Preparation for Patient Rounds It’s 8: 30 AM, time to begin patient rounds. Today we’ll make patient rounds with the pulmonary team. In room 1107, we find 65yr. old Mr. Smith who was admitted yesterday afternoon. The pulmonary team includes the attending physician, senior pulmonary fellow, junior resident, and 3 medical students. The admitting junior resident who admitted the patient the previous day begins the case presentation. Mr. Smith presents with a sore throat, productive cough and shortness of breath; he's been febrile for 5 days; his illness failed to respond to IV Annkacin given during his hospitalization at a small local hospital so he was transferred to our hospital with the diagnosis of pneumonia. His family brought his medical records including a Chest X- ray and lab reports performed in the local hospital, but the junior resident left them in his on-call sleeping room. One of the medical students quickly retrieves the nursing chart from the nursing station. Review of the vitals is noteworthy for a progressive increasing pulse and respiratory rate during the night. The junior resident now briefly reexamines the patient, lung auscultation, and then the pharynx. After completing the physical exam, he notes the patient has "crackles" in the right lung base and purulent pharyngeal exudate. No results of yesterday's Chest X-ray, CBC, and ABG were provided. An ABG or pulse oximetry forgotten. Further examination notes bilateral diffuse crackles, BP 90/60,pulse 120, resp.32/min. He orders a stat ABG and Chest X- ray and while waiting we request the nurse check the patient’s O2 saturation using pulse oximetry and discover the O2 saturation is only 80%. Urgent arrangements are made to transfer the patient to ICU. A subsequent ABG shows pH 7.50, PC O2 30rnnff/g and P O2 46mm Hg. Within 1 hr. of ICU admission, the patient requires intubation and mechanical ventilation. Adequate preparation for patient rounds is essential for efficient, quality patient care. Poor preparation not only prolongs patient rounds, but worse it may delay “timely” decisions concerning the patient treatment, and even delay recovery and discharge. Ultimately it may compromise the quality of medical care and ominously even result in premature death! Adequate preparation for patient rounds should first include knowledge of the patient’s current condition, which may be obtained by a brief “pre-round” chart review, including the nursing record and a bedside evaluation as well. This should be followed by collecting current lab, X-ray, and pathology reports to be available for review during rounds. Although the written reports may not be available on the chart, often a preliminary report may be obtained either by phone or from a computer monitor on the ward. These results may then be discussed with other team members during patient rounds, which will facilitate earlier diagnosis and treatment. “Tools” are extremely necessary to perform a proper physical exam. No physician should ever begin rounds without a stethoscope and penlight in his coat pocket. Although he may not always carry a tongue blade, chopsticks or a teaspoon could be substituted for the oropharyngeal exam. Inspection of the oral mucosa may faciltate diagnosis of such diseases as pharyngitis, tonsillitis, mucositis, oral candidiasis or oral ulcerations, each of which may present clues to such diseases as SLE, HIV infection, herpes simplex, leukemia, megaloblastic anemia, or Behcet’s disease. The obvious importance of a stethoscope for physical examination should need no explanation. Lung auscultation may detect rales, rhonchi or wheezes; valuable clues to such illnesses as pneumonia, asthma or congestive heart failure (CHF). Decreased breath sounds may be noted with a pleural effusion, COPD, atelectasis and pneumothorax. The Cardiologist uses the stethoscope for cardiac auscultation; listening carefully to detect irregular rhythms, an S3 or S4 often noted in CHF and heart murmurs heard with stenotic valve lesions. Likewise, the stethoscope allows the examiner to detect mid systolic clicks in mitral valve prolapse and pericardial friction rubs. Other useful tools for patient rounds include the following:
A small ruler to measure skins lesions, nodules and PPD skin test reactions; A reflex hammer to assess DTR’s during the neurologic exam; A small pocketsize reference book that lists medications and their dosage. Alternatively, many physicians now purchase hand-held mini-computers such as the Palm Pilot that stores a veritable “wealth” of medical information accessed with a mere tap of the finger During patient rounds the resident should bring the nursing record to the bedside where the team can readily review pertinent patient data such as vital signs, fluid volume intake and urine output during the previous 24 hrs. The current medication list and the nurse's notes that may report frequent changes in the patient’s condition must also be reviewed. Often several medications may be discontinued or switched to the oral route. Finally, the physician’s attire and clothing must bear a professional appearance. Usually white coats are the standard physician’s attire. However, frequently physicians neglect to change their coat when it becomes “soiled” with blood, ink, urine or even fecal matter. This not only presents an unpleasant appearance to the patient, but also poses a risk of transmitting infection. An identification badge that identifies the physician’s name and level of training (attending, fellow, resident) must be clearly visible to the patient. This is important not only to identify the physician, but also for security reasons. n summary, adequate preparation for patient rounds is essential for efficient, organized and productive patient care. It not only facilitates efficient care, but also will engender patient confidence and trust in the physician team. Furthermore, poor preparation for patient rounds often leads to the omission of pertinent patient information and thus compromises the quality and safety of patient care.