What are the steps to evaluate and manage a patient's presenting illness during an exam?

Evaluation and Management of a Patient's Presenting Illness

The most effective approach to evaluate and manage a patient's presenting illness involves a structured assessment beginning with a detailed history of the chief complaint, followed by a targeted physical examination, appropriate diagnostic testing, and development of a management plan based on the findings.

History Taking

Chief Complaint and History of Present Illness

• Document the onset, duration, and progression of symptoms 1
• Record the index date (when the first symptom appeared) 1
• Ask about associated symptoms that may indicate systemic involvement 1
• Determine aggravating and alleviating factors
• Note any previous episodes or treatments attempted

Past Medical History

• Document previous or ongoing medical problems 1
• Record all medications taken over the previous 2 months, including over-the-counter and complementary therapies 1
• Note any previous history of allergies, including details of reaction types 1
• Document relevant chronic disorders that may influence current presentation 1

Social and Family History

• Ask about relevant epidemiological risk factors (travel, exposures, contacts with similar illness) 1
• Document occupational factors that may contribute to illness 1
• Note family history of similar conditions, especially for potentially hereditary disorders 1

Physical Examination

General Assessment

• Record vital signs (temperature, pulse, respiratory rate, blood pressure, oxygen saturation) 1
• Assess general appearance and level of distress 1
• Document baseline body weight 1

Targeted Examination

• Perform a systematic examination focused on the organ system(s) related to the presenting complaint 1
• Document physical findings on appropriate body maps or diagrams 1
• Compare bilateral structures when appropriate (e.g., extremities) 2
• Assess for signs that may indicate specific diagnoses or differential diagnoses 1
• Evaluate cognitive function when appropriate 1

Diagnostic Testing

Laboratory Investigations

• Order targeted laboratory tests based on the differential diagnosis 1
• Consider basic tests: complete blood count, inflammatory markers, metabolic panel 1
• Order specialized tests only when indicated by history and physical findings 1

Imaging Studies

• Select appropriate imaging based on the suspected diagnosis 1
• Consider urgent imaging for potentially serious conditions 1
• Avoid unnecessary imaging when history and physical examination are sufficient 1

Assessment and Management

Differential Diagnosis

• Formulate a differential diagnosis based on history and physical examination findings 3
• Consider common conditions that present with similar symptoms 1
• Recognize that 76% of diagnoses are made from the medical history alone 3

Initial Management

• Address immediate concerns (pain, distress, vital sign abnormalities) 1
• Discontinue potential causative agents if identified 1
• Establish appropriate monitoring based on severity of illness 1
• Initiate treatment for the most likely diagnosis while awaiting confirmatory tests 1

Patient Communication

• Explain findings and diagnostic impressions clearly to the patient 4
• Address patient concerns and expectations to improve satisfaction 4
• Provide clear instructions for follow-up and warning signs 1

Special Considerations

Psychiatric Presentations

• Perform focused medical assessment to exclude medical etiology for psychiatric symptoms 1
• Assess for cognitive disorders such as delirium or dementia 1
• Evaluate for life-threatening manifestations requiring urgent intervention 1

Undifferentiated Symptoms

• Recognize that patients without a specific diagnosis often report more illness worry and dissatisfaction 4
• Provide thorough explanations even when a definitive diagnosis cannot be made 4
• Schedule appropriate follow-up for evolving symptoms 4

Documentation

• Record all findings systematically using appropriate terminology 1
• Document the assessment and plan clearly 1
• Include differential diagnoses considered and reasons for the chosen diagnosis 1, 3
• Note patient education provided and follow-up plans 1

Remember that while the history leads to the final diagnosis in approximately 76% of cases, physical examination and laboratory investigations increase physician confidence in the correct diagnosis and help exclude certain diagnostic possibilities 3.