The history is usually the single most important tool in obtaining a diagnosis. The art of seeking this information in a nonjudgmental, sensitive, and thorough manner cannot be overemphasized.
Applying “book learning” to a specific clinical situation is one the most challenging tasks in medicine. To do so, the clinician must not only retain information, organize facts, and recall large amounts of data but also apply all of this to the patient. The purpose of this text is to facilitate this process.
The first step involves gathering information, also known as establishing the database. This includes taking the history, performing the physical examination, and obtaining selective laboratory examinations, special studies, and/or imaging tests. Sensitivity and respect should always be exercised during the interview of patients. A good clinician also knows how to ask the same question in several different ways, using different terminology. For example, patients may deny having “congestive heart failure” but will answer affirmatively to being treated for “fluid on the lungs.”
The history is usually the single most important tool in obtaining a diagnosis. The art of seeking this information in a nonjudgmental, sensitive, and thorough manner cannot be overemphasized.
1. Basic information:
a. Age: Some conditions are more common at certain ages; for instance, chest pain in an elderly patient is more worrisome for coronary artery disease than the same complaint in a teenager.
b. Gender: Some disorders are more common in men, such as abdominal aortic aneurysms. In contrast, women more commonly have autoimmune problems, such as chronic idiopathic thrombocytopenic purpura or systemic lupus erythematosus. Also, the possibility of pregnancy must be considered in any woman of child-bearing age.
c. Ethnicity: Some disease processes are more common in certain ethnic groups (such as type 2 diabetes mellitus in the Hispanic population).
Family Medicine illustrates the importance of longitudinal care; that is, seeing the patient in various phases and stages of life.
2. Chief complaint: What is it that brought the patient into the hospital? Has there been a change in a chronic or recurring condition or is this a completely new problem? The duration and character of the complaint, associated symptoms, and exacerbating/relieving factors should be recorded. The chief complaint engenders a differential diagnosis, and the possible etiologies should be explored by further inquiry.
The first line of any presentation should include Age, Ethnicity, Gender, Marital Status, and Chief Complaint. Example: A 32-year-old married white male complains of lower abdominal pain of 8-hour duration.
3. Past medical history:
a. Major illnesses such as hypertension, diabetes, reactive airway disease, congestive heart failure, angina, or stroke should be detailed.
i. Age of onset, severity, end-organ involvement.
ii. Medications taken for the particular illness, including any recent changes to medications and reason for the change(s).
iii. Last evaluation of the condition (eg, When was the last stress test or cardiac catheterization performed in the patient with angina?)
iv. Which physician or clinic is following the patient for the disorder?
b. Minor illnesses such as recent upper respiratory infections.
c. Hospitalizations, no matter how trivial, should be queried.
4. Past surgical history: Date and type of procedure performed, indication, and outcome. Laparoscopy versus laparotomy should be distinguished. Surgeon and hospital name/location should be listed. This information should be correlated with the surgical scars on the patient’s body. Any complications should be delineated including anesthetic complications, difficult intubations, and so on.
5. Allergies: Reactions to medications should be recorded, including severity and temporal relationship to medication. Immediate hypersensitivity should be distinguished from an adverse reaction.
6. Medications: A list of medications, dosage, route of administration and frequency, and duration of use should be developed. Prescription, over-the-counter, and herbal remedies are all relevant. If the patient is currently taking antibiotics, it is important to note what type of infection is being treated.
7. Immunization history: Vaccination and prevention of disease is a principal goal of the family physician; hence, recording the immunizations received including dates, age, route, and adverse reactions, if any, is critical.
8. Screening history: Cost-effective surveillance for common diseases or malignancy is another cornerstone responsibility of the family physician. An organized record-keeping is important to a time-efficient approach to this area.
9. Social history: Occupation, marital status, family support, and tendencies toward depression or anxiety are important. Use or abuse of illicit drugs, tobacco, or alcohol should also be recorded. Social history, including marital stressors, sexual dysfunction, and sexual preference, are of importance.
10. Family history: Many major medical problems are genetically transmitted (eg, hemophilia, sickle cell disease). In addition, a family history of conditions such as breast cancer and ischemic heart disease can be a risk factor for the development of these diseases.
11. Review of systems: A systematic review should be performed but focused on the life-threatening and the more common diseases. For example, in a young man with a testicular mass, trauma to the area, weight loss, and infectious symptoms are important to note. In an elderly woman with generalized weakness, symptoms suggestive of cardiac disease should be elicited, such as chest pain, shortness of breath, fatigue, or palpitations.
1. General appearance: Mental status, alert versus obtunded, anxious, in pain, in distress, interaction with other family members, and with examiner.
2. Vital signs: Record the temperature, blood pressure, heart rate, and respiratory rate. An oxygen saturation is useful in patients with respiratory symptoms. Height and weight are often placed here with a body mass index calculated (weight in kg/height in m squared = kg/m2).
3. Head and neck examination: Evidence of trauma, tumors, facial edema, goiter and thyroid nodules, and carotid bruits should be sought. In patients with altered mental status or a head injury, pupillary size, symmetry, and reactivity are important. Mucous membranes should be inspected for pallor, jaundice, and evidence of dehydration. Cervical and supraclavicular nodes should be palpated.
