Assessment and Plan (same case discussed in Background page):
Deriving an assessment or summary statement is a critical step to diagnosing and cognitively processing the data collected. No matter the complexity of the case, the goal is to deliver a succinct statement (1-3 sentences) that concisely highlights key words and concepts collected (from records, H&P, diagnostics). A well-constructed summary statement is meant to TRIGGER you and your listeners to quickly generate and narrow down potential differential diagnoses considerations.
Writing a summary statement is definitely not easy for students, as knowledge and clinical experiences are required to help prioritize data and weed extraneous information.
Too long of a summary statement will confuse and distract yourself (and listeners) as the actual clinical problem will not be clearly understood.
“90 year old woman with COPD, CHF, HTN, GERD, Allergies, 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 inability to generate or narrow down a differential diagnoses list
“60 year old patient with shortness of breath...
“In summary, this is a 75 year old female with diabetes, difficult to control hypertension, presenting with new orthostatic dizziness after medication change. Aside from an improved systolic blood pressure of 120, her exam did not demonstrate orthostatic changes nor focal neurologic findings. Labs shows good 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 polypharmacy, dehydration, cardiac or cerebrovascular dz, and dysequilibrium. Her orthostatic sensation correlates with a recently intensified medication regimen and a much improved blood pressure. Her daily function is otherwise unchanged, she has no cardiac symptoms or signs of neurologic event. 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 to consider include GI or renal loss, as well as hyperaldosteronism given her longstanding uncontrolled blood pressure. 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.
(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).