Close Window
The University of Iowa Teaching Cases

The Process of Working through a Patient Case: Development of Clinical Problem Solving

Jay D. Currie, BSPharm, PharmD

Jeanine P. Abrons, PharmD, MS

Steps in Clinical Problem Solving

The process used to work through a patient case, whether a written case or one in a clinical setting, involves a series of steps. These steps, if repeated each time a case is presented, give the student pharmacist or pharmacist a formal approach to finding a useful resolution of the patient case. This resolution is not dependent on the individual's knowledge of the subject matter prior to beginning the process.

The overall steps in the process are (1) data collection, (2) analysis, (3) problem solving, and (4) plan implementation. However, analysis of a patient case often is not a linear process but instead may be thought of as a dynamic and ongoing process. Data collection is needed prior to problem identification in the analysis step. Data collection can also be necessary for sorting through potential options in the problem-solving step. Then, data analysis can again be needed prior to implementation of the care plan. Different types of data may be needed at each step to arrive at a solution to a patient case; for example, therapeutic information on medications, prior responses to medication (both safety and efficacy related), a patient's health beliefs, or the goals of treatment. Data on socioeconomic status, health literacy, and numerous other factors may be used in the decision-making process and may affect patient care.

In some patient case scenarios, all of the data necessary for arriving at a useful resolution of the patient case are available. In such cases, subtle decision-making skills can be tested as knowledge is applied to a well-defined situation. More often in clinical practice, not all details are known. The patient may not be using his or her medications as proposed and presented in the nicely organized medication list. Medical records often do not allow ready extraction of a medication history, including past treatments and responses to these therapies. Laboratory test results may be missing, and comprehensive records may not always be readily accessible.

In clinical reality, practitioners often must do their best with the information or data currently available. In many practice settings, a significant responsibility of the pharmacist may be to collect additional information from the patient or caregivers for all to use in future care of the patient. Student pharmacists or pharmacists often must decide whether a recommendation can be made on the basis of the data collected and the information currently available. They must ask themselves questions such as, What information is critical to have before proceeding? What information would be useful, but not required, for offering an opinion on care? How can a recommendation be made when lack of information limits the confidence in a recommendation?

Finding and Fixing Drug Therapy Problems

Is there a drug therapy problem?

The first step in arriving at a useful resolution to the patient case is to determine whether a drug therapy problem (DTP) exists in the patient's regimen. This can be done by comparing the available patient information with the desired outcomes for that patient's medical problems (i.e., disease or symptoms). For example, if the patient has diabetes mellitus, are the blood glucose values and the hemoglobin A1c at targeted goals? If the patient has hypertension, is the blood pressure at desired levels, given the patient's co-morbidities? In regard to resolution of symptoms, such as pain, has the pre-established pain level been achieved on a scale of 1 to 10 or another pain scale? The determination that a DTP exists must be based on an analysis of the initial data collected. At times, a decision on the presence or absence of a DTP cannot be made with certainty until further information is collected. Data collection strategies may then be focused on determining the necessary facts for deciding whether a problem exists.

What is the drug therapy problem, and how can it be labeled or communicated?

If a DTP exists, then a pharmacist or student pharmacist must undertake problem-solving strategies. Identifying the source of the problem and labeling or describing the problem to others must occur. Learning to appropriately label or describe an identified problem by using a standard vocabulary is important for clearly defining and communicating the problem to others. The problem labels proposed by Tomechko, Strand, et al. work well; they categorize DTPs and describe the causes or reasons for problems. Using this list of seven DTPs forces student pharmacists or pharmacists to identify a reason for the problem. The seven categories are (1) unnecessary drug therapy, (2) wrong drug, (3) dosage too low, (4) adverse drug reaction (ADR), (5) dosage too high, (6) inappropriate compliance, and (7) needs additional drug therapy. All DTPs can be labeled according to these categories, and problems with nondrug therapies can be labeled as well (e.g., needs additional treatment—dietary therapy for blood pressure reduction; inappropriate compliance—with physical therapy exercises at home or suggested dietary regimen).

Deciding on the existence and prioritization of DTPs is a matter of asking oneself several logical questions about the data possessed or needed. The use of a question- or grid-based thought process in the data analysis and problem-solving steps will challenge student pharmacists and pharmacists to refine their skills and develop a well-thought-out rationale for identification of a DTP as well as for their decision on action to resolve the problem.

The questions in Table 1 can be used in the process of identifying a DTP.

