[Music] Hello friends and welcome to Stereo Field Guide, a podcast dedicated to medical student general surgical education. I'm Alex and I'll be your guide. [Music] Hello friends, welcome to Stereo Field Guide. This is our very first episode. My name's Alex. I'm a third year med student. I am so happy that you're here. Today we're going to be talking about how to present a patient. I wanted to let you know up front that there's going to be a lot of information in this podcast, but not to worry if you miss some stuff. There will be little summary slides on our Instagram. You can find us at Stereo Field Guide on Instagram. So don't worry if you miss some stuff. There will be slides for you to review later if you get lost. So today we're talking about a super key experience as a medical student and that is how to present a patient. I remember just starting out on the wards and having absolutely no idea what I was doing despite having practiced presentations in my first year of medical school. And I feel like perfecting or getting sort of good even out of presentation is so key for showcasing your talents in the hospital because this is the one place where you can show the residents and the attending and the other people on your team that you know how to think about a patient and you can approach it in a systematic way. That being said, I think anyone can benefit from improving their presentation. So let's just go ahead and jump into it. Today we're talking about the SOAP presentation, the SOAP. Most of you have probably heard of this. If you haven't, welcome. This will be super useful for you on your clerkships. The SOAP presentation stands for subjective objective assessment and plan and we are just going to go through those things one by one, talk about the components of each section and sort of an example of what that might look like when you're giving a presentation. So before you jump into the nitty gritty details of your presentation, it's a good idea to always give a one liner and a one liner is basically who the patient is while they're in the hospital. You can also include pertinent pass medical history in this and their most pressing issues especially if they're super complex. It is not a great idea to include every single diagnosis they've ever had in their pass medical history in your one liner. This should be very brief and orient the team to who you're talking about and what is going on with them right now. An example of a one liner would be something like this. Miss Smith is a 42 year old woman with a pass medical history of polytraumas, status post bowel resection in 2016 who presented to the hospital on Tuesday with abdominal pain, nausea and vomiting. You'll notice that my one liner sort of clues the audience into the differential diagnosis that I'm thinking of right away. If you have a patient who has had passed abdominal surgery, they're coming in with abdominal pain, nausea and vomiting, something that should be on your differential would be a small valve obstruction or some sort of other obstruction. If they've never had abdominal surgery, this is going to be less likely. So including key elements of the history in the one liner is important. Okay, so you made it past your one liner and now we are on to subjective. So subjective is exactly what it sounds like. These are things that are not concrete data. A lot of times this is what the patient reports to you when you talk to them in the morning as well as any overnight events. If you're talking to the patient in the morning and their pain is not well controlled, if they've been having trouble sleeping, if they have worsening symptoms, those sorts of things would be something you would talk about in the subjective. In addition, events overnight would be like patient went for MRI, patient decompensated, needed suctioning, RT had to see them, or you could say something like no acute events overnight if they slept peacefully and nothing crazy happened. I also like to include in this section, if a lot of consultants saw the patient from the last time the patient was presented, I like to give a summary of who saw them and what their recommendations were. So for example, if overnight plastic surgery saw them, wound care saw them, I would say plastic surgery saw this patient, they recommended XYZ wound care saw this patient and put their wound care wrecks in the chart. So that's another thing that can go in your subjective as well. Okay, so moving on to the objective section, this section has a lot of components and so this is the one we're going to spend the most time on. And like I mentioned earlier, there will be summaries of what I'm talking about as well as examples on the Instagram after this episode goes up. So don't worry if this is a little bit overwhelming. So a list of components that could be in your objective section would be the patient's vitals, labs, imaging, their physical exam, and sometimes I would do medications and use of PRNs or as needed medications if you're not familiar with that term. So starting with the vitals, I present the vitals on the patients every single time and I usually present them in sort of a systematic way. So find what works for you or listen to how other people present their vitals and follow their lead. An example of how I would present vitals would be like the patient is a febrile, they have a normal respiratory rate, they were tachycardic to the 110s overnight, systolic, ranged from 90s to 120s overnight and they're setting 92% on two liters of oxygen. This would also be a time where you would want to know what their ventilator settings are if the patient is intubated and on a ventilator. It's important to sort of know what's contributing to their oxygen saturations and we'll go over ventilator settings and sort of what that means in a separate episode, but that's kind of beyond the scope of what we're talking about today. Another thing that you can present as far as their vitals go is their ins and outs. So this is basically a summary of what the patient has consumed as far as liquids goes, what they have put out as far as urine or blood or those sorts of things. I would always have a lot of this stuff is going to be stuff that you're not going to talk about in your presentation sometimes, but you would want to have it written down in case