Medicine Presentations

Inpatient Presentations Workshop

Primary Resident Presentation

• One sentence overview 

• One sentence PERTINENT overnight events

• One sentence PERTINENT physical exam 

• Problem List

Example:

Jane Smith is a 72 yo retired teacher with CHFrEF admitted 5 days ago for acute hypoxic resp failure due to CHF exacerbation.  Overnight, she weaned down to 1 L O2 by NC, but the nurses report a new stage 1 pressure ulcer on her sacrum.  Physical exam reveals trace bibasilar lung crackles, 1+ BLE pitting edema, and a 5x5 cm area of erythematous, non-blanching skin over her sacrum.  Problem number:

1. Acute hypoxic resp failure secondary to CHFrEF –  TTE on admission showed LVEF of 40%, on Coreg 12.5 mg, losartan 50 mg, and Lasix 40 mg BID.  BP controlled, O2 demand improving.  I’d like to start spironolactone 25 mg daily for better diuresis and to improve Lasix induced hypokalemia.

2. Sacral pressure ulcer – New, nurses offloading area, monitor.  Consider wound care consult.

3. Depression – stable on home Zoloft, mildly worse in hospital, assess mood daily.

4. FEN – No IVF due to fluid overload.  Hypokalemia, replaced, starting spironolactone.  Mg was appropriate.  Continue cardiac diet.

5. DVT Prophylaxis – Lovenox

6. Dispo – anticipate discharge home tomorrow, PT/OT cleared for home with HH.

DRAFT Table Rounding Guide

1. Primary resident presents patient

• One-line summary

• Problem List

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2. Pharmacy learner contributes (students or residents)

3. Supervising resident offers feedback

4. TCRN

5. Attending

• Identify follow up teaching points

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