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Do…
  1. Proactively see patients
  2. Take a thorough but focused history and physical
  3. Construct an emergency department appropriate differential diagnosis
  4. Construct a plan for your patient including diagnostic workup and treatment plan
  5. Present your case to an EM resident
  6. With the help of the resident, hone your presentation and thought process
  7. Present your case to the attending
  8. Follow up on test results and reevaluate your patient frequently
  9. Help with procedures
  10. Follow critically ill patients in the department for your own learning

 

Do Not…
  1. Minimize patient complaints – assume complaints are legitimate
  2. Run in the department
  3. Be disrespectful to any ED staff member
  4. Be disrespectful to any ED patient
  5. Be late
  6. Dress unprofessionally

 

How to Proactively See Patients

 
Keep your eyes on the patient tracking board and remind the resident with whom you’re working that you would like to see a patient.  Do not be discouraged if the resident sees patients without you.  The ED resident will often be very busy and potentially overwhelmed with their own workload, try to find a moment of down time to politely remind the resident that you would like to see a patient.  If the resident is too busy, feel free to ask the attending to see a patient.

 

An ED Appropriate History
  1. When in doubt, be thorough and do a full h&p.  That said.  Don’t do that.
  2. Obtain a chief complaint from the patient.  Do not assume that the patient’s chief complaint in the nursing note or on the tracking board is accurate.  In order to obtain an accurate chief complaint form the patient, you may have to ask the patient specifically why they came to the emergency department that day.  Sometimes asking the patient what you or the ED can do for them that day will also elicit a different request or complaint.  This approach will prevent you from going down the wrong pathway with a patient.
  3. Obtain an HPI.  Don’t forget OPQRST – onset, palliation, quality, radiation, severity, timing.  Try to learn some of the things that are important specifically for the ER – i.e. for cardiac patients – when was their most recent cath/stress test, who is their cardiologist.  We often forget to think of these pieces of information as part of the HPI – but they can often give you a greater insight into the patient’s reasons for presenting to the ED and help with plan and disposition.
  4. Do a review of systems and past medical history – but be very focused.  At this point in your history you should already have a small differential that is forming in your mind given the chief complaint and HPI.  Ask ROS and PMH questions that coincide with the specific differential in your mind.  Use your knowledge of clinical decision tools such as PERC for PE and Nexus rule for CT c-spine to help direct some of your ROS questions – i.e. if you are trying to rule out a PE you can add to your ROS questions about DVT signs/symptoms, hormone use, recent travel, etc.
  5. At the end of your history it is often helpful to give the patient an opportunity to ask any additional questions or to remind you of anything you may have forgotten to talk about.
  6. During the history, you may encounter patients that are circumstantial or tangential.  It is important to rapidly redirect these patients in a polite manner.  Most patients respond well to the following, “I’m very sorry to interrupt, but it is important that I obtain some information so we can expedite your care in the emergency department – we can talk more about this other topic a little bit later.”  If you do not become good at redirecting patients, your history will easily take 20 or 30 minutes instead of 5-10 minutes.
  7. Before leaving the room, let your patient know that you will be discussing the case with other physicians and you will get back to them with information regarding their plan.  Do not tell them anything regarding plan until discussion with the resident or attending.  Otherwise, the patient may get conflicting and confusing information.

 

An ED Appropriate Physical
  1. When in doubt, perform a thorough and complete physical examination.
  2. However, if you can, perform a focused exam.
  3. At the very least, your exam should consist of a very thorough visual exam of the patient – note their appearance, their level of distress.  A cardiopulmonary exam is appropriate for most patients with any systemic or cardiopulmonary complaint.  For neurologic complaints – perform an HEENT exam, a full neuro exam, etc.
  4. When you leave the room you should have in your mind an answer to the question, “Do you think this patient is sick, or not sick?

 

Constructing a Differential
  1. When in the ED, your goal is primarily to rule-out life and limb threatening diagnoses.
  2. So, when constructing your differential for chest pain, your top diagnoses to consider are acute coronary syndrome, pulmonary embolism, and aortic dissection – not musculoskeletal pain, GERD, and pleurisy.
  3. When you present your differential, it is appropriate to say something like – “I want to rule-out ACS, PE, and Dissection, but I think the patient most likely has GERD.”
  4. Don’t say something like, “I think the patient has GERD. I want to give them pepcid and send them home.”  This will make your superiors believe that you did not consider the other more morbid diagnoses, which is your job as an emergency medicine student.

 

Presenting
  1. Follow the standard method of presenting, but give only pertinent findings.
  2. Your HPI should contain only pertinent past medical history and medications.
  3. Your physical exam should include only relevant positives and negatives, not entire systematic exams.  Never forget vital signs!
  4. Include ROS questions, if pertinent, in your HPI.
  5. Give a short differential, impression, and plan.

 

An Example Presentation

 
Mr. F is a 69 y M with a history of CAD, MI, DM, and HTN.  He presents today with 6 hours of L sided non radiating chest pain that feels like a pressure and is worse with movement of his left arm but did not improve with rest and motrin.  The pain is constant.  He has not had any fevers, chills, nausea, vomiting, diaphoresis.  His last cath was 2 years ago and revealed no critical stenoses. He is here because he wants to make sure he’s not having a heart attack.  He is well appearing, in no acute distress.  His HR is 90 BPM, his blood pressure is 140/80 and his O2 sat is 98% on room air.  He is afebrile.  His cardiopulmonary exam was within normal limits.  His chest pain was reproducible with palpation at the costosternal margin and with both passive and active movement of his left arm. His EKG shows normal sinus rhythm with an old left bundle branch block but no acute signs of ischemia or infarction.  Given his history, I am concerned about acute coronary syndrome.  However, given his presentation today I think he most likely has musculoskeletal chest pain.  Other diagnoses of concern that I believe are less likely are PE, dissection, pneumonia, pneumothorax, pleural effusion, pericarditis and pericardial effusion.  I would like to order basic lab tests, a troponin, a chest x-ray and treat the patient with analgesics and anti-inflammatories.  If we can rule out ACS and the patient feels better, I believe it would be safe to send him home.

Author: Steven Kornweiss