicians, this should be noted as well. If a problem was described in detail during
the “acute” history, it doesn’t have to be re-stated here.
Past Surgical History (PSH): All surgeries, along with the year when they were performed
Medications and allergies: All meds, including dosage, frequency and over-the-counter preparations.
Allergies (and the type of reaction) should be described.
Social: Work, hobbies, exposures.
Sexual activity – may include type of activity, number and sex of partner(s), partner’s health.
Smoking, Alcohol, other drug use: including quantification of consumption, duration of use.
Family history: Focus on heritable illness amongst first degree relatives. May also include whether
patient married, in a relationship, children (and their ages).
Physical Exam: Vital signs and relevant findings (or their absence).
Key labs and imaging if they’re available. Also when and where they were obtained.
Summary, assessment & plan(s) presented by organ system and/or problems. As many
systems/problems as is necessary to cover all of the active issues that are relevant to that clinic. This
typically concludes with a “health care maintenance” section, which covers age, sex and risk factor
appropriate vaccinations and screening tests.

The Follow-up Visit to a Primary Care Clinic

Purpose of the presentation

Organize the presenter (forces you to think things through).

Accurately review any relevant interval health care events that might have occurred since the last visit.
Identification of new symptoms or health related issues that might need additional evaluation and/or
treatment
If the patient has no concerns, then verification that health status is stable
 Review of medications
Provide an opportunity for listeners to intervene and offer input

Duration

5-7 min

Key features of the presentation

Reason for the visit: Follow-up for whatever the patient’s main issues are, as well as stating when the last
visit occurred
*Note: There may well not be a “chief complaint,” as patients followed in continuity at any clinic may
simply be returning for a visit as directed by their doctor.
Events since the last visit: This might include emergency room visits, input from other
clinicians/specialists, changes in medications, new symptoms, etc.
Review of Systems (ROS): Depth depends on patient’s risk factors and known illnesses. If the patient has
diabetes, then a vascular ROS would be done. On the other hand, if the patient is young and healthy, the
ROS could be rather cursory.
PMH, PSH, Social, Family, Habits are all OMITTED. This is because these facts are already known to
the listener and actionable aspects have presumably been added to the problem list (presented at the end).
That said, these elements can be restated if the patient has a new symptom or issue related to a historical
problem has emerged.
MEDS: A good idea to review these at every visit.
Physical exam: Vital signs and pertinent findings (or absence there of) are mentioned.
Lab and Imaging: The reason why these were done should be mentioned and any key findings
mentioned, highlighting changes from baseline.
Assessment and Plan: This is most clearly done by individually stating all of the conditions/problems
that are being addressed (e.g. hypertension, hypothyroidism, depression, etc.) followed by their specific
plan(s). If a new or acute issue was identified during the visit, the diagnostic and therapeutic plan for that
concern should be described.

The Focused Visit to a Primary Care Clinic

Purpose of the presentation

Accurately review the historical events that lead the patient to make the appointment.
Identification of risk factors and/or other underlying medical conditions that might affect the diagnostic or
therapeutic approach to the new symptom or concern.
Generate an appropriate assessment and plan
Allow the listener to comment

Duration

5 min

Key features of the presentation:

Reason for the visit

History of Present illness: Description of the sequence of symptoms and/or events that lead to the
patient’s current condition.
Review of Systems: To an appropriate depth that will allow the listener to grasp the full range of
diagnostic possibilities that relate to the presenting problem.
PMH and PSH: Stating only those elements that might relate to the presenting symptoms/issues.
MEDS
 PE: Vital signs and key findings (or lack thereof)
Labs and imaging (if done)
Assessment and Plan: This is usually very focused and relates directly to the main presenting
symptom(s) or issues.

The Specialty Clinic Visit

Specialty clinic visits focus on the health care domains covered by those physicians. For example, Cardiology
clinics are interested in cardiovascular disease related symptoms, events, labs, imaging and procedures.
Orthopedics clinics will focus on musculoskeletal symptoms, events, imaging and procedures. Information that
is unrelated to these disciples will typically be omitted. It’s always a good idea to ask the supervising physician
for guidance as to what’s expected to be covered in a particular clinic environment.