you get a question asked about it. So what would be relevant and why would you want to talk about the ins and outs? If you're monitoring the patient's renal function, it would be important to sort of have an idea of how much urine output they have. You could even go the extra mile and see calculate what their urine output is per hour, per kilogram, and there are certain cutoffs for what we like to see as far as renal function is concerned, especially with burn patients or people that you're really targeting some sort of urine output. If you gave the patient lasex or some other diuretic and you want to see if that's working, you're going to want to keep an eye on the output. The patient has any renal disease, you're going to want to keep an eye on the ins and outs. Another thing is if the patient has some sort of tube, like a chest tube or a JP drain from an abdominal surgery, you're going to want to know how much came out of that tube in the last 24 hours, because that can inform when that tube can come out or if something needs to be done to stop that much fluid from coming out of it. There are certain cutoffs for when you would pull a chest tube, when you would pull a JP drain, but there are also things that would be concerning like if it starts to put out a lot more than it was before. That is something to keep track of. All right, moving on to the lab section. There are a couple components of this that you'll want to keep track of to be a star med student. And I think the first and most important component is knowing the results of the new labs. And then what labs are still pending at the time of your presentation. One step further, knowing the trend of the labs is really important. For example, if you have a white count of 14, and it was 17 yesterday, that's good progress, but if you have a white count of 14 and it was nine yesterday, that's a new problem. So it's important to know what the labs were yesterday. And there is a way to denote these. I don't know if you all have heard of the fish bones or the ways to keep track of, especially like a CBC and a BMP has kind of a systematic way that you can write it down. And these will be included on the Instagram, but one way to keep track of the labs from yesterday is to put them in parentheses next to the new labs. That way, when you're giving your presentation, you can easily reference what the labs were yesterday, especially if you don't have access to a computer or a phone to get onto the EHR during your presentation, which I typically didn't, I don't know how it works at your med school. I also would recommend not presenting normal, normal lab values, but having them written down. It is possible that when you're just starting out on the words that your attendings or residents will ask you to say everything, and it's important to have these handy in case that happens to you. But if you're trying to give us a synced presentation and show that you know how to think critically, I wouldn't present normal lab values unless they are newly normal. If the BMP has absolutely nothing new about it, I would not present the potassium in the bicarb, and you just don't need to do that if it's not new, but have it available in case somebody asks you what it is. So an example of how I would present the lab values would be white count is 14 up from 13 yesterday. The hemoglobin is stably low at 8. BMP is unremarkable. Blood cultures from yesterday are no growth to date, and the urine culture is still pending. The next section we're going to talk about is imaging. So in this section, pretty self-explanatory, you're going to want to know the results of any new imaging that has resulted since the last time we talked about them. You don't have to read the entire radiology report, but you should report the pertinent finding. At least in our institution, there is a radiology report that's extremely long, and then there is a secondary report that just gives you the nitty gritty of what you need to know. I'd recommend that you read both of these, and if there's anything that you think is extremely important in the longer report, you can also bring that up. You can also talk about what imaging has been ordered, but not yet completed, especially if it's like over the weekend, and you haven't got an MRI back, you can say, patient is going for MRI at 2pm today. The next section in your presentation.
will probably be something like your physical exam. This is something you've probably already learned, but in the case that you would like a little review, I like to go from head to toe, starting with mental status. A normal exam for mental status would be alert and oriented to person place of time. Then you can move on to your head and neck exam, lymph exam, and normal example of a lymphadenopathy exam would be there's no cervical lymphadenopathy or tenorinistopalpation. You can then move on to your chest exam, a normal chest exam would be lungs are clear bilaterally to osculation, then talking about the heart, you could describe it as normal rate regular rhythm, no murmurs, rubs, or gallops. If the patient has lines, tubes, and drains, this is the time to make note of that as well. So if they have a central line in their neck, that would be something that you wanna note in the neck exam. If they have a chest tube, that would be something that you would note in the chest exam. Some of the language around chest tubes, you could say something like chest tube to water seal on the right with this many milliliters of sarosanguines output. We will talk about chest tubes in a different episode. So there's different ways that you can have chest tube, you can have them to suction, to water seal, et cetera. That's not really the scope of this episode. So we'll talk about that at some other time, but you can always ask your team if you're not sure yet. And then we can talk about what different types of outputs are as well in a different episode. Sarosanguines would be sort of normal. For your abdominal exam, normal language would be bowel sounds or present and all four quadrants, no tenderness to palpation, soft and non-distended and all four quadrants. And then obviously if they have anything abnormal, you would wanna note that as well. For the GU exam, this is where I would probably note like fully information, like if they have a fully