4. Breast examination: Inspection for symmetry and skin or nipple retraction, as well as palpation for masses. The nipple should be assessed for discharge, and the axillary and supraclavicular regions should be examined.
5. Cardiac examination: The point of maximal impulse (PMI) should be ascertained, and the heart auscultated at the apex and base. It is important to note whether the auscultated rhythm is regular or irregular. Heart sounds (including S3 and S4), murmurs, clicks, and rubs should be characterized. Systolic flow murmurs are fairly common as a result of the increased cardiac output, but significant diastolic murmurs are unusual.
6. Pulmonary examination: The lung fields should be examined systematically and thoroughly. Stridor, wheezes, rales, and rhonchi should be recorded. The clinician should also search for evidence of consolidation (bronchial breath sounds, egophony) and increased work of breathing (retractions, abdominal breathing, accessory muscle use).
7. Abdominal examination: The abdomen should be inspected for scars, distension, masses, and discoloration. For instance, the Grey-Turner sign of bruising at the flank areas may indicate intra-abdominal or retroperitoneal hemorrhage. Auscultation should identify normal versus high-pitched and hyperactive versus hypoactive bowel sounds. The abdomen should be percussed for the presence of shifting dullness (indicating ascites). Then careful palpation should begin away from the area of pain and progress to include the whole abdomen to assess for tenderness, masses, organomegaly (ie, spleen or liver), and peritoneal signs. Guarding and whether it is voluntary or involuntary should be noted.
8. Back and spine examination: The back should be assessed for symmetry, tenderness, and masses. The flank regions particularly are important to assess for pain on percussion that may indicate renal disease.
9. Genital examination:
a. Female: The external genitalia should be inspected, then the speculum used to visualize the cervix and vagina. A bimanual examination should attempt to elicit cervical motion tenderness, uterine size, and ovarian masses or tenderness.
b. Male: The penis should be examined for hypospadias, lesions, and discharge. The scrotum should be palpated for tenderness and masses. If a mass is present, it can be transilluminated to distinguish between solid and cystic masses. The groin region should be carefully palpated for bulging (hernias) upon rest and provocation (coughing, standing).
c. Rectal examination: A rectal examination will reveal masses in the posterior pelvis and may identify gross or occult blood in the stool. In females, nodularity and tenderness in the uterosacral ligament may be signs of endometriosis. The posterior uterus and palpable masses in the cul-de-sac may be identified by rectal examination. In the male, the prostate gland should be palpated for tenderness, nodularity, and enlargement.
10. Extremities and skin: The presence of joint effusions, tenderness, rashes, edema, and cyanosis should be recorded. It is also important to note capillary refill and peripheral pulses.
11. Neurologic examination: Patients who present with neurologic complaints require a thorough assessment including mental status, cranial nerves, strength, sensation, reflexes, and cerebellar function.
A thorough understanding of functional anatomy is important to optimally interpret the physical examination findings.
12. Laboratory assessment depends on the circumstances
a. CBC, or complete blood count, can assess for anemia, leukocytosis (infection), and thrombocytopenia.
b. Basic metabolic panel: electrolytes, glucose, BUN (blood urea nitrogen), and creatinine (renal function).
c. Urinalysis and/or urine culture to assess for hematuria, pyuria, or bacteruria. A pregnancy test is important in women of child-bearing age.
d. Aspartate aminotransferase (AST), alanine aminotransferase (ALT), bilirubin, alkaline phosphatase for liver function; amylase and lipase to evaluate the pancreas.
e. Cardiac markers (creatine kinase myocardial band [CK-MB], troponin, myoglobin) if coronary artery disease or other cardiac dysfunction is suspected.
f. Drug levels such as acetaminophen level in possible overdoses.
g. Arterial blood gas measurements give information about oxygenation, carbon dioxide, and pH readings.
13. Diagnostic adjuncts
a. Electrocardiogram if cardiac ischemia, dysrhythmia, or other cardiac dysfunction is suspected.
b. Ultrasound examination is useful in evaluating pelvic processes in female patients (eg, pelvic inflammatory disease, tuboovarian abscess) and in diagnosing gall stones and other gallbladder disease. With the addition of color-flow Doppler, deep venous thrombosis and ovarian or testicular torsion can be detected.
c. Computed tomography (CT) is useful in assessing the brain for masses, bleeding, strokes, and skull fractures. CTs of the chest can evaluate for masses, fluid collections, aortic dissections, and pulmonary emboli. Abdominal CTs can detect infection (abscess, appendicitis, diverticulitis), masses, aortic aneurysms, and ureteral stones.
d. Magnetic resonance imaging (MRI) helps to identify soft tissue planes very well. In the emergency department setting, this is most commonly used to rule out spinal cord compression, cauda equina syndrome, and epidural abscess or hematoma.
e. Screening tests: Fasting lipid panel can demonstrate the cholesterol level, including the low-density lipoprotein (LDL) levels, which have prognostic significance in coronary heart disease; fasting glucose and thyroid tests may be important; in many centers, dual-energy x-ray absorptiometry (DEXA) is the test of choice to monitor bone mineral density; the mammogram is the examination of choice to assess for subclinical breast cancer; the double-contrast barium enema and colonoscopy are used to detect colonic polyps or malignancy.