Introduction
- Is a process that summarise the key issues about a patient’s condition
- It is the essential step before fully developing investigative strategy and a management plan
- Invariably as various tests and treatments are entertained, the clinician realises that more information may still need to be obtained before fully committing to this process
- Be aware that multiple problems may need to be simultaneously addressed and may also lead to untoward interactions
- The key questions that need to be answered are demonstrated in the following graphic.
that systematically addresses:
- The Chronology of the Illness and rapidity of evolution
- The Severity of the Symptoms
- Triggering/Precipitating events
- Predisposing or perpetuating factors (including the individual’s behaviour and the environment they live in)
- The Anticipated or Potential Complications of the Condition
- The Prognosis of the Patient
Alongside this should also include the impact of previous clinical encounters
- Investigations initiated, their reason and their outcomes
- Prior diagnoses
- Treatments continued or ceased including rate of response and any complications
- Previous advice given
- Patient’s compliance