Clinical Diagnosis
The process of diagnosing a patient based on symptoms and vital signs is called "clinical diagnosis" or "focused medical assessment." 1, 2
Definition and Core Components
Clinical diagnosis refers to the diagnostic verdict reached through systematic evaluation of a patient's history, physical examination findings, and vital signs, with selective use of confirmatory or exclusionary testing only when indicated by these initial assessments. 1, 2, 3
The term encompasses several key elements:
- History-taking to identify presenting symptoms, their onset, temporal pattern, and associated features 2, 3
- Physical examination with particular attention to neurologic, cardiac, and respiratory systems 1, 2
- Vital signs assessment including temperature, pulse, blood pressure, respiratory rate, and oxygen saturation 1, 4
- Mental status examination when psychiatric or cognitive symptoms are present 2
The Diagnostic Process
The clinical diagnostic process follows a structured algorithmic approach: first, establish pre-test probability through history and examination; second, use this information to guide selective testing; third, integrate test results to confirm or exclude diagnostic hypotheses. 3, 5
Step 1: Initial Assessment
- Obtain comprehensive history focusing on symptom onset, duration, progression, and associated features 1, 2
- Assess vital signs, as abnormal vital signs are among the most important predictors of underlying pathology 2, 6
- Perform targeted physical examination of systems suggested by the presenting complaint 1, 2
Step 2: Formulate Diagnostic Hypothesis
- Use history and examination findings to estimate pre-test probability of disease 3, 5
- Consider differential diagnoses based on clinical presentation 1, 2
- Determine if additional testing is warranted based on clinical findings 1, 2
Step 3: Selective Testing (Only When Indicated)
- Order laboratory or imaging studies ONLY when indicated by abnormal history, physical examination, or vital signs 1, 2
- When pre-test probability is high, use tests with high specificity to confirm diagnosis 3, 5
- When pre-test probability is low, use tests with high sensitivity to exclude disease 3, 5
Alternative Terminology
The medical literature uses several related terms interchangeably:
- "Focused medical assessment" - preferred by ACEP for psychiatric patients, emphasizing targeted evaluation rather than routine testing 1
- "Medical clearance" - older term being replaced by "medical stability" determination 1
- "Bedside diagnosis" - emphasizes diagnosis made without extensive testing 1
Critical Importance of Clinical Assessment
History and physical examination have a pooled diagnostic yield of 15.6% and 14.9% respectively for detecting clinically significant conditions requiring management changes - far superior to routine laboratory testing (1.1% yield). 2
This evidence demonstrates that:
- Clinical assessment is the foundation of accurate diagnosis 2, 3
- Routine "screening" laboratory panels are costly, low-yield, and increase false-positive results 1, 2
- Vital signs assessment is critical and its neglect places patients at risk of poor outcomes 6
Common Pitfalls to Avoid
- Over-reliance on laboratory testing rather than clinical assessment 2
- Ordering routine test batteries without clinical indication 1, 2
- Inadequate attention to vital signs, which are critical predictors of medical pathology 2, 6
- Neglecting the physical examination, which has 14.9% yield for detecting conditions requiring management changes 2
- Failing to obtain collateral information from family or caregivers when patients cannot provide reliable history 2
Documentation
When documenting clinical diagnosis, specify the clinical findings (symptoms, signs, vital signs) that support the diagnosis, and document if specific diagnostic measures are consciously withheld and why. 1, 7
The term "medically stable" is preferred over "medically cleared" when referring to patients who have undergone appropriate clinical assessment. 1, 7