Problem Identification and Plan

Problem Identification

Following the "one liner," identify and prioritize a list of problems uncovered to assess and manage.  Problems are biomedical (diabetes, hyponatremia) or biopsychosocial (lack of insurance, family stress) challenges to help our patient with. Identifying and prioritizing the right problems to manage each visit is a vital task. Think, what are the current barriers to wellness and good function for this patient? What should be addressed today versus or next visit together? Managing too many complex problems in one outpatient visit can overwhelm or both patient and clinicians.  Not accurately or adequately identifying problems at hand, especially what concerns patients, will make the visit unhelpful for patients.

The patient's chief concern is always problem #1 (so docs don’t “draw our own touchdown lines” L Weed 1971). Next are the clinician's concerns/findings from today’s H&P. After that include chronic diseases that require active management. An assessment of preventive care is the last “problem” to address.

Some tips

  • Describe a problem ONLY to the current level of certainty. For example, “dyspnea” if you are not yet sure it’s heart failure. Once you have fully weighed the various ddx and gotten labs and testing back, and are now convinced that it is CHF, the next visit “CHF” becomes the problem to manage.

  • Differential discussion always happens as a part of each defined problem. After the discussion of possible differentials, commit to one and state why you choose it. Then articulate your diagnostic/therapeutic plans for that problem.

  • Problems should be constantly shuffled up/down list based on acuity. Stable chronic conditions are NOT always problems- (why bother saying “GERD-stable, continue rx”, don't distract yourself from current problems that need your attention)

 

SBAP case Example

Problems  

  1. Dry cough for over a month- duration is longer than usual for upper respiratory infection, she also did not report a typical cold. She has a hx of allergic rhinitis and cough but that is usually in the spring and triggered by nasal symptoms. She is not a smoker and has not had weight loss to suggest malignancy.  I am most suspicious of the ACE which gives around 7% of patients dry cough.  
    • Plan – Will stop the lisinopril follow symptoms, if persist will do chest imaging
  2. Hyperkalemia/hypertension/CKD 3b - differential of hyperkalemia includes new ACE inhibitor use, as well as dietary intake. There are no other meds or change in renal function.  Her blood pressure is better with lisinopril, but we can’t continue it, ARB is good for cough but also causes hyperkalemia
    • Plan- increase amlodipine to 10mg daily, reassess bmp next time
  3. Diabetes-  a1c is uptrending slightly, discussed diet,  she is open to going up on metformin and will start walking now that her back is feeling better.
    • Plan- increase metformin to 1000mg bid, repeat a1c in 3 months, book ophtho exam
  4. Health Maintenance (the last problem of each visit is preventive care. Take a moment to review vaccine schedules, screening tests, or behavioral counseling. Prioritize delivery based on patient specific yield and preference)
    • Plan- Flu shot today. Discussed risk and benefit of shingles vaccine with patient again, she is still thinking this over. She has identified her son as her proxy
  5. Follow up -return in 2 months. please call us things are not better in 2 weeks we will reasses again