What is the best approach to build an admission problem list for a patient?

Building an Admission Problem List

The admission problem list should be structured systematically by organ system and acuity, prioritizing active issues requiring immediate intervention, followed by chronic conditions affecting hospital management, and concluding with relevant historical problems that may impact current care.

Framework for Problem List Construction

The problem list serves as the foundation for hospital care planning and must be comprehensive yet prioritized. 1 The cognitive approach to admission ordering and problem identification follows a problem-based framework rather than purely categorical organization. 2

Primary Active Problems Requiring Immediate Intervention

List first any life-threatening or acute metabolic complications that prompted admission:

• Acute metabolic derangements including diabetic ketoacidosis (glucose ≥250 mg/dL with pH <7.30 and bicarbonate <15 mEq/L), hyperglycemic hyperosmolar state (glucose ≥600 mg/dL with elevated osmolality >320 mOsm/kg), or severe hypoglycemia with neuroglycopenia 3

• Cardiovascular instability such as hemodynamically significant arrhythmias, acute coronary syndromes, or heart failure requiring continuous monitoring 4

• Respiratory compromise including moderate to severe pulmonary disease requiring supplemental oxygen, high-flow oxygen, or noninvasive ventilation 3, 4

• Severe electrolyte abnormalities requiring cardiac monitoring: hypokalemia (<2.0 mEq/L), hyperkalemia (>6.0 mEq/L), severe hypomagnesemia (<1.2 mg/dL with symptoms or ECG changes), hypocalcemia, or hyponatremia/hypernatremia with altered mental status 3, 5

• Acute infectious processes such as community-acquired pneumonia with severity indicators (respiratory rate >30/min, systolic BP <90 mmHg, confusion, multilobar involvement, pleural effusion) or sepsis responding to fluid resuscitation 3, 6

Secondary Active Problems Affecting Hospital Course

Document conditions requiring multidisciplinary intervention and frequent monitoring:

• Renal dysfunction including acute kidney injury, chronic kidney disease exacerbation (creatinine >1.2 mg/dL or BUN >20 mg/dL), or hypertension requiring frequent IV medication 3, 4

• Hematologic abnormalities such as severe anemia (hemoglobin <9 mg/dL or hematocrit <30%) without hemodynamic compromise, coagulopathy, or sickle cell crisis complications 3, 4

• Gastrointestinal issues including acute GI bleeding without hemodynamic instability, need for emergency endoscopy, or chronic GI conditions requiring close monitoring 3

• Neurologic conditions requiring frequent assessment but without life-threatening deterioration, such as seizures responsive to therapy or altered sensorium with stable trajectory 3, 4

• Postoperative status following cardiovascular, thoracic, neurosurgical, or other major procedures requiring multidisciplinary care 3, 4

Chronic Comorbidities Impacting Current Management

Include all chronic conditions that significantly affect diabetes control, treatment decisions, or prognosis:

• Cardiovascular disease including chronic heart failure, coronary artery disease, or cerebrovascular disease 3

• Pulmonary disease such as COPD, bronchiectasis, or sleep apnea requiring monitoring 3, 6

• Endocrine disorders including diabetes mellitus (document if newly diagnosed, poorly controlled with A1C levels, or requiring insulin pump therapy), thyroid disease, or other metabolic conditions 3

• Chronic kidney or liver disease that may affect medication dosing and treatment planning 3

• Malignancy with or without active treatment 3, 4

• Chronic alcohol abuse or malnutrition affecting overall prognosis 3

Historical and Social Factors

Document relevant historical problems and social determinants:

• Previous hospitalizations within the past year, as this represents a risk factor for complicated course 3

• Medication-related problems that contributed to admission, including non-compliance (taking too much or too little), adverse drug reactions, or drug-drug interactions 7

• Social factors such as absence of responsible caregiver or unstable home situation that influenced admission decision 3

• Pregnancy status if applicable, particularly with uncontrolled or newly discovered insulin-requiring diabetes 3

Organizational Approach

Structure the problem list in descending order of acuity and relevance to current admission:

1. Active acute problems (reason for admission)
2. Active chronic problems being actively managed during hospitalization
3. Inactive chronic problems relevant to treatment decisions
4. Historical problems that may impact current care

Each problem should include relevant severity markers, such as laboratory values, vital sign abnormalities, or functional status indicators that guided admission decisions. 3, 6

Common Pitfalls to Avoid

• Failing to prioritize by acuity - The most urgent, life-threatening problems must appear first to guide immediate treatment decisions 6

• Omitting severity indicators - Include specific values (e.g., "hypokalemia 1.8 mEq/L" rather than just "hypokalemia") that justify admission level of care 3, 5

• Neglecting social factors - Social determinants that influenced admission decisions should be documented as they affect discharge planning 3

• Listing problems in isolation - Consider how problems interact (e.g., refractory hypocalcemia in the setting of hypomagnesemia) 5