Synthesis of the Assessment and Plan

Development of the Assessment and Plan

Assessment is formulated by considering the information that has been obtained from the history and physical examination (H&P) within the context of the reason the patient as being seen. The assessment of a general practitioner performing a yearly checkup will be different from that of specialist addressing a specific condition. This chapter will focus on the specialist assessment and plan.

To develop the assessment, the neurologist formulates an opinion using algorithmic and syndromic approaches.

In the algorithmic approach, the neurologist considers the information they have obtained and then localizes the lesions by their knowledge of neuroanatomy and neuropathology. Can the presentation be explained by a single lesion in one location? If so, where? What types of pathology could produce that focal deficit? If not one lesion, might there be multiple discrete lesions? Is the presentation explained by a diffuse process affecting a range of neuronal types and loci? What systems other than neurologic are affected, and is that because of the direct relation to the neurologic diagnosis or to a concurrent unrelated condition?

When the neurologist has localized the lesion, they then consider what pathologies can produce the presentation. They identify tests or additional H&P findings that need to be explored to further narrow the differential diagnosis.

In the syndromic approach, we take the data that we have obtained through the standard H&P and determine whether the clinical presentation fits into one or more syndromes. If so, that becomes the foundation of the differential diagnosis. The neurologist then leverages further H&P or study data to narrow the differential diagnosis. An example includes a patient with parkinsonism, where a constellation of neurologic findings indicates the clinical diagnosis but none of them in isolation would define the diagnosis.

There are merits to both the algorithmic and the syndromic approach. The algorithmic approach should be used extensively by people early in training when they are establishing their skills at evaluation, diagnostic thought processes, and approaches to diagnostic confirmation. The algorithmic approach is more time-intensive, but it is less likely to be derailed by anchoring on the part of the provider.

The syndromic approach is used by many neurologists in practice. In an emergent situation, this is often the first approach that the neurologist uses. When seconds count, the algorithmic approach is often too slow. If the syndromic approach is not working well, the neurologist stabilizes the patient, initiates essential studies and treatments, and then takes a little more time to think though the case with an algorithmic approach. This is often the method of action when the first couple of considered diagnoses are not correct.

When there is a proposed diagnosis, there must always be a differential diagnosis. This is essential, because it is not uncommon for a confident conclusion to be incorrect. In that case, the neurologist starts the process again, often repeating portions of the examination and exploring new avenues to get additional history.

Plan can be an action that the neurologist takes directly, as when they are seeing a patient in the emergency department or in clinic. Alternatively, if the neurologist is a consultant giving a report to a referring provider, they are not expected to execute the plan directly. In that case, they write recommendations. It is a recommendation rather than a plan for the referring provider, because the provider may have information or an insight into the case that might make some of the neurologist’s recommendations inappropriate, or the patient or other decision makers may decide against the recommendations. If the neurologist does not directly execute the plan, they do not want to commit the referring provider to the wrong course or action.

There are multiple methods of documenting assessments and plans. The problem-based approach is common for primary care, internal medicine, general pediatrics, and admitting services where each diagnosis is given a brief assessment and plan. This works for neurologists also when they are the principal provider in the inpatient or outpatient arena. However, neurologists are commonly consultants, so that they confine their assessments and recommendations to the neurologic issues.

We generally provide an assessment that is a short paragraph, summarizing the essential facts of the case, our reasoning, and the journey to the diagnosis. One useful approach is to have a bulleted or numbered list of diagnoses, beginning with the one(s) we feel is most applicable to our specialty. We do not list all of the diagnoses for that patient, but we do list the nonneurologic diagnoses that pertain to the neurologic presentation or diagnosis.

The plan or recommendation section should likewise be a list that is either bulleted or numbered. The plan should be granular. If medications are recommended, the neurologist should suggest specific doses, because not every provider is savvy to medication dose adjustments for organ insufficiency or concurrent medications. Tests also should be specific, so that the referring provider does not have to wonder whether the neurologist wanted that scan with contrast or not.

Long discussions typical of a textbook are not helpful; most providers do not have the time to work through that. For example, for a patient with a transient ischemic attack (TIA), the provider does not need to be instructed on an ABCD2 score for diagnosis. Instead, the neurologist should perform the calculation and place their specific recommendations based on that and other data.

Occasionally there is some nonneurologic issue that the requesting provider might not have seen or considered. This should be mentioned as appropriate to the neurologic presentation and report, but it should done with sensitivity and should not place other providers in a situation where they could become defensive or even targeted for critique. If there is an issue in this arena, the neurologist should talk with the provider directly.

Below are two sample Assessment and Recommendation sections for hypothetical clinical scenarios.