or a super pubic cath or a condom catheter. I would just use discretion when doing a genital urinary exam. There's no need to violate a patient's privacy if it's not indicated. It's also sort of like a star medical student quality is to know what day the fully catheter is on and if there are plans to take it out, just because for prevention of catheter associated infections, it's good to know when that catheter needs to be changed out or if it's been into long, that's something that you can note. You'll also want to make note of the output of the catheter and a normal output would be clear yellow urine. Moving on, you can focus on the extremities, is where you would look at the skin for rashes, wounds, swelling, you can note pitting a DEMA in the extremity exam. And again, you're gonna wanna make sure that you make note of all lines, tubes and drains, as well as access points. So if the patient has two large borrilles, this is very important in a trauma patient or in a burn patient. The next thing on my list, this is like a plus minus thing you might include this, but it's not a bad idea to be familiar with and that is what medications your patient is on. Some common medications that you may want to make a note of if you do choose to include medications and your presentation would be PRNs for pain or as needed medications for pain. This is a good way for providers to keep track of both how well the pain is controlled and if the patient is getting closer to discharge, there are different criteria for what kind of pain regimen you need to be on to be considered for discharge. So good to know how often they're taking it and what dose, but also if their pain is not well controlled and you know how often they're taking that, this gives you a good place to start for adjustments. Another common medication to keep track of would be anti-coagulants. A lot of patients in the hospital are on deep vein thrombosis or DVT prophylaxis agents, like HEPRAN or anti-10A agents. It's a good idea to keep an eye on these medications to make sure that your patient is on them if they need prophylaxis and if they are not on them, what reason are they not on them? Like if they're a bleeding risk as it is or they have another another injury that would preclude them from getting prophylaxis, it's important to note what they're on especially if you're concerned for things like HIT. Next, antacids are fairly common especially critically ill patients are often put on PPI's to prevent stress ulcers and you'll want to know if your patient is receiving the appropriate prophylaxis. Understanding if your patient is on an antacid can help you understand their pathology. For example, it's a risk factor for some ventilator associated pneumonia and C-DIF. So you want to make sure if your patient is having these symptoms or you're concerned for this pathology to know if your patient is on an antacid. Finally, a bowel regimen is something that you'll want to make note of. If you haven't already, many patients in the hospital have trouble having bowel movements. This seems pretty intuitive. It is hard to have a bowel movement in an unfamiliar place especially if you're critically ill, especially if you've just had abdominal surgery. And it is a requirement for discharge in many conditions if not all conditions. So you'll want to make sure that you're keeping track of how often your patients are having bowel movements if they're passing gas, et cetera. But also if they are not doing those things, what laxatives are your patients taking? Are they on mirror lax? Are they on docu-sate? Have we done an enema? Have we done suppositories? It's important to sort of know if your patient has bowel regimen. And then also just being familiar with your institution's bowel regimen recommendations is a pro tip. So if you're already giving the patient mirror lax and it's not working, for how many days do you try that before you add another agent? A lot of institutions will have sort of a protocol that they follow as far as bowel regimens are concerned. And that is a lot of information on what to keep track of with your patients as far as meds are concerned. And I have sort of a checklist system that is good to run through as far as objective data. And I will include this fishbone in the Instagram, but I'll go ahead and run through those different things with you right now. Another fishbone checklist that you can use to make sure that you're paying attention to sort of the human components of a patient that they should be able to do prior to discharge. And again, this fishbone will be available to you for free on Instagram. But these components are air details. So like if the patient is on room air or if they have any oxygen requirement, some examples of this would be patient is on room air, patient is on two liters, patient is on 10 liters, high flow nasal cannula, patient is intubated with these ventilator settings. The next section is the diet that they're on or what kind of feeds they're getting. So you could say regular diet soft feeds, awaiting a swallow study. You could also say tube feeds at goal. The next thing to keep track of is if the patient is avoiding and this is also a term for having urinary output. This is important to keep track of in the hospital. The next section is bowel movements which we just had an extensive conversation on. So just if they have or have not had a bowel movement since hospitalization, there's a prophylaxis section which we just talked about three pretty common prophylaxis medications, which again are anti-coagulants, antacids and a bowel regimen. There may be other prophylaxis medications depending on what service you're on. But those are three pretty common meds that a lot of patients in the hospital are on. And then this may be specific for higher acuity or traumatic injuries, but understanding where PT and OT have recommended this patient for discharge is important or just in general understanding what the expected discharge will be. Discharge planning is hugely important in the hospital and understanding like when patients need to go where is important for their care. And the final thing on this fishbone is noting the patient's code status. It has been proven that reminders of code status if it's not documented have improved code status documentation. So even if