What constitutes a comprehensive workup (complete medical evaluation)?

Medical Advisory BoardAll articles are reviewed for accuracy by our Medical Advisory Board
Educational purpose only • Exercise caution as content is pending human review
Article Review Status
Submitted
Under Review
Approved

Last updated: May 19, 2025View editorial policy

Personalize

Help us tailor your experience

Which best describes you? Your choice helps us use language that's most understandable for you.

From the Guidelines

A good work-up for a patient involves a comprehensive assessment, including a detailed history taking, thorough physical examination, and appropriate laboratory and imaging tests, as outlined in the most recent guidelines, such as those from the American Society of Clinical Oncology 1. The work-up should start with a detailed history taking, including chief complaint, history of present illness, past medical history, medications, allergies, family history, and social history.

  • This should be followed by a thorough physical examination focusing on relevant body systems.
  • Laboratory tests, such as complete blood count, comprehensive metabolic panel, urinalysis, and specific tests based on suspected conditions, should be ordered.
  • Imaging studies, such as X-rays, ultrasound, CT scans, or MRIs, should be included when indicated.
  • Specialized tests, like electrocardiograms, pulmonary function tests, or endoscopies, should be considered depending on symptoms. The work-up should be tailored to the patient's specific presentation while being comprehensive enough to identify the underlying cause of their symptoms, as recommended by recent studies 1. The most recent and highest quality study, such as the 2021 ASCO guideline update 1, should be prioritized when making a definitive recommendation, and the work-up should include pulse oximetry and CT chest preferably with contrast if concerned for other etiologies, as well as infectious workup and COVID-19 evaluation as needed.

From the Research

Components of a Good Work Up

A good work up involves several key components, including:

  • Taking a comprehensive patient history
  • Conducting physical assessments
  • Ordering laboratory investigations

Importance of History Taking

History taking is a crucial part of the work up process, as it allows healthcare professionals to gather relevant information from patients and inform diagnosis and treatment 2. This process is structured but flexible, and requires important communication skills such as:

  • Active listening
  • Empathetic communication
  • Cultural sensitivity

Benefits of Comprehensive History Taking

By taking a thorough patient history, healthcare professionals can:

  • Make accurate diagnoses
  • Develop effective management plans
  • Facilitate patient participation and autonomy in their care 2

References

Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

Research

How to take a comprehensive patient history.

Emergency nurse : the journal of the RCN Accident and Emergency Nursing Association, 2024

Related Questions

What is the differential diagnosis for a female with abdominal cramping, frequent urination, and delayed menstruation, with negative urine pregnancy and dipstick results, and a history of sexual activity?
What is the appropriate workup and differential diagnosis for a 21-year-old female with chronic facial, neck, and scalp pain, who has a normal (Magnetic Resonance Imaging) MRI, overbite, and temporomandibular joint (TMJ) symptoms, including jaw popping and point tenderness?
What is the recommended next step in evaluating a 24-year-old female with chronic generalized abdominal pain, gas, bloating, and intermittent diarrhea, who has a history of ovarian cysts and appendectomy, with normal laboratory results, including a normal white blood cell (WBC) count, and has been avoiding gluten?
What are the preoperative concerns for a 35-year-old white male with a past medical history (PMH) of alcoholism, Gastroesophageal Reflux Disease (GERD), Obstructive Sleep Apnea (OSA), and bipolar disorder, who is on Bilevel Positive Airway Pressure (BiPAP) therapy, taking Nexium (esomeprazole), Disulfiram (generic), and Propranolol (as needed), with a history of medical recommendations for bariatric surgery?
Is a headache in a 15-year-old patient with Obsessive-Compulsive Disorder (OCD) likely due to sertraline (Zoloft), given that the headache worsened after the dose was increased to 75 milligrams?
What medication adjustments are recommended for a 26-year-old female with uncontrolled depression, currently taking fluoxetine (Prozac) 80 mg daily, trazodone 150 mg nightly, buspirone (BuSpar) 15 mg three times daily as needed, and brexpiprazole (Rexulti) 0.5 mg daily, who has just become pregnant?
Can a person develop sepsis after a Urinary Tract Infection (UTI)?
What are the treatment options for knee pain (arthralgia)?
What is the History of Present Illness (HPI)?
What is the appropriate workup for elevated vitamin B12 (cobalamin) levels?
What is the recommended dose of verapamil for rapid ventricular contractions (RVCs)?

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

Have a follow-up question?

Our Medical A.I. is used by practicing medical doctors at top research institutions around the world. Ask any follow up question and get world-class guideline-backed answers instantly.