Establish a working definition of the problem at the highest level of explicitness and certainty that the data allow. You may be limited to a symptom, such as "tension headache, cause unknown." At other times, you can define a problem more specifically based on its anatomy, disease process, or cause. Examples include "bacterial meningitis, pneumococcal," "subarachnoid hemorrhage, left temporoparietal lobe," or "hypertensive cardiovascular disease with left ventricular dilatation and heart failure."
Although most diagnoses are based on the identification of abnormal structures, disease processes, and clinical syndromes, patients frequently have clinically unexplained symptoms. You may not be able to move beyond simple descriptive categories such as "fatigue" or "anorexia." Other problems relate to stressful events in the patient's life such as losing a job or a family member that increase the risk for subsequent illness. Identifying these events and helping the patient develop coping strategies are just as important as managing a headache or a duodenal ulcer.
Another increasingly prominent item on problem lists is Health Maintenance. Routinely listing Health Maintenance helps you track several important health concerns more effectively: immunizations, screening tests such as mammograms or colonoscopies, instructions regarding nutrition and breast or testicular self-examinations, recommendations about exercise or use of seat belts, and responses to important life events.
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