Evaluation
Core content
Evaluation closes the loop: did the plan work, is it safe, and does it need revision? Assess goal attainment with objective data, adherence, adverse effects, patient experience, and quality metrics. Know standard monitoring intervals: basic metabolic panel one to two weeks after starting or titrating an ACE inhibitor, ARB, or diuretic; TSH six to eight weeks after any levothyroxine dose change; A1c every three months until at goal, then every six months; lipids four to twelve weeks after starting a statin; INR per protocol for warfarin.
When a patient is not improving, distinguish four explanations: the diagnosis was wrong, the dose is inadequate, the patient is not taking the therapy as prescribed, or the therapy is working but the endpoint is wrong. Each requires a different response, so ask before assuming nonadherence.
Traps
Failing to recheck a laboratory value after a medication change is the most frequent evaluation error in questions. Others: assuming nonadherence without asking, continuing an ineffective drug indefinitely, missing a new problem that emerged during treatment, and choosing an outcome that cannot be measured.
Rule of thumb
Every chronic medication needs a named parameter and a recheck date. If you cannot state what you will measure and when, the plan is incomplete.
Worked example
A 70-year-old with CKD stage 3 starts lisinopril for hypertension and proteinuria. A basic metabolic panel is due in one to two weeks. A creatinine rise of more than 30% from baseline warrants evaluation for volume depletion or renal artery stenosis and dose adjustment rather than simply continuing the drug.