Purpose of the presentation

Organize the presenter (forces you to think things through)

Highlight the reason(s) for the visit
Review key data
Generate an appropriate assessment and plan
Provide an opportunity for the listener(s) to comment

Duration

5-7 minutes

Key features of the presentation:

Reason for the visit

If it’s a consult, state the main reason(s) that the patient was referred as well as who referred them.
If it’s a return visit, state the reasons why the patient is being followed in the clinic and when the
last visit took place
If it’s for an acute issue, state up front what the issue is
Note: There may well not be a “chief complaint,” as patients followed in continuity in any clinic
may simply be returning for a return visit as directed
Relevant acute/sub-acute history
For a new patient, this highlights the main things that might be troubling/bothering the patient.
For a specialty clinic, the history presented typically relates to the symptoms and/or events that are
pertinent to that area of care.
Review of systems, focusing on those elements relevant to that clinic. For a cardiology patient, this will
highlight a vascular ROS.
PMH/PSH that helps to inform the current presentation (e.g. past cardiac catheterization
findings/interventions for a patient with chest pain) and/or is otherwise felt to be relevant to that clinic
environment.
Meds and allergies: Typically all meds are described, as there is always the potential for adverse drug
interactions.
Social/Habits/other: as relates to/informs the presentation and/or is relevant to that clinic
Family history: Focus is on heritable illness amongst first degree relatives
Physical Exam: VS and relevant findings (or their absence)
Key labs, imaging: For a cardiology clinic patient, this would include echos, catheterizations, coronary
interventions, etc.
Summary, assessment & plan(s) by organ system and/or problems. As many systems/problems as is
necessary to cover all of the active issues that are relevant to that clinic.

Example Presentation to an Outpatient Cardiology Clinic

Reason for visit: Patient is a 67 year old male presenting for first office visit after admission for STEMI.
He was referred by Dr. Goins, his PMD.
HPI:
The patient initially presented to the ER 4 weeks ago with acute CP that started 1 hour prior to his
coming in. He was found to be in the midst of a STEMI with ST elevations across the precordial
leads.
Taken urgently to cath, where 95% proximal LAD lesion was stented
EF preserved by Echo; Peak troponin 10
In-hospital labs were remarkable for normal cbc, chem; LDL 170, hdl 42, nl lfts
Uncomplicated hospital course, sent home after 3 days.
ROS:
Since home, he states that he feels great.
Denies chest pain, sob, doe, pnd, edema, or other symptoms.
No symptoms of stroke or TIA.
No history of leg or calf pain with ambulation.
PMH/PSH:
Prior to this admission, he had a history of hypertension which was treated with lisinopril
40 pk yr smoking history, quit during hospitalization
No known prior CAD or vascular disease elsewhere. No known diabetes, no family history of
vascular disease; He thinks his cholesterol was always “a little high” but doesn’t know the numbers
and was never treated with meds.
History of depression, well treated with prozac
Meds and Allergies
Discharge meds included: aspirin, metoprolol 50 bid, lisinopril 10, atorvastatin 80, Plavix; in
addition he takes Prozac for depression
Taking all of them as directed.
No allergies
Social/Habits/Other
Patient lives with his wife; they have 2 grown children who are no longer at home
Works as a computer programmer
Smoking as above
ETOH: 1 glass of wine w/dinner
No drug use
Family history
No known history of cardiovascular disease among 2 siblings or parents.
Physical Exam
Well appearing; BP 130/80, Pulse 80 regular, 97% sat on Room Air, weight 175lbs, BMI 32
Lungs: clear to auscultation
CV: s1 s2 no s3 s4 murmur
No carotid bruits
ABD: no masses
Ext; no edema; distal pulses 2+
Labs and Imaging of note:
Cath from 4 weeks ago: R dominant; 95% proximal LAD; 40% Cx.
EF by TTE 1 day post PCI with mild Anterior Hypokinesis, EF 55%, no valvular disease, moderate
LVH
Labs of note from the hospital following cath: hgb 14, plt 240; creat 1, k 4.2, lfts normal, glucose
100, LDL 170, HDL 42.
EKG today: SR at 78; nl intervals; nl axis; normal r wave progression, no q waves
Assessment/Plan:
1. S/P STEMI: Proximal LAD disease which was appropriately treated with a stent. No immediate
complications and now doing well. No other critical lesions which require intervention at the
moment.
Plan: aspirin 81 indefinitely, Plavix x 1y
 Given nitroglycerine sublingual to have at home.
Reviewed symptoms that would indicate another MI and what to do if occurred
2. Hypertension: now well treated with metoprolol and lisinopril. No problems with adherence. Blood
pressure on target.
Plan: continue with current dosages of meds
Chem 7 today to check k, creatinine
3. Lipids: On high potency statin. No side effects
Plan: Continue atorvastatin 80mg for life
4. Smoking cessation: Doing well since discharge without adjuvant treatments, aware of supports.
5. Vascular Screening: Known vascular disease and history of smoking
Plan: AAA screening ultrasound
Disposition: Return to clinic 6 months.

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