Problem Statement

In the context of diagnosis, articulating a problem statement involves clearly identifying and describing the patient’s main complaint and any related issues. The problem statement can be considered as a short version of the full problem representation.

Example

A 45-year-old female presents with a two-hour history of acute, sharp chest pain radiating to the left arm, exacerbated by physical activity and partially relieved by rest, associated with shortness of breath and nausea.

Here is one way to look at the diagnostic process:

  1. Gathering initial information
    • The process begins during the patient interview, where the clinician asks open-ended questions to gather comprehensive information about the patient’s symptoms and medical history.
    • This includes understanding the nature, onset, duration, and severity of the symptoms.
  2. Clarifying symptoms
    • Through more specific questions, the clinician seeks to clarify the details of each symptom.
  3. Defining the problem clearly and concisely
    • The clinician synthesizes the information into a succinct problem statement.
    • This should encapsulate the patient’s primary complaint and critical information about the manifestation and impact of the symptoms.
    • This statement is often framed as the “chief complaint.”
  4. Identifying possible causes
    • Based on the symptoms and the medical history, the clinician hypothesizes potential underlying causes.
    • This step involves medical knowledge and differential diagnosis to guide further testing and examination.
  5. Determine what further information is needed
    • Determine what additional history, examination or diagnostic tests are needed to confirm the diagnosis.
    • This helps in managing the direction of the subsequent medical interview and physical examination.
  6. Involving the patient
    • Throughout history taking, it’s vital to keep the patient engaged.
    • Validate their concerns and ensure they understand the questions and the reasons for them.
    • This involvement can provide more accurate and relevant information.
  7. Review and adjust
    • The problem statement may need to be adjusted as more information becomes available from ongoing assessments, tests, or changes in the patient’s condition.

For more details, see the full problem representation page.