Presenting the Pediatric Patient
This is intended as a practical guide for making presentations of new
or existing patients on either rounds or sign-outs.
The purpose of these presentations is to make the listener aware of the
present situation, how things came to be this way, and what you intend
to do about it.
New Patient
If a patient has just been admitted, a full presentation should be made.
In general, it follows the format of the history
and physical, with each element in the same order. After recounting
the initial history, vital signs, and physical exam, summarize the initial
assessment and plan. Then continue as below, describing the interim
hospital course, present vital signs, physical exam, labs, and an updated
assessment and plan. As always, present the assessment and plan organized
by system, with the systems presented in order of importance. The
entire presentation for a new patient should be between five and ten minutes
long. If new team members are present, existing patients should be
presented in this format for the sake of continuity.
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Identification
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HPI, all pertinent negatives, ER course
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PMHx details which supplement HPI
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Meds (dose, frequency)
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Allergies (reaction)
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Diet, Development, Immunizations, Family Hx (relevant parts), Social
History (short)
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Pertinent items from review of systems
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Vital Signs, General Assessment, Pertinent (+) and (-) on PE
-
Labs: which ones performed, all odd values, any changes from previous
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Assessment and Plan by System
Existing Patient
If the team has already heard the initial presentation once, the daily
presentations can be made shorter. The initial presentation and hospital
course are compressed down to a few sentences. State the patient's
name, how long they have been in the hospital, why they are here, and then
begin a presentation following the form of a SOAP
note.
-
Name, age, disease, problems, hospital day
-
Overnight hospital course
-
Vital Signs
-
PE (brief)
-
Assessment and Plan by System
-
Overall Summary, Discharge Planning
Sign in/out
Sign in/out, while less formal, must be sufficiently detailed to transfer
patient coverage responsibilities from one care provider to another.
It is generally more brief than formal rounding. The presentation
concentrates on practical issues, particularly what must be followed up,
monitored, and adjusted in the immediate future. An effort should
also be made to project likely events during the next shift, and make plans
for all contingencies related to the patient's condition, such that when
they occur, a plan is already in place. The weight should be stated
so that no one has to go searching in case emergency meds are needed.
It is also important to state which attending is responsible for the patient,
and who to call if there are problems.
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Room number
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Patient Name, Age, Gender
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Patient weight
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Attending
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Diagoses
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Allergies
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DNR status
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Most recent Chem and CBC (other labs if pertinent)
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All Meds, including O2 requirement
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IVF type and rate
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Diet
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Labs and Tests that need to be checked
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Any items that need to be ordered
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Any people that need to be contacted
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Assessment and Plan by System
Acknowledgements
Zack, BG. 1982. A guide to pediatric case presentations.
Resident and Staff Physician (Nov):71-80.
Please direct all comments to: 
Last modification: February 21, 1998