The Patient Presentation

Angkor Hospital for Children

Faculty Development Course

Good patient presentations begin with asking:
Who am I presenting to?
What am I presenting for?
Where do I start? Differential diagnosis
Why is it important? The life of my patient
How do I present? Short, simple & complete


Audience
(. )

Purpose
(.....)

Length
(...)

Essential elements
(.[.j.:..[....)
New patient


IPD patient


ICU patient


OPD patient


Consultation


Morning
Check-out
(night doc to
day doc)


Evening Check-
out (day doc to
night doc)


The Patient Presentation

Angkor Hospital for Children
Faculty Development Course

Patient Scenarios
These scenarios arent complete but are meant to give you some ideas for your presentation.
Feel free to can make up more details to complete your presentation.
You dont need to present all the information, only what is relevant to your presentation.
New patient
(senior to senior)

HPI: 12yo male with 2 month history of hemoptysis and some weight loss (about 2 kg).
Mother states coughing worse at night but no other sick contacts. Patient goes to school,
father works as farmer, mother cooks at home and uses firewood. Many farm animals and
dogs. 2 other brothers and a younger sister. Grandmother died of colon cancer. Grandfather
had a heart attack. Paternal grandparents died in war. Patient likes to go fishing.
PE: 37.8 80 16 110/80 27kg. Gen: Alert, no acute distress; HEENT: PEERL, EOMI,
TMs clear, NP moist; Lungs: faint wheezing R mid-field, good air movement; Abd: Flat, soft,
non-tender; GU: L hernia easily reducible; Ext: no cyanosis, clubbing, edema; neuro: non-
focal.
IPD patient
(senior to senior)

5yo female hospitalized for pneumonia. Given fluids initially (5 days ago) and started on
ceftriaxone. Patient with good response and now off oxygen. Eating well. PE: afebrile, vital
signs stable, lungs clear, breathing comfortably on room air. Lives close to the hospital.
Father works as a motorcycle taxi driver.
ICU patient
(senior to senior)

12 day old female admitted for rule out sepsis. First child, no complications in pregnancy or
delivery. Mother not ill. Breastfeeding. CBC, UA, blood cultures, LP done but results not
back yet. CXR clear. Started on amp/gent. PE: 37.9 - 155 60. 3.3 kg Child appears toxic.
OPD patient
(senior to junior)

4yo male brought in by mother with history of fever, malaise, sore throat, and vesicular rash
over trunk and face. No ill contacts. The child is usually taken care of by his grandmother.
He has an older brother and younger sister. Neither have had chicken pox before. Mother is 4
months pregnant. PE: 38.0, rash as described.
Consultation
(senior to
consultant)

8yo female with stage C heart failure due to rheumatic heart disease she is mildly dyspneic
at rest but cannot do significant activity without discomfort. She doesnt take any
medications, do any specific exercises or follow a particular diet. She attended school until
about two weeks ago when she noticed swelling in her feet and greater difficulties breathing.
She is the oldest in her family with 3 younger siblings. She hopes to become a teacher when
she grows up.
Morning
Check-out
(night doc to
day doc)

13 yo female was admitted 1 day ago for observation due to abdominal pain overnight
became diaphoretic, increasing abdominal pain, emesis x 2, temp 37.5.
Evening Check-
out (day doc to
night doc)

12 yo male who has been in the ICU for 5 days for community-acquired pneumonia (CAP)
was extubated today. Oxygen sats 98% on 4L. Desats on coughing. On ceftriaxone and
erythromycin. Sister recently treated for malaria.