AAO-HNSF Primary Care Otolaryngology Handbook

CHAPTER 2

Presenting on Rounds

Patient presentations should be goal directed and follow this format: • Initial description: Describe the patient’s name, age, gender, and primary diagnosis or diagnoses. » » This often includes the patient’s hospital day and any recent surgical procedures. • Daily updates/tests: Include updates and tests since the last time rounding, such as procedures, imaging, consults, and change in clinical status. • Status/vitals: Note subjective complaints, vitals, and key physical exam findings. » » This often includes the ins and outs, and drain output. • Labs and imaging: Highlight relevant results. • Plan: Include actions that will move the patient closer to discharge. » » Discuss the disposition of tubes, lines, and drains. » » Consider diet and activity as well as consults and imaging. Here is an example following this format: Mr. Jones is a 63-year-old man with a T3 cancer of the tonsil that failed to respond to radiation therapy. He is postoperative day (POD) 3 status post a mandibulotomy, neck dissection, hemiglosectomy and partial pharyngectomy, tracheostomy, and a radial forearm free-tissue transfer for the reconstruction. His pain is well controlled, he is afebrile (with a maximum temperature of 38.2°C [100.8°F]), and his perioperative antibiotics have been discontinued. He is tolerating his tube feeds at 100 cubic centimeters (cc) per hour, and his drains has each put out 30 cc over the last 24 hours.

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