In May 2015, members of EMRA (Emergency Medicine Residents Association) and CDEM (Clerkship Directors in Emergency Medicine) created a how-to video on effective patient presentations in the ER.
Presenting a patient can be like telling a story. Much of this is dependent on starting with a good differential diagnosis. As Dr. Gordon says in the video above, there are three parts to this story.
☑ Demographics: name, age & gender
☑ Pertinent PMHx only
☑ Reason they are here (chief complaint)
☑ History arranged according to illness script
☑ PMHx, ROS, Soc Hx integrated into narrative
☑ Vitals: highlight abnormalities (or “unremarkable”)
☑ General Appearance
☑ Physical attributes based on DDx
☑ Most imminent
☑ Most likely
☑ High-risk, do not miss
☑ High-risk, considered but excluded
☑ Low-risk and low probability