How to evaluate a patient?

How to Evaluate a Patient

Begin by obtaining a detailed medical history, which establishes the diagnosis in approximately 76% of cases and is the single most critical component of patient evaluation. 1

Essential Components of History Taking

Chief Complaint and Present Illness

• Document the patient's description of their problem in their own words first, then ask targeted questions to clarify 2
• Assess onset (abrupt vs. gradual), duration, severity, and progression of symptoms 2
• Identify associated symptoms including fever, pain characteristics, functional limitations, and systemic manifestations 2
• Evaluate impact on activities of daily living and quality of life 2

Past Medical History

• Review all chronic conditions including cardiovascular disease, diabetes, hypertension, COPD, chronic kidney disease, and psychiatric disorders 2
• Document prior surgeries, hospitalizations, and significant illnesses 2
• Assess for conditions predisposing to specific complications (e.g., immunosuppression, prior gastrectomy, extremes of age) 2

Medication Assessment

• List all current medications including prescription drugs, over-the-counter medications, supplements, and herbal remedies 2
• Specifically identify high-risk medications: vasodilators, diuretics, antipsychotics, sedative/hypnotics, anticoagulants, and antihypertensives 2
• Document recent antibiotic use, antacids, or anti-motility agents 2

Social and Behavioral History

• Tobacco use (quantify pack-years for lung cancer screening consideration) 3
• Alcohol consumption patterns 3
• Occupational exposures and employment status 2
• Living situation, social support, and caregiver availability 2
• Sexual history when relevant (including receptive anal intercourse or oral-anal contact for infectious diarrhea evaluation) 2

Epidemiological Risk Factors

• Recent travel to developing areas 2
• Day-care center attendance or employment 2
• Consumption of unsafe foods (raw meats, eggs, shellfish, unpasteurized products) 2
• Contact with animals, farms, petting zoos, or reptiles 2
• Knowledge of other ill contacts 2

Review of Systems

• Conduct a psychiatric review of systems including anxiety, panic attacks, sleep abnormalities, mood changes, and cognitive concerns 2
• Cardiovascular: chest pain, palpitations, dyspnea, orthopnea, edema 2
• Neurological: headaches, dizziness, syncope, weakness, sensory changes 2
• For specific conditions, tailor questions (e.g., exertional leg symptoms and claudication for PAD evaluation) 2

Physical Examination Priorities

Vital Signs and General Assessment

• Measure blood pressure in both arms, pulse rate, respiratory rate, temperature, and oxygen saturation ("the fifth vital sign") 2
• Perform orthostatic blood pressure measurements (lying, sitting, standing) for patients with falls, syncope, or dizziness 2
• Calculate body mass index and measure waist circumference 2
• Assess general appearance, nutritional status, and level of distress 2, 4

Cardiovascular Examination

• Palpate all peripheral pulses (carotid, brachial, radial, femoral, popliteal, dorsalis pedis, posterior tibial) 2
• Auscultate for carotid, abdominal, and femoral bruits 2
• Assess jugular venous pressure and examine for edema 2
• Perform thorough cardiac auscultation 2

Neurological Assessment

• Evaluate orientation to person, place, time, and situation 4
• Test coordination, gait, and balance (including "get up and go" test for fall risk) 2, 4
• Assess for peripheral neuropathies and proximal motor strength 2
• Check for involuntary movements or abnormalities of motor tone 4
• Evaluate cranial nerves, reflexes, and sensory function 4

Focused Examinations Based on Presentation

• For PAD: inspect legs and feet with all lower garments removed, assess skin temperature, check for ulcers or gangrene 2
• For infectious diarrhea: assess volume depletion (skin turgor, mucous membranes, mental status) 2
• For erectile dysfunction: examine genitalia for testicular abnormalities, penile fibrosis, retractable foreskin 2
• For geriatric patients: complete head-to-toe evaluation even with seemingly isolated injuries 2

Mental Status Examination

• Assess mood, affect, thought process, thought content, and perception 2, 4
• Screen for suicidal ideation (active or passive thoughts) 4
• Evaluate for aggressive or psychotic ideas 4
• Use validated cognitive screening tools (MoCA, Mini-Cog, MMSE) for patients ≥65 years or with cognitive concerns 3, 4

Laboratory and Diagnostic Testing

Principle: Test Selection Based on History and Examination

Order laboratory investigations only after completing history and physical examination, as testing leads to diagnosis in only 11% of cases but increases diagnostic confidence 1

Baseline Screening (Age and Risk-Appropriate)

• Complete blood count if clinically indicated 3
• Comprehensive metabolic panel including electrolytes, renal function, liver function 2
• Fasting glucose or HbA1c for diabetes screening 3
• Lipid panel for cardiovascular risk assessment 3
• Urinalysis when indicated 3

Condition-Specific Testing

• For PAD: ankle-brachial index (ABI), toe-brachial index if ABI abnormal 2
• For hypertension evaluation: ECG, assessment for target organ damage 2
• For infectious diarrhea: stool studies only if bloody diarrhea, fever, severe dehydration, or immunocompromised 2
• For erectile dysfunction: testosterone level if hypogonadism suspected, PSA and rectal exam before hormone therapy 2

Advanced Imaging

• Order imaging based on specific clinical indications from history and examination 5
• Avoid routine surveillance imaging without clinical indication 2

Special Populations

Geriatric Patients (≥65 years)

• Perform comprehensive geriatric assessment including functional status (ADLs, IADLs), fall risk, cognitive screening, and polypharmacy review 2, 3
• Assess for delirium using validated tools if altered mental status present 2
• Evaluate gait and mobility with timed assessments 3
• Screen for depression using standardized instruments 3

Patients with Acute Illness

• Use physiological track-and-trigger systems (e.g., NEWS) to identify deteriorating patients 2
• Assess for signs of sepsis, shock, or organ failure 2
• Determine urgency: emergency (<6 hours), urgent (6-24 hours), or routine 2

Common Pitfalls to Avoid

• Never discontinue oxygen therapy to obtain room air oximetry readings in patients who clearly require supplemental oxygen 2
• Do not rely solely on pulse oximetry in carbon monoxide poisoning (check carboxyhemoglobin levels) 2
• Avoid ordering extensive testing before completing thorough history and examination 6, 1
• Do not overlook medication-related causes of presenting symptoms 2
• Fail to consider cultural factors, language barriers, and education level when interpreting findings 4
• Missing collateral information from family or caregivers, especially in cognitive impairment 4
• Overlooking subtle cognitive deficits in high-functioning elderly patients 4

Documentation Requirements

• Record all findings systematically including negative pertinent findings 2
• Document inspired oxygen device and flow rate with oxygen saturation readings 2
• Note patient's own description of symptoms verbatim when possible 2
• Include assessment of suicide risk or aggressive behavior risk when relevant 4