Assessment and Plan (same case discussed in Background page):
Deriving an assessment or summary statement is a critical step to diagnosing and cognitively processing raw data collected. No matter the complexity of the case, the goal is to deliver a very brief statement (1-3 sentences) that very concisely highlights key words/clinical concepts collected from the bedside (H&P) and from diagnostics (labs/radiology). A well constructed summary statement is meant to TRIGGER you and your listeners to GENERATE AND NARROW down potential differential considerations.
Writing a summary statement is definitely not easy for students, as knowledge and clinical experiences are required to help prioritize information and identify pertinents.
Too long of a summary statement will confuse and distract yourself (you listeners) as the actual clinical problem will not be clearly understood. (this is the most common challenge for early learners)
“90 year old woman with COPD, CHF, HTN, Hyperlipidemia, A fib, DJD, MDD, presenting with acute on chronic shortness of breath, stomach ache, headache, and back pain.“
Too short of a summary statement will result in an unfocused differential diagnoses list
60 year old patient with shortness of breath...
“In summary, this is a 75 year old female with diabetes and longstanding difficult to control hypertension presenting with new onset orthostatic dizziness after a recent medication change. Aside from an improved systolic blood pressure of 120, the exam did not demonstrate orthostatic changes nor neurologic findings. Labs showed excellent diabetes control with mild hypokalemia.”
Following the summary line, articulate each “problem” encountered in the case, discuss potential differentials and your next steps (the Plan follows the discussion of each problem).
Dizziness- has a wide variety of causes, in this elderly hypertensive patient, potential causes to consider include orthostatic sensation with the recently intensified anti-hypertensive regimen; new cardiac ischemia or failure; a cerebrovascular event, and less likely in this case disequilibrium due to arthritis related gait disorder or an anemia due to aspirin related GI bleed. Based on the recurrent and predictably triggered nature of the symptom with standing up, the preserved functional status, the benign physical exam notable only for significantly lowered blood pressure; I am pretty certain the cause of this dizziness relates to recent medication change.
Plan- Given the good response of blood pressure to the higher calcium channel blockade, will stop chlorthalidone and keep amlodipine at 10mg. This may even help with her polyuria.
Hypokalemia- the differential include GI or renal loss, as well as hypertension inducing hormonal conditions like Conn’s syndrome. Since it is new, it is most likely chlorthalidone related potassium depletion.
Plan- d/c chlorthalidone and repeat her potassium level at my next visit. If it remains low we will do further evaluation.
Diabetes- very well controlled with no low fsg results. Her CKD does not preclude continual use of metformin.
Plan- given the stability of her good control, will repeat the hgba1c in 6 months. She is due for her annual eye exam.
Problem #4 (the penultimate problem of each outpatient visit is preventive care, a patient centered recommendation of vaccines, screening tests, or behavioral counseling)
-Discussed risk and benefit of shingles vaccine with patient again, she is still not sure. Patient is considering making her daughter her health care proxy, forms have been given. She is due for a repeat of her bone density next year.
Problem #5 (Lastly define when you want the patient back for follow up)
Follow up Will schedule a return to follow up her symptoms and her blood pressure and labs in 2 months.
Common errors in the A/P include
- Skipping the assessment and summary line and going straight to the plan
- Including too much information in summary statements- no longer a “summary”
o Avoid including pertinent negatives in summary statements as it may clutter the content and make it hard for others hear key + details.
o Do not initiate discussion of differential diagnoses at the end of the summary statement. DDx discussions must always occur after defining the PROBLEM that you are generating the differential for.
- Generating too short of a diff dx and anchoring too early (sometimes even HPI’s sound like they were taken with someone’s mind already made up).
- Not naming clinical “problems” and reviewing by organ system individually – This approach (very necessary in ICU settings) does make it difficult to identify actual clinical problems at hand. For example a clinical problem of “dyspnea” is better discussed by reviewing the concepts and differentials of “heart failure, renal failure, pulmonary edema, versus ARDS” rather than being discussed as a part of your comprehensive review of the heart, the lung, and the kidney”