Oral Presentation Guidelines

Framing statement
Chief concern / ID / One Liner

o This is a 60 year old F with a history of (up to 3 relevant

things) who presents [from where? If relevant] with
shortness of breath, admitted for CHF exacerbation

HPI (include relevant ROS, PMHx, etc. here)

o
o

Baseline / USOH describe status of PMH items from CC

Now: pt was in this state until ___ ago, when they developed
____

Past History
o PMHx / PSurgHx
List new items; give state / severity (last FEV1, uses 2L
O2 for COPD)
For writeup; list previously mentioned items w/o
description too
o Meds (doses, indications, etc)
o Allergies / Intolerance (describe rxn)

o FamHx
o SocHx incl. functional status (ADLs / IADLs) and
cognitive status
ROS (relevant)

Physical Exam
o Vital Signs (with ranges as needed)
o General Appearance give a good descriptive picture of
the patient

o Rest of exam by system

Labs / Data: CBC, BMP CMP, LFTs, U/A, micro, Imaging

(simple complex)
o Group related (e.g. WBC & diff, Hbg / MCV, Na/Cl/bicarb & AG

Assessment / Plan
o Summary: CC + p/w SOB, found to have (hx, PE, Data),
admitted

o Problem #1 - _______
Subjective / Objective brief summary to set
up for

Assessment

If Dx unknown: 2-3 item DDx; most likely,

reasoning
If Dx known: assess if better, worse, same

Workup (for each item on DDx)

Treatment plan

Plan:

o Problem #2 - _______
o For problems, remember social issues, functional
status, dispo
The follow-up presentation:
1. 8-10 word headline reminder of who the patient is
(or one-liner)
2. Problem list
a. Problem #1: _______
i. Overnight events / updates
ii. Current PE
iii. Assessment / Plan
b. Problem #2: _______

The Interview, Clinical Reasoning, DDx

Start by getting a full list of concerns

Frame the situation whats important
Keep a running DDx / questions to ask / PE exam
maneuvers to do
o VITAMIN C
o Most common
o Worst-case scenario

VITAMIN C:
Vascular
Infection
Trauma
Autoimmune
Metabolic / Medications
Idiopathic
Neoplastic
Congenital