What is the initial approach for a new patient or new diagnosis as a Family Nurse Practitioner (FNP)?

Initial Approach for a New Family Nurse Practitioner Patient

Begin with a structured, symptom-focused history that identifies the chief complaint, characterizes the presenting symptoms, and screens for red flags requiring urgent intervention or specialist referral.

Step 1: Establish the Chief Complaint and Symptom Characterization

• Ask the patient to describe their problem in their own words to understand what brought them to seek care 1
• Obtain specific details about symptom onset, duration, quality, severity, aggravating/relieving factors, and associated symptoms 2
• The history alone leads to the correct diagnosis in approximately 76% of cases, making this the most critical diagnostic step 3

Step 2: Targeted History Taking Based on Presenting Complaint

For Respiratory Complaints:

• Ask structured questions about exposure history including occupational exposures, environmental triggers, pets, hobbies, and home environment (mold, water damage) 1
• Document temporal patterns: seasonal, perennial, or episodic symptoms 1
• Identify specific symptoms: nasal/ocular itching, sneezing, clear rhinorrhea, cough, dyspnea 1

For Cardiac/Chest Pain:

• Characterize chest pain quality and associated symptoms within 10 minutes of first contact 1
• Assess cardiovascular risk factors: age, smoking history, prior MI, hypertension, diabetes 1
• Obtain immediate ECG if acute coronary syndrome is suspected 1

For Cognitive Complaints:

• Document progressive memory loss and functional decline affecting daily activities 4
• Screen for reversible causes: medication effects, depression, metabolic abnormalities 4
• A clinical diagnosis can be made based on history and examination alone in primary care 4

Step 3: Identify Red Flags Requiring Urgent Action or Referral

Screen for symptoms suggesting serious underlying pathology:

• Unilateral symptoms (nasal obstruction, rhinorrhea) suggest structural lesions, tumors, or CSF leak 1
• Severe headache, epistaxis, or anosmia warrant further investigation for sinusitis, granulomatous disease, or malignancy 1
• Constitutional symptoms (weight loss, fever, night sweats) in cancer patients require urgent multidisciplinary evaluation 1, 5
• Acute vision changes in cancer patients demand immediate ophthalmologic evaluation for metastases or infection 5

Step 4: Focused Physical Examination

Perform examination targeted to the presenting complaint:

• Vital signs are mandatory including blood pressure in all patients 1
• For respiratory complaints: examine nasal mucosa for pallor/edema, assess for nasal polyps, evaluate conjunctival injection 1
• For cardiac complaints: cardiovascular and pulmonary examination 1
• For cognitive complaints: neurological examination and mental status assessment 4
• Limit examination to what is clinically indicated rather than comprehensive screening in asymptomatic patients 1, 6

Step 5: Initial Diagnostic Testing Strategy

Order tests based on clinical suspicion, not as routine screening:

• The physical examination increases diagnostic confidence from 7.1/10 to 8.2/10, while laboratory testing increases it to 9.3/10 3
• For allergic rhinitis: consider serum IgE testing only when history/exam suggest allergic etiology 1
• For acute coronary syndrome: troponin, CK-MB, CBC, creatinine, ECG within 60 minutes 1
• For cognitive decline: exclude reversible causes with basic metabolic panel, thyroid function, B12 level 4
• Avoid unnecessary testing that increases cost and patient risk without changing management 7

Step 6: Determine Need for Specialist Referral

Refer when:

• Diagnostic uncertainty exists after initial evaluation 4
• Atypical presentations that don't fit common patterns (young patients with chronic symptoms, unilateral findings, severe symptoms unresponsive to initial therapy) 1
• Specialized testing is required (bronchoscopy, surgical biopsy, advanced imaging) 1
• Multidisciplinary care is needed for complex conditions like cancer, interstitial lung disease, or advanced dementia 1

Critical Pitfalls to Avoid

• Do not order imaging or extensive testing before taking a thorough history - this leads to unnecessary costs and potential harm 7
• Do not assume all rhinitis is allergic - irritant exposure, vasomotor rhinitis, and structural abnormalities present similarly 1
• Do not delay urgent referral when red flags are present - unilateral symptoms, vision changes in cancer patients, or suspected acute coronary syndrome require immediate action 1, 5
• Be aware of self-referral legal implications when ordering imaging or services that may create financial conflicts of interest 8