How do you initially assess a patient?

Initial Patient Assessment Protocol

The initial assessment of a patient should include a thorough history and physical examination to identify cardiac and noncardiac disorders or behaviors that might cause or accelerate the development of health conditions. 1

Step 1: Initial Approach and Safety

• Ensure the area is safe for both provider and patient
• Assess airway, breathing, and circulation (ABCs) immediately for unresponsive patients 2
• Check vital signs: blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation
• Perform rapid neurological evaluation for level of consciousness if indicated 2

Step 2: Comprehensive History

1. Chief Complaint and Present Illness

   • Ask the patient to describe their problem in their own words
   • Document onset, duration, severity, and associated symptoms
   • Assess impact on daily activities and quality of life 1

2. Medical History

   • Past and current medical conditions
   • Past hospitalizations and surgeries
   • Current medications (prescribed, over-the-counter, supplements)
   • Allergies and drug sensitivities 1
   • Past or current neurological disorders 1

3. Psychiatric History (when applicable)

   • Past and current psychiatric diagnoses
   • Prior psychiatric treatments and responses
   • Assessment of suicidal/homicidal ideation if indicated 1

4. Substance Use History

   • Current and past use of tobacco, alcohol, and other substances
   • Misuse of prescribed or over-the-counter medications 1

5. Family History

   • Relevant medical and psychiatric conditions in biological relatives 1

6. Social History

   • Living situation and support systems
   • Occupational status and exposures
   • Educational background
   • Cultural beliefs and explanations of illness 1

Step 3: Physical Examination

1. General Assessment

   • General appearance and nutritional status
   • Height, weight, and BMI calculation 1
   • Orthostatic blood pressure changes 1

2. System-Specific Examination

   • Cardiovascular: heart sounds, pulses, edema
   • Respiratory: breath sounds, respiratory effort
   • Neurological: mental status, cranial nerves, motor/sensory function
   • Musculoskeletal: gait, coordination, strength
   • Skin: integrity, color, lesions, signs of trauma or self-injury 1

Step 4: Mental Status Examination (when applicable)

• Mood, level of anxiety
• Thought content and process
• Perception and cognition
• Assessment of hopelessness or suicidal ideation if indicated 1

Step 5: Initial Diagnostic Testing

Based on clinical presentation, consider:

• Complete blood count
• Urinalysis
• Serum electrolytes (including calcium and magnesium)
• Blood urea nitrogen and serum creatinine
• Fasting blood glucose or glycohemoglobin
• Lipid profile
• Liver function tests
• Thyroid-stimulating hormone 1
• 12-lead ECG 1
• Chest radiograph (PA and lateral) 1

Step 6: Assessment and Plan Development

1. Formulate Initial Impression

   • Document primary and secondary diagnoses
   • Estimate risk factors (e.g., suicide risk if applicable) 1

2. Develop Treatment Plan

   • Document rationale for treatment selection
   • Explain differential diagnosis, risks, and treatment options to patient 1
   • Collaborate with patient on treatment decisions 1

3. Establish Follow-up Plan

   • Determine need for specialty referrals
   • Schedule appropriate follow-up appointments
   • Consider transition planning needs 1

Special Considerations

• For stroke patients: Initial assessment should be conducted by rehabilitation professionals as soon as possible after admission 1
• For heart failure patients: Include assessment of volume status and functional capacity 1
• For psychiatric patients: Include quantitative measures of symptoms and functioning 1

Communication Best Practices

• Introduce yourself and explain your role
• Maintain eye contact and demonstrate active listening
• Use clear, non-technical language
• Verify patient understanding of their condition and plan 3
• Document the patient's treatment preferences 1

Pitfall to avoid: Failing to ask patients about their emotional symptoms, preferences for family involvement, and desired level of participation in medical decision-making. Research shows these areas are frequently overlooked during initial assessments. 4

The quality of initial assessment directly impacts patient satisfaction, understanding of care plans, and health outcomes. Patients with clear understanding of their management plan show better compliance and improved outcomes. 3, 5