Formulation/Summary Statement, Assessment, Plan when writing or presenting cases


Summary or Formulation Statement

Conceptually, the summary statement or formulation, is ~3 sentences that give a brief overview of the case, highlighting the most important findings from history, physical, and lab review. This summary is used to help you cognitively process the case, and launch you (and your audience) to the final part of the clinical assessment- defining problems and generating differential and plans for each problem.  This statement is also very vital to daily rounds as it allows the care team to quickly catch each other up on the status of patients.  The ideal summary or formulation statement is informative and concise, this of course is much easier said than done. To get better, you will need to actively practice this throughout MCY and the rest of your career.

 

You will see many different approaches to a summary statement, some people use it as way of highlight findings (both + and -) in persuading others toward a likely diagnosis- like a lawyer’s closing argument.  Given our comprehensive approach to patient care in primary care, we recommend you stay neutral, and use the summary statement simply to highlight key findings, even if they do not “fit” one preferred clinical picture.  With the high complexity of patients seen in our academic center, stating the facts and staying neutral helps you avoid early anchoring to preferred diagnosis. Doing so also allows you to open cognitive space up to define and consider multiple problems and multiple differentials in each case. The neutral summary statement also acknowledge of the ever present uncertainty faced in real time patient care.

 

Mechanically this means the summary statement simply brings together positive findings in the history, physical, and testing.  Pertinent negatives should be avoided, as their presence can clutter the concise overview, AND push listeners toward YOUR preferred diagnosis. 

 

Putting a fun spin on the concept of review statements, think of it as “wake up call” for your attending who may have dozed off during the long presentation, but who can still be triggered by the statement to consider the right diagnoses.  So the goal is to be concise, accurate, and thought provoking. 

 

All elements below should be included in a review statement:

·         Who is this patient? Giving the pt’s epi and pmhx back ground  help set the stage for your listener/readers so they understand the significance of what’s to come (“this is a 68 year old with longstanding uncontrolled diabetes and hypertension”)

o   What is challenging –Keeping this concise and listing only relevant hx as a overloaded intro is distracting and confusing.

·         Why are they here? chief complaint(s), most people present with several symptoms, you have to decide what is most concerning to the patient AND most relevant to the clinical problem at hand. Duration and qualifier (acute worsening)  is important as it further narrows the ddx.  presenting with progressive dypnea and edema for 2 months”.

o   What is challenge here-  Deciding which complaint to use, too many will be disorienting for you and others and confuse the cognitive process.   

·         What did you find?  Use terminology to be concise, “”heart rate of 130=tachycardia, short of breath when I walk a lot” =dyspnea on exertion)

o   Positive findings on history “Her history and ROS are notable for 3 pillow orthopnea and facial swelling in the morning” (make sure to highlight most important positives, while weeding out less important extras that convey the same idea), when the clinical picture is obvious, you can also synthesize into a general medical concept “her history and ROS suggest progressive fluid overload”

o   Positive findings on exam:  On exam, pt was tachypneic, she had distended JVP, and pitting sacral edema” or synthesized to a higher level of understanding “on exam patient had multiple signs of severe fluid overload”

o   Positive findings on testing: “labs showed a doubling of her baseline creatinine, severe anemia, and elevated liver enzymes”

You can see how this sample statement launches you and listeners toward the final part of the clinical evaluation- which is defining problems encountered, and generating differential dx for each problem. 

Assessment and Plan

Before you start to “assess” and generate a differential consideration -  You must identify the PROBLEMS in the case (what are you concerned about?).

·         This is a critical step- defining and recognize the problems, both primary and secondary is what drives how we care for patients.

·         Problem #1 is always the main problem and generally relates to the chief complaint.

·         Problems are symptoms, findings, or established diagnosis. And can only defined to the level of the current level of understanding. This means “elevated creatinine doesn’t always = ARF, or dyspnea doesn’t always mean CHF”

·         An assessment of each problem includes generating 3-5 differentials (from most likely to do no miss, taking into account fasting/slow thinking and potential biasis) and writing an argument for or against diagnosis based on patient specific findings.

·         At the end of each problem based assessment discussion, you will then define the PLAN- the next steps -diagnostic, therapeutic to do to better clarify or manage each problem

For example

problem #1 –dyspnea x 2 months- the most likely diagnoses I am considering are …. Based on…, we should also consider… because….

            Plan: