How to present in the emergency department
In the emergency department, you present a patient in about the time it takes the attending to walk to the room. Sixty to ninety seconds, and the first sentence has to say whether the patient is sick.
- Target
- 60 to 90 seconds, leading with sick or not sick
- Lead with
- Sick or not sick, and the can't-miss diagnoses
Here is the worst-first format, a word-for-word example from a fictional patient with a likely pulmonary embolism, and the decision rules and questions that come up on every shift.
What your attending listens for
ED attendings are juggling a full board. Don't tell the story in order from 2018. Lead with the chief complaint, the abnormal vitals and the can't-miss differential, then say exactly what you want to order and where you think the patient is going.
The structure
Step 1: Room, acuity and one-liner
The room, who the patient is, the chief complaint and how long, and whether the patient looks sick or well.
Step 2: Focused HPI and red flags
OPQRST of the main symptom, plus the pertinent positives and negatives that rule the deadly diagnoses in or out: radiation to the back, pleuritic pain, syncope, focal deficits.
Step 3: Vitals and high-yield exam
Every abnormal vital sign, then only the exam findings that rule emergencies in or out: equal pulses in both arms, clear lungs, no peritoneal signs.
Step 4: Worst-first differential
Never lead with reflux or musculoskeletal pain. Name the life threats you are ruling out: ACS, PE, aortic dissection, esophageal rupture.
Step 5: Plan and disposition
Bedside now (ECG, point-of-care ultrasound, IV, oxygen, monitor), labs and imaging (troponin, D-dimer, CT angiography), symptom control, and the expected disposition: admit, or discharge if the workup is negative.
A word-for-word example
Step 1: Room, acuity and one-liner
Dr. Lee, Room 12 is a 48-year-old woman with a prior DVT, off anticoagulation, with sudden pleuritic right-sided chest pain and shortness of breath for 3 hours. She looks uncomfortable, and she is tachycardic and hypoxic.
Step 2: Focused HPI and red flags
The pain is sharp, 7 out of 10. No hemoptysis and no recent surgery, but she flew 8 hours from London two days ago.
Step 3: Vitals and high-yield exam
Heart rate is 114, she is satting 91% on room air, blood pressure is 126/80, and she is afebrile. Her heart is tachycardic but regular, her lungs are clear, and her right calf is mildly swollen and tender.
Step 4: Worst-first differential
My top concern is pulmonary embolism, with ACS and pneumothorax next. Her Wells score is 9, so PE is likely.
Step 5: Plan and disposition
I'd like a stat ECG, 2 liters of oxygen, a CBC, BMP, troponin and BNP, and to go straight to a CT pulmonary angiogram without a D-dimer. Unless you see a bleeding risk, I'd start heparin now rather than wait for the scan, and admit her to medicine if the CT is positive.
Ward pearls
- Say whether the patient looks sick or well in your first sentence, so the attending knows whether to walk into the room right now.
- Use decision rules out loud (HEART, Wells, PERC, NEXUS, Canadian C-spine, Ottawa ankle) to justify ordering an image, or skipping one.
- Finish with a conditional disposition: "If his repeat troponin at 3 hours is negative, he can go home with cardiology follow-up."
Classic pimp questions
- The HEART score for chest pain: history, ECG, age, risk factors, troponin
- PERC versus Wells for pulmonary embolism
- NEXUS versus the Canadian C-spine rule for imaging after trauma
- STEMI equivalents and high-risk ECG patterns: Wellens, de Winter T waves, Sgarbossa criteria in LBBB, posterior MI
Not sure how to field them? How to take the questions
Practice it out loud
A script you have read is not one you can say. Present a fictional patient to an AI attending who cuts in, asks why, and grades you on a rubric, then drills whatever you missed.
Try a free caseOne case, free. No signup, no card.
Other rotations
Educational content with fictional patients, not medical advice. Teams and institutions differ: follow your attending, your institution's protocols and current guidelines.