What is the best course of action for a patient with no apparent underlying condition and normal physical examination results?

Management of a Patient with Normal Physical Examination Findings

For a patient with no apparent underlying condition and normal physical examination results, the most appropriate course of action is to discharge the patient with reassurance if there are no concerning symptoms or risk factors that would warrant further evaluation.

Assessment of the Normal Physical Examination

The presented physical examination shows:

• General: No acute distress, steady gait, alert and oriented x4
• HEENT: White sclera, no icterus
• Cardiovascular: Regular heart rate, no pedal edema
• Lungs: Clear to auscultation bilaterally, no prolonged expiration
• Abdomen: Soft, non-tender, no masses, normal bowel sounds, no bruit
• Respiratory: Equal and unlabored respirations, no shortness of breath
• Integument: Warm and dry, no lesions or rashes
• Extremities: Good movement, no peripheral edema

Clinical Decision-Making Algorithm

1. Evaluate for concerning symptoms

   • If the patient presented with chest pain, shortness of breath, or other concerning symptoms despite normal examination, further evaluation may be warranted 1
   • If the patient is asymptomatic or has resolved symptoms, discharge is appropriate

2. Consider risk stratification

   • Low risk: No symptoms, normal physical exam, no risk factors
   • Intermediate risk: Normal exam but with risk factors or resolved symptoms
   • High risk: Normal exam but with concerning symptoms or high-risk features

3. Determine appropriate disposition

   • Low risk → Discharge with reassurance
   • Intermediate risk → Consider limited testing or follow-up
   • High risk → Further evaluation despite normal exam

Evidence-Based Approach

According to ACC/AHA guidelines, patients who are pain-free, have a normal or nondiagnostic ECG, and have normal initial cardiac biomarkers are candidates for discharge after appropriate screening for non-ischemic causes of their symptoms 1. The ESC guidelines similarly note that a normal physical examination should prompt evaluation for non-cardiac causes of symptoms if present 1.

For patients with no symptoms and a normal physical examination, there is no evidence supporting routine additional testing. The physical examination itself provides valuable information about the patient's current status and can help rule out many conditions 2.

Special Considerations

• Age and risk factors: Older patients or those with multiple risk factors may warrant closer follow-up even with a normal examination 1
• Recent symptoms: If the patient recently had concerning symptoms that have resolved, consider whether further evaluation is needed despite the normal exam 1
• Follow-up recommendations: Provide clear instructions on when to return for care (new symptoms, worsening of condition)

Common Pitfalls to Avoid

1. Overinvestigation: Ordering unnecessary tests for asymptomatic patients with normal examinations increases costs and may lead to incidental findings requiring further workup 3

2. Underestimation of subtle findings: While the examination is reported as normal, ensure that subtle findings were not overlooked, particularly in high-risk populations

3. Failure to document baseline: A normal examination provides an excellent baseline for future comparison if the patient develops symptoms later

4. Neglecting patient education: Even with a normal exam, educate patients about warning signs that should prompt return evaluation

In summary, a patient with no apparent underlying condition and normal physical examination results can typically be safely discharged with appropriate follow-up recommendations, provided there are no concerning symptoms or risk factors that would necessitate further evaluation.