Table 1: Questions for identification of a drug therapy problem (DTP) in clinical problem solving
Is the patient on a medication for which there is no valid indication?
  • What is this patient's complete prescription medication list?
  • What is this patient's complete nonprescription (over-the-counter) medication list?
  • What is this patient's complete nondrug treatment list?
  • Is there a valid medical reason for each medication?
  • Is there a valid reason to use a medication without an indication?
  • What is the risk of the therapy in question?
  • What social drug use is present?
  • What illegal or addictive drug use is present?
If the patient has a legitimate need to be treated for a condition or symptoms, is the current treatment the most effective and safe?
  • What are the appropriate treatments for this condition?
  • What patient factors (e.g., diagnoses, allergies, previous patient responses, pharmacokinetic variables, social conditions) are present that may affect the choice of agent?
  • What other medication is the patient taking, and how might this affect the choice of agent?
  • What has the patient's response been to the current therapy or to past therapy?
If the patient is on the correct drug, is he or she receiving too little of this drug?
  • What dose of the drug is the patient getting?
  • What are the acceptable doses of this drug?
  • How do we titrate this drug for this condition?
  • What are the appropriate monitoring parameters for this condition, and have they been used to justify a higher dose?
  • Is the patient likely to tolerate a higher dose?
  • What patient factors (e.g., diagnoses, allergies, previous patient responses, pharmacokinetic variables, social conditions) are present that may justify an increased dose?
  • What other medication is the patient taking, and how might this cause a need for an increased dose?
Is there an adverse drug reaction present?
  • What symptoms does the patient have that might indicate an adverse drug reaction to one of his or her medications?
  • How likely is it that a drug would cause that effect?
  • What other explanations are there for that effect?
  • Is the patient on drugs that are commonly used to treat the side effects of other drugs?
  • Does the time sequence of drug therapy and adverse effect make sense?
  • Are there drug interactions that could explain the presence of this adverse drug reaction?
  • What patient factors (e.g., diagnoses, allergies, previous patient responses, pharmacokinetic variables, social conditions) are present that may increase the risk of the adverse drug reaction?
If the patient is on the correct drug, is he or she receiving too much of this drug?
  • What dose of the drug is the patient getting?
  • What are the acceptable doses of this drug?
  • What are the criteria used to determine the maximum dose of this drug for this condition?
  • What signs or symptoms is the patient having that might indicate an excessive dose?
  • What are the appropriate monitoring parameters for this condition, and have they been used to justify a lower dose?
  • Is the patient's condition likely to become uncontrolled at a lower dose?
  • What patient factors (e.g., diagnoses, allergies, previous patient responses, pharmacokinetic variables, social conditions) are present that may justify a decreased dose?
  • What other medication is the patient taking, and how might this cause a need for a decreased dose?
Is the patient not receiving some therapy that has been recommended and that would help in reaching the therapeutic goals?
  • What is this patient's complete prescription medication list?
  • What is this patient's complete nonprescription (over-the-counter) medication list?
  • What is this patient's complete nondrug treatment list?
  • How does the patient take (i.e., dose, schedule) all his or her medications and treatments?
  • What has been recommended but not currently used?
  • What patient factors (e.g., diagnoses, abilities, previous patient responses, social conditions) are present that may affect the patient's ability to receive his or her treatments?
  • Are there signs present that could be explained by the patient's not receiving his or her therapies?
  • What does the patient refill record show?
  • Does the patient admit to noncompliance?
  • Has the patient experienced any problems with the therapy that might lead to noncompliance?
  • Would not taking the treatment as recommended be a good decision on the part of the patient?
  • What are the patient's health care beliefs, and how would they affect medication usage?
Does the patient have a condition or symptoms that need to be treated?
  • What complaint or symptoms does the patient have?
  • Is this a treatable malady?
  • If so, what is the most appropriate therapy for this patient and how should it be implemented and monitored?
  • What is the basis for your decision to recommend therapy and to recommend this specific therapy for this patient?
Specifically in regard to assessing for issues with drug–drug interactions, consider the following:
  • What is this patient's complete prescription medication list?
  • What is this patient's complete nonprescription (over-the-counter) medication list?
  • What is this patient's complete social drug intake and alternative medication list?
  • How does the patient take (i.e., dose, schedule) all his or her medications?
  • In what order were the patient's medications added to the regimen?
  • What known drug interactions are present in the patient's regimen?
  • How significant are these interactions?
  • What patient factors (e.g., diagnoses, allergies, previous patient responses, pharmacokinetic variables, social conditions) are present that may affect the risk of drug interaction?
  • What drugs may interact (based upon drug factors) that may not yet be reported?
  • What information would I need to feel confident that a drug interaction of significance is present or could occur in the current regimen?


Often, it may seem that several labels could be selected to describe one DTP. In these instances, it is best to label the DTP with the root cause, rather than the effects of the initial problem. For example, a patient experiencing abdominal pain from aspirin therapy may elect to discontinue use of the medication. This DTP could be appropriately labeled either as an ADR to aspirin or as inappropriate compliance with aspirin therapy. However, the label ADR would be preferred, as it represents the root cause of the inappropriate compliance. Either way, the DTP should be labeled as only one problem, not two.

There are other examples in which more than one label for a DTP may be appropriate; however, one label should be selected to clearly communicate your assessment to others. The suggested resolution of the DTP must correspond to the label selected. For example, the starting dose of an antihypertensive, captopril, is not resulting in the achievement of a goal blood pressure; however, the therapy is well tolerated. The student pharmacist or pharmacist may conclude that the DTP should be labeled as either dosage too low (captopril) or wrong drug (captopril). The label of wrong drug may be considered if patient factors limit the therapeutic efficacy of the drug for this patient. These two different DTPs require two very different courses of action to achieve resolution. Labeling the DTP as wrong drug and then suggesting that the dose of captopril be increased to achieve therapeutic efficacy would not be logical. One initial label and course of resolution for a DTP must be pursued.

