Problem representation involves summarizing and framing a patient’s case in a clear, concise manner that captures the essential aspects of their condition. This process helps healthcare providers understand the key issues, prioritize problems, and plan appropriate interventions. Effective problem representation integrates various pieces of information, including the patient’s history, symptoms, physical examination findings, and diagnostic test results. It is a longer version of the problem statement.
Key Components of Problem Representation
- Patient Demographics: Age, gender, and relevant medical history.
- Chief Complaint: The primary reason for the patient’s visit.
- History of Present Illness (HPI): Detailed description of the symptoms and their progression.
- Past Medical History (PMH): Previous medical conditions and treatments.
- Medications and Allergies: Current medications and known allergies.
- Social and Family History: Lifestyle factors and family medical history that might influence the condition.
- Physical Examination Findings: Key findings from the physical exam.
- Diagnostic Test Results: Relevant laboratory and imaging results.
- Differential Diagnosis: List of potential diagnoses based on the available information.
- Plan: Proposed diagnostic and therapeutic steps.
Examples
Example 1: Acute Abdominal Pain
Patient Demographics:
- 45-year-old male
Chief Complaint:
- Severe abdominal pain for 2 days
History of Present Illness (HPI):
- The pain started suddenly in the right lower quadrant
- Described as sharp and constant
- Associated with nausea and vomiting
- No bowel movement for the past 24 hours
- No similar previous episodes
Past Medical History (PMH):
- Hypertension
- No history of abdominal surgery
Medications and Allergies:
- Lisinopril for hypertension
- No known allergies
Social and Family History:
- Smoker (1 pack/day)
- No family history of gastrointestinal diseases
Physical Examination Findings:
- Tenderness in the right lower quadrant
- Positive rebound tenderness and guarding
- Fever (38.5°C)
Diagnostic Test Results:
- Elevated white blood cell count (WBC)
- CT abdomen shows signs consistent with acute appendicitis
Differential Diagnosis:
- Acute appendicitis
- Diverticulitis
- Renal colic
- Gastroenteritis
Plan:
- Surgical consultation for appendectomy
- Intravenous fluids and antibiotics
- Nil by mouth
- Pain management
Problem Representation:
45-year-old male with a 2-day history of acute onset of sharp right lower quadrant abdominal pain, associated with nausea, vomiting, and fever. Examination shows rebound and guarding. Investigations show elevated WBC and CT abdomen suggests acute appendicitis. Plan: NBM, IV fluids, antibiotics, analgesia and surgical consultation for appendectomy.
Example 2: Chronic Cough
Patient Demographics:
- 65-year-old female
Chief Complaint:
- Persistent cough for 6 months
History of Present Illness (HPI):
- Non-productive cough, worse at night
- No fever or weight loss
- History of mild shortness of breath on exertion
- Previous episodes of bronchitis
Past Medical History (PMH):
- Asthma
- Diabetes Mellitus Type 2
Medications and Allergies:
- Inhaled corticosteroids for asthma
- Metformin for diabetes
- No known allergies
Social and Family History:
- Non-smoker
- No significant family history of respiratory diseases
Physical Examination Findings:
- Mild wheezing on auscultation
- No clubbing or cyanosis
Diagnostic Test Results:
- Chest X-ray: No acute pathology
- Pulmonary function tests: Mild obstructive pattern
- Sputum culture: No growth
Differential Diagnosis:
- Asthma exacerbation
- Gastroesophageal reflux disease (GORD)
- Chronic obstructive pulmonary disease (COPD)
- Post-nasal drip syndrome
Plan:
- Increase dose of inhaled corticosteroids
- Trial of proton pump inhibitor for possible GORD
- Referral to respiratory physician for further evaluation
Problem Representation:
65-year-old female with a 6-month history of non-productive cough worsening at night, mild shortness of breath, and past episodes of bronchitis. No fever or weight loss. Examination reveals mild wheezing. Chest X-ray is normal; pulmonary function tests show a mild obstructive pattern. Suspected asthma exacerbation with possible GORD. Plan: Increase inhaled corticosteroids, trial proton pump inhibitor, and referral.
Importance of Problem Representation
- Clarity and Focus: Summarises complex cases succinctly for easy understanding.
- Diagnostic Accuracy: Helps in forming a logical differential diagnosis.
- Efficient Communication: Facilitates clear communication among healthcare providers.
- Effective Planning: Guides appropriate diagnostic and therapeutic interventions.
- Education and Training: Enhances learning for medical students and junior doctors.
By structuring patient information in this way, healthcare providers can ensure they are addressing the most critical aspects of a patient’s condition and making well-informed clinical decisions.