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So you have assigned yourself to a patient, and have come to speak to your supervising doctor (Senior Reg or Consultant).

TL;DR
- Start with the working diagnosis / issue that needs to be addressed by the emergency department.
- Do not mention positive/negative findings on your assessment (hx/ex/ix) unless prefaced by a working differential.
- Only discuss disposition once there is a clear working differential and plan.

Part 1: ED Workflow

ED workflow is very straightforward. Assign yourself to a patient. As a rule of thumb, do not spend more than 15 minutes with a patient before seeking advice from a senior clinical decision maker (SCDM). This could be a consultant or senior registrar / advanced trainee. 30 minutes after assigning your name to a patient, the following three issues need to be determined:

• A reasonable ED working diagnosis
• Investigations have been ordered
• A tentative disposition has been determined.

[Working diagnosis] Not necessarily the final discharge diagnosis and can be changed at any time. eg. “Moderate risk angina”. It then needs to be followed up by a somewhat reasonable plan, with endpoints. The final diagnosis may be a NSTEMI, but that’s not important at this stage. You need an initial reasonable working diagnosis in ED.

[Investigations] need to be focused, specific, and justified. Do not go fishing for unknown differentials. “The patient has abdo pain, hence i’ve ordered an ultrasound” – is almost always inappropriate. Ultrasounds in particular take a lot of time (sonographer / resource intensive) and are quite unpleasant for a patient in pain. “The patient has a positive murphy’s sign and a history of biliary colic – hence i’ve ordered an ultrasound of the gallbladder to exclude cholecystitis and to look for an obstructive gallstone.”. The same can be said for CT scans and labs in general. I am less interested in the tests that you ordered than the reason behind the ordering of the tests.

[Disposition] needs to be determined early as bed managers need warning of pending admissions to do their job effectively. If a patient is unlikely to go home, there needs to be a bed requested. Dont worry, this can always be changed later and you will not get into trouble for requesting beds and then standing down the bed request. As a rule of thumb, if a patient will likely go home within 4-24 hours, an ED short stay (ESSU) bed is appropriate. Otherwise, an inpatient bed under the most likely speciality should be requested.

Part 2: Presenting a Patient to your supervisor.

There is nothing more annoying/irritating than a random list of positives and negatives being blurted out without any differentials or thought processes. You are not a scribe. You are not a medical student. Have faith in your years of study, experience at intership, and medical school. The most important thing you need to do is to consolidate the information you have and present it in a (somewhat) logical manner. Every positive or negative finding must be presented in context of the patient and why it is relevant to the case. Below is a template you could use:

(Most Senior Registrars will present patients at this level)

Mr/Ms Patient has [Clear ED Issue / Working dx] evidenced by [X]. I have excluded [red flags] from my [assessment], and the plan is for [treatment]. The patient will be [admitted / discharged]. 

- Social/psychosocial issues have been addressed. 
- Goals of care discussed if appropriate. 
- Referrals/consults have been made.

(Most Registrars will present patients at this level)

"I saw Mr/Ms Patient, who presented with [PC]. My working diagnosis is [X] evidenced by [Y]. I dont think it is [differentials] as on focused assessment the patient hasnt had any [...]. I plan to perform [investigations] to look for [differentials]. I have given [initial treatment].

The patient can be discharged within 4 hours, and does not need an admission to ESSU or an inpatient unit.
                  ----- OR -----
As the patient would likely be discharged within 4-12 hours, I would like to request an ESSU bed awaiting investigations to be completed to exclude [differentials], with a tentative discharge plan as follows...
                  ----- OR -----
The patient would likely need an admission for [inpatient treatment required], hence i've requested a [subspeciality] bed.

(Most HMOs/Residents will present patients at this level)

"I saw Mr/Ms Patient, who presented with [PC]. I dont have clear working diagnosis, but my primary differentials after assessing the patient are [x] [y] [z]. Considering [x], the patient has [insert positive/negative findings]. Considering [y]...[z]...[repeat as necessary].

If you have absolutely no idea about what is happening, with no real working diagnosis or differentials, then revert to the standard format of presenting a physician long case. It is the responsibility of the SCDM to figure out a reasonable working diagnosis and differentials to be excluded. It is not uncommon for interns to present patients this way. This is completely appropriate given presentations in ED can often be very complex and not straightforward. The SCDM will attempt to guide you and crystalize the plan. The SCDM will also likely review the patient in person – do not feel disheartened, this is completely normal and part of the job description of the SCDM. It is done to uphold a standard of care in the ED and is usually not a reflection on your performance.

The patient presents with [PC]
On history, he/she describes... [HOPC]
On examination... [Ex]
I have ordered [investigations / Ix]. Is there anything else I should add?
What disposition do you think the patient will have? (ESSU vs Home vs Admit vs Transfer)