What is the recommended management for a stable adult patient with no signs of acute distress, normal physical examination findings, and no significant known medical history?

Management of Stable Adult Patient with Normal Physical Examination

For a stable adult patient with no acute distress, normal vital signs, and unremarkable physical examination findings, routine laboratory testing or imaging is not indicated; the patient should be reassessed for specific symptoms or concerns that prompted the visit, and if none exist, can be discharged with appropriate follow-up instructions. 1

Initial Assessment Framework

The evaluation should focus on identifying any specific presenting complaint that brought the patient to medical attention, as the physical examination findings alone do not drive management decisions 1:

• History-directed evaluation: Determine if there was a specific symptom (chest pain, dyspnea, abdominal pain, psychiatric concern) that prompted the visit, even if resolved at time of examination 1
• Vital sign verification: Confirm hemodynamic stability with normal blood pressure (systolic ≥90 mmHg), heart rate, respiratory rate, and oxygen saturation 1
• Mental status assessment: Verify the patient is alert, oriented to person/place/time, and cooperative without cognitive impairment 1

Diagnostic Testing Approach

Routine screening tests are not warranted in asymptomatic patients with normal examinations 1:

• Laboratory testing should be directed by specific clinical findings from history or examination, not performed as a screening battery 1
• The yield of routine testing in patients with normal vital signs and noncontributory examinations is extremely low, with false positives (occurring 8 times more frequently than true positives) leading to unnecessary follow-up 1
• Imaging studies should only be obtained when specific clinical suspicion exists based on presenting symptoms 1

Common Clinical Scenarios

If Patient Presented with Resolved Chest Discomfort

Even if currently pain-free with normal examination and ECG 1:

• Low-risk patients (no prior cardiac history, atypical symptoms, normal ECG, negative initial cardiac biomarkers) can be observed for 6-8 hours with serial ECGs and cardiac markers 1
• Discharge with outpatient stress testing within 72 hours if observation period remains negative 1
• Provide sublingual nitroglycerin and aspirin with explicit return precautions 1

If Patient Presented with Psychiatric or Behavioral Concerns

For alert, cooperative patients with normal vital signs and examination 1:

• Selective testing only: Routine laboratory panels, urine drug screens, and imaging are not indicated unless specific findings suggest medical etiology 1
• The history and physical examination have 96% sensitivity for identifying patients requiring acute medical treatment within 24 hours 1
• Focus on identifying new-onset psychiatric symptoms (which warrant more thorough medical evaluation) versus chronic stable conditions 1

If No Specific Complaint Identified

When the patient ambulated to clinic without distress and examination is entirely normal 1:

• Reassess the reason for visit: Clarify what prompted the patient to seek care, as there may be underlying concerns not initially articulated
• Preventive care discussion: If this represents a wellness visit, address age-appropriate screening and risk factor modification rather than acute diagnostic workup
• Discharge with follow-up: Arrange outpatient primary care follow-up within 72 hours if any residual concerns exist 1

Critical Pitfalls to Avoid

Do not reflexively order testing based on protocols rather than clinical indication 1:

• Routine "medical clearance" batteries in psychiatric patients lead to unnecessary costs and false positive results without improving outcomes 1
• Extensive laboratory screening in asymptomatic patients has sensitivity of only 20% for detecting organic disease 1
• Testing should address specific clinical questions, not serve as blanket screening 1

Do not discharge without explicit instructions 1:

• Provide specific return precautions for concerning symptoms (chest pain, dyspnea, syncope, neurological changes) 1
• Document the normal examination findings and clinical reasoning for conservative management 1
• Ensure follow-up arrangements are concrete, not vague recommendations 1

Disposition and Follow-Up

Discharge criteria for stable patients 1:

• Hemodynamically stable throughout observation period 1
• No evolution of symptoms or examination findings 1
• Patient understands return precautions and has access to follow-up care 1
• Specific follow-up appointment scheduled within 72 hours if any clinical concern exists 1

Documentation should include 1:

• Specific presenting complaint (or lack thereof) that prompted evaluation
• Pertinent negative findings on history and examination
• Clinical reasoning for not pursuing additional testing
• Explicit discharge instructions and follow-up plan