your patient does not have a code status documented, it's not a bad idea to say no code status on file. So I'll go ahead and run through a verbal example of what running through this fishbone really quickly would be like sort of at the end of your objective section. So you could say the patient is on room air has tube feeds at goal, has voided, has had a bowel movement, is on antacids, is on heparin for DVT prophylaxis and has a bowel wedge. PT, OT have recommended them for IPR and their code status is not on file. And that is a good summary of your objective section. Moving on to assessment and plan. These sections are sometimes added together and that's typically what I do and there's two ways to approach this. You can do a plan by problem or a systematic assessment and plan. And so for a plan by problem, this is usually useful if your patient has just a couple of problems and you can list all of them. I would say maximum of five problems for a plan by problem 'cause it can get pretty lengthy and hard to follow as a listener if you're not doing a systematic plan. For instance, if your patient's only problem is they have a new fever, you could do a plan by problem. During your assessment, you're gonna want to state your differential and sort of your reasoning for why that's on your differential. This can be short. So you could say this patient has a new fever. My differential includes clobsy which is a central line associated bacterial infection. So you could say my patient has had a central line since this date and so this is on my differential. I'm also concerned for a catheter associated UTI because the patient has a foley that's been in for this long. I'm also concerned for pneumonia because such and such. And you'll want to with your differential say the thing that you think is the most likely first. And when you're stating the thing that you think it is, you can say because I'm concerned that this patient has a central line associated infection, I would like to get blood cultures. Because pneumonia is on my differential for these reasons, I would like to get a chest X-ray.
And so those are some things that you would include in your assessment implant. Another way that you can approach this is a plan by system and this is pretty common when patients are critically ill or have a ton of problems and it really helps you to keep track of all the things that could be going on with your patient. There will be a list of these things in order on the Instagram but I'll run through them right now. A plan by system would be addressing neurology, respiratory and cardiac, FENGI. FENGI stands for fluids, electrolytes and nutrition as well as GI. The next system would be renal and genocurinary, endocrine and then extremity. Some examples of the things that go in the neurosection are like pain, orientation, those sorts of things. So you will, if your patient has poorly controlled pain, you'll address them in your neurosection and that's a pretty common complaint. There are also examples of things that you can address in the neurosection on the Instagram post. For respiratory and cardiac, these would be anything that has to do with the patient's work of breathing, the clearness of their lungs, infectious causes, as well as blood pressure, tachycardia, concerns about the heart and the lungs. For FENGI, these would be things like I want to start a diet, I want to get a swallow study as well as any concerns about the patient's electrolytes or their GI. So if they have like an abdominal complaint, you would include this in the FENGI section. For renal and GU, this is a place where you can include things about their urine output, concerns about their kidneys, plans about a foley, plans about a UTI, etc. For endocrine, this is pretty commonly going to be managing things like diabetes and thyroid concerns, but you can also include things like the need for steroids, the need for a consult to endocrinology or any other endocrine need that this patient may have. And then for the extremities, if the patient has an extremity concern, you can include that. That's not typically included, but it can be if your patient has a specific concern. Finally, if you do an assessment before you do a plan and you keep them separate, you'll do your assessment and then plan, you can do a plan by problem. That's pretty self-explanatory. I would also just really encourage you. I think the best learning in medicine sometimes occurs when we're wrong or we don't really know what the answer is and I would encourage you with every patient every time as soon as you hear this trying to make a plan, even if you're wrong, you're attending and your residents and the rest of the people on your team probably do not expect you to be correct. They probably will appreciate that you're trying to learn and doing your best by making a plan. And the thing is, is that some of the things that you learn in first year or second year, depending on how your program works, are not actually the way that medicine is practiced. So making a plan based on what you learned and saying that out loud can help you learn that that's not actually how we do things. So it doesn't hurt to try. It's really great practice and it helps you ask questions without asking questions and sort of solidify your learning. All right, friends, and that is how to present a patient. I hope that you enjoyed this very first episode. Some reminders. I said a million times this episode, but you can find a lot of additional information or resources on the Instagram page at Steerlefield Guide. We also have a Patreon. You are absolutely not required to sign up, but if you are able, you can sign up as a supporter for $1 a month or you can sign up for $5 a month and receive exclusive educational content once a month in the form of an educational video. I would love to see you there. And I'm so happy that you're here. So take care and I'll talk to you soon. That's it for today's podcast. You can support this podcast and receive exclusive educational content on Patreon and find us on Instagram @SteerlefieldGuide. Questions and requests can be submitted to our Gmail @
[email protected]. Thank you for listening. And until next time, may your retraction be superb and your sutra tales be the perfect like.
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