Assessment

Problem represent the case with a case summary statement 

Communicate the essence of case with the “one liners". The task distills the large amount of raw data collected to identify some key facts (pertinents) most helpful with diagnostic and therapeutic decision making. What are pertinents? Think of these as pivots (decision points) on a diagnostic schema, their presence help triage and narrow down potential diagnoses. The on liner always includes 3 key elements: the patient risk profile (epidemiology), problem duration (timing), and the syndrome (key findings from- history, exam, and testing if performed). The one liner slows down our thinking, moving us from system 1 thinking (This abdominal pain is probably just reflux) to system 2 processing (Let's review the key features of the case).

Tips for one liner:

o Be concise- Too many details/concepts, overwhelms yourself and listeners.  Aim to communicate cleanly, succinctly. Use pertinent negatives very very sparingly, as they can distract.

o Be informative- highlight the unique nuances of this case (how is this pt w chest pain, different from another pt with chest pain?)

o Don’t use the one liner as a “closing argument” for 1 preferred diagnosis. Keep your mind open so you don't anchor this early, This way you don't throw away key facts that "don't fit".

o Just give the key facts here - Differential discussion only comes after problem identification.  

o Writing a summary statement is not easy, knowledge and clinical experiences are required to help prioritize data and weed extraneous information. So keep practicing. 

Examples

Too long of a summary statement TMI makes it hard to focus on the key findings:

75 year old woman with uncontrolled HTN, diabetes, allergies, CKD 3b, chronic low back pain, psoriasis, presents for follow up 6 weeks after our last appointment. On the last visit her blood pressure was high and we added on lisinopril, her back pain was improving with PT recdently so we gave her acetaminophen refill. She is here today and blood pressure is better with the new medicine. She now reporting a dry cough for over a month, it's doesn't happen a lot, but it does affect her sleep as it comes on at nite. She is concerned about cancer as a friend has been battling lung cancer for years and it all started with a chronic cough. Pt denies travels, sick contact, fever, chills, hemoptysis, weight loss. She has never smoked before. She doesn't recall having anything like this before. She is still able to work. On exam her vital signs were stable,  Her heart and lung exam were normal Her labs show high potassium and a bump in the a1c

Too short of a summary statement lack of specifics doesn't help narrow down differentials:

75 y.o. F with DM HTN presenting a month of dry cough

Better:

75 year old never smoker with a hx of uncontrolled hypertension/CKD3b, diabetes, and seasonal allergic rhinitis,  she started lisinopril 6 weeks ago, and is here for follow up. Today she reports over a month of  dry intermittent, mild, but noctournally annoying cough.  She has not had other red flag symptoms,  she is concerned about cancer. On exam she is afebrile and her lungs were clear. Labs showed new hyperkalemia and a rising a1c