How to evaluate a patient's condition?

How to Evaluate a Patient's Condition

Begin with a comprehensive history of present illness that documents onset, duration, severity, characteristics of symptoms, impact on daily activities, associated symptoms, modifying factors, and relevant risk factors, followed by a focused physical examination targeting the systems suggested by the history. 1

History of Present Illness: The Foundation

The history is the single most important diagnostic tool, leading to correct diagnosis in approximately 66-78% of cases before any physical examination or testing. 2, 3

Essential HPI Components

Document these specific elements for every patient:

• Symptom characterization: Precise descriptions of the primary complaint, avoiding vague terms 1
• Temporal factors: Exact onset time, frequency, duration, and progression pattern 1
• Severity quantification: Use numerical scales or standardized descriptors to establish baseline 1
• Contextual features: Triggers, exacerbating factors, and alleviating factors 1
• Functional impact: How symptoms affect activities of daily living, work, relationships, and quality of life 1
• Associated symptoms: Related complaints that establish patterns or syndromes 1
• Risk factor assessment: Individualized factors relevant to the presenting complaint 1
• Previous treatments: Prior interventions attempted and their effectiveness 4
• Patient perspective: The patient's understanding and concerns about symptoms 1

Domain-Specific History Elements

For cardiovascular complaints, document dyspnea characteristics, chest pain quality/radiation/timing, palpitations, syncope, orthopnea, and cardiovascular risk factors (hypertension, diabetes, smoking, family history). 4, 1

For peripheral artery disease evaluation, specifically ask about exertional leg symptoms including claudication, atypical leg pain (pain starting at rest but worsening with exertion, pain not stopping walking, pain not relieved within 10 minutes of rest), ischemic rest pain, and nonhealing wounds. 4 Most PAD patients do not have typical claudication but have atypical symptoms or are asymptomatic, yet still have significant functional impairment. 4

For cognitive/neurological complaints, obtain information about changes in memory, speed of thinking, mood, behavioral changes, functional abilities in instrumental activities of daily living, and obtain collateral information from informants when available. 4, 1

For heart failure assessment, evaluate the patient's ability to perform routine and desired activities of daily living, and obtain history of alcohol use, illicit drugs, alternative therapies, and chemotherapy drugs. 4

Physical Examination: Targeted and Efficient

The physical examination contributes to diagnosis in approximately 8% of cases but significantly increases diagnostic confidence. 2

Universal Examination Elements

Every patient evaluation should include:

• Vital signs: Blood pressure (including orthostatic changes), heart rate, respiratory rate, temperature, oxygen saturation 4
• Anthropometrics: Height, weight, body mass index, waist circumference 4
• General appearance: Nutritional status, signs of distress, coordination and gait 5
• Skin assessment: Signs of trauma, self-injury, substance use 5

System-Specific Examination

For cardiovascular evaluation, perform cardiovascular examination including heart auscultation and assessment of volume status. 4

For PAD evaluation, palpate all lower extremity pulses (femoral, popliteal, dorsalis pedis, posterior tibial), auscultate for femoral bruits, and inspect legs and feet with all lower garments removed. 4

For preanesthesia evaluation, at minimum assess airway, perform pulmonary examination with lung auscultation, and cardiovascular examination. 4 For high surgical invasiveness, these examinations should be performed prior to the day of surgery. 4

Brief Mental Status Examination

When cognitive or psychiatric concerns exist, assess:

• Appearance and behavior: General appearance, coordination, gait, involuntary movements 5
• Speech: Fluency and articulation 5
• Mood and affect: Current mood, anxiety level, hopelessness, suicidal ideation (active or passive) 5
• Thought process: Logical flow, presence of aggressive or psychotic ideas 5
• Cognition: Orientation to person/place/time/situation, memory (short and long-term), executive functioning 5

Use validated tools for cognitive screening:

• Mini-Cog (first-line, 2-3 minutes): 76% sensitivity, 89% specificity for dementia; score <3 is concerning 5
• Montreal Cognitive Assessment (MoCA) (10-15 minutes): More sensitive for mild cognitive impairment 5
• Short Test of Mental Status (STMS) (10-15 minutes): More sensitive than MMSE for subtle deficits 5

Laboratory and Diagnostic Testing

Laboratory investigations contribute to diagnosis in approximately 13% of cases and should be ordered based on specific clinical indications from history and examination. 2, 3

Initial Laboratory Evaluation

For heart failure patients, obtain complete blood count, urinalysis, serum electrolytes (including calcium and magnesium), blood urea nitrogen, serum creatinine, fasting glucose (glycohemoglobin), lipid profile, liver function tests, and thyroid-stimulating hormone. 4

For all patients, order tests based on specific clinical indications identified in the history and physical examination, not as routine screening. 4 A "routine test" ordered without specific clinical indication has limited value. 4

Imaging Studies

For heart failure evaluation, obtain 12-lead electrocardiogram and chest radiograph (PA and lateral) initially, plus two-dimensional echocardiography with Doppler to assess left ventricular ejection fraction, size, wall thickness, and valve function. 4

For cognitive impairment workup, consider brain MRI when comprehensive evaluation indicates need for structural assessment. 4

Critical Pitfalls to Avoid

Do not overlook functional impact of symptoms on daily activities, as this provides crucial diagnostic and treatment context. 1

Do not neglect modifying factors (what improves or worsens symptoms), as these offer important diagnostic clues. 1

Do not miss relevant risk factors through inadequate individualized risk assessment. 1

Do not fail to obtain collateral information from family or caregivers, especially when evaluating cognitive impairment. 5

Do not interpret cognitive screening scores in isolation; a "normal" score does not exclude subtle impairment or functional problems. 5

Do not order tests without specific clinical indications from the history and physical examination. 4, 3

Do not ignore education level, language barriers, or cultural factors when interpreting examination findings and test results. 5

Timing Considerations

For high surgical invasiveness or high severity of disease, complete the initial assessment including record review, patient interview, and physical examination prior to the day of surgery. 4

For low surgical invasiveness and low severity of disease, the initial assessment may be performed on or before the day of surgery. 4

For emergency procedures (life or limb threatened within <6 hours), there is time for no or very limited clinical evaluation. 4

For urgent procedures (life or limb threatened within 6-24 hours), there may be time for limited clinical evaluation. 4