Further, in labeling DTPs, it is important to recognize that problems can be potential or actual and to identify them as such. A potential DTP may be a problem that might occur if action is not taken at this time. For example, in a patient with chronic renal failure presenting with a new prescription for a nonsteroidal anti-inflammatory drug (NSAID), a possible ADR—NSAID use in a patient with chronic renal failure—could be identified. Furthermore, it is not possible to identify an ADR caused by a specific medication (e.g., possible ADR—dizziness from antihypertensive) without ruling out other causes. An actual DTP is a problem that is currently occurring or has recently occurred. An example of an actual DTP would be an intravenously administered aminoglycoside used to treat an uncomplicated urinary tract infection in an otherwise healthy woman. This would be an example of a wrong drug, as aminoglycoside therapy represents a deviation from practice guidelines.

What are potential resolutions of the problem?

Once a DTP is identified, it is the responsibility of the pharmacist or student pharmacist to assist in either preventing or resolving the problem. Identifying a DTP and deferring the problem to another health care professional does not distinguish the value of the pharmacist or student pharmacist to the health care system.

It is important that as student pharmacists and pharmacists, we do not rely only on our current knowledge to solve problems. This is especially the case early in the educational process when a practitioner's knowledge base is limited. Student pharmacists and pharmacists must brainstorm and consider all the possible solutions for a DTP, not just those that are easily recalled. Sometimes, identifying potential resolutions may require further research and reading by the practitioner. Any solution that will allow us to accomplish the therapeutic goal that has been established for the patient should be considered. In the example of the patient with hypertension, this would involve considering available options for decreasing the patient's blood pressure to the therapeutic goal. In the example of the patient with pain, this would involve considering all available options to achieve reported pain of less than 3 on a 1–10 pain scale. Weighing the risk and benefits of each possible solution may help student pharmacists or pharmacists to arrive at the best solution for the current situation. The options may include drug therapies, nondrug therapies, and ongoing monitoring. Do not dismiss any possibilities on first thought, do not think about drugs of choice, do not forget to include nondrug therapies, and be sure to consider "do nothing" as one of the options—sometimes, time is what is needed.

What is the best solution to the problem, given the case details?

Once you have a list of the alternatives for accomplishing the therapeutic goal, you are ready to make your recommendation for resolving the DTP. Start by applying the knowledge gained from clinical studies or expert panels. Then consider patient factors. Are there co-morbidities that affect drug selection, lifestyle issues that need to be taken into account, other medications that will interact with therapy or outcomes? After these considerations, there often are only a few choices from which to select. At this point, factors such as cost and patient acceptability can be used to make the final recommendation.

Remember that a recommendation includes not only the drug, but the dose, route, frequency of dose, and duration of therapy. A plan for implementing your recommendation is also needed. What do you need to do to get your suggestion applied to the patient's care? Without this final step, even the best therapeutic recommendation does not improve a patient's health. Ideas without action to implement them have the same result as doing nothing. Each recommendation should include two components: a succinct statement of the recommendation and a process for implementing the recommendation.

Was the proposed solution for resolution of the problem correct?

It is irresponsible for student pharmacists and pharmacists to make recommendations for a patient's drug therapy and not follow up or monitor whether resolution of a DTP is achieved. In instances where other health care professionals are responsible for the follow-up, the student pharmacist or pharmacist has a responsibility to plan accordingly to ensure that the follow-up is conducted. Student pharmacists and pharmacists cannot learn from recommendations and proposed resolutions to DTPs without appropriate monitoring. Patients should not be solely responsible for monitoring resolution of a DTP.

Each therapeutic plan should include a monitoring plan with two components: (1) what should be monitored for both safety and efficacy and (2) when this monitoring should be completed. Monitoring for safety and efficacy includes determining whether the recommendation resulted in the intended outcome, whether there were any adverse consequences, and whether any further DTPs developed. The appropriate timing for monitoring may depend on factors such as what is reasonable in a health care setting. A monitoring plan should take into consideration the anticipated time necessary to see progress toward or achievement of the therapeutic outcome of a recommendation. In selecting the frequency for monitoring the safety of a recommendation, student pharmacists and pharmacists should anticipate when adverse effects would reasonably develop. Monitoring for safety and efficacy of a recommendation may be ongoing. Defining a monitoring schedule and the manner in which follow-up on a recommendation should occur will help ensure that the patient achieves the desired therapeutic outcomes with greatest efficiency.

Summary

Working through a patient case and applying clinical problem solving to develop a recommendation for improving patient care involves use of a systematic process. As with any process, efficiency and effectiveness rely on repetition and consistent application of the same procedure. With time, the steps will fade from consciousness and only the process will remain.

Bibliography

© 2012 American Pharmacists Association. All Rights Reserved.