In clinical practice, doctors personally assess patients in order to diagnose, treat, and prevent disease using clinical judgment. The doctor-patient relationship typically begins an interaction with an examination of the patient's medical history and medical record, followed a medical interview and a physical examination. Basic diagnostic medical devices (e.g. stethoscope, tongue depressor) are typically used. After examination for signs and interviewing for symptoms, the doctor may order medical tests (e.g. blood tests), take a biopsy, or prescribe pharmaceutical drugs or other therapies. Differential diagnosis methods help to rule out conditions based on the information provided. During the encounter, properly informing the patient of all relevant facts is an important part of the relationship and the development of trust. The medical encounter is then documented in the medical record, which is a legal document in many jurisdictions. Followups may be shorter but follow the same general procedure.
The components of the medical interview and encounter are:
- Chief complaint (cc): the reason for the current medical visit. These are the 'symptoms.' They are in the patient's own words and are recorded along with the duration of each one. Also called 'presenting complaint.'
- History of present illness / complaint (HPI): the chronological order of events of symptoms and further clarification of each symptom.
- Current activity: occupation, hobbies, what the patient actually does.
- Medications (Rx): what drugs the patient takes including prescribed, over-the-counter, and home remedies, as well as alternative and herbal medicines/herbal remedies. Allergies are also recorded.
- Past medical history (PMH/PMHx): concurrent medical problems, past hospitalizations and operations, injuries, past infectious diseases and/or vaccinations, history of known allergies.
- Social history (SH): birthplace, residences, marital history, social and economic status, habits (including diet, medications, tobacco, alcohol).
- Family history (FH): listing of diseases in the family that may impact the patient. A family tree is sometimes used.
- Review of systems (ROS) or systems inquiry: a set of additional questions to ask, which may be missed on HPI: a general enquiry (have you noticed any weight loss, change in sleep quality, fevers, lumps and bumps? etc.), followed by questions on the body's main organ systems (heart, lungs, digestive tract, urinary tract, etc.).
The physical examination is the examination of the patient looking for signs of disease ('Symptoms' are what the patient volunteers, 'Signs' are what the healthcare provider detects by examination). The healthcare provider uses the senses of sight, hearing, touch, and sometimes smell (e.g., in infection, uremia, diabetic ketoacidosis). Taste has been made redundant by the availability of modern lab tests. Four actions are taught as the basis of physical examination: inspection, palpation (feel), percussion (tap to determine resonance characteristics), and auscultation (listen). This order may be modified depending on the main focus of the examination (e.g., a joint may be examined by simply "look, feel, move". Having this set order is an educational tool that encourages practitioners to be systematic in their approach and refrain from using tools such as the stethoscope before they have fully evaluated the other modalities).
The clinical examination involves study of:
- Vital signs including height, weight, body temperature, blood pressure, pulse, respiration rate, hemoglobin oxygen saturation
- General appearance of the patient and specific indicators of disease (nutritional status, presence of jaundice, pallor or clubbing)
- Head, eye, ear, nose, and throat (HEENT)
- Cardiovascular (heart and blood vessels)
- Respiratory (large airways and lungs)
- Abdomen and rectum
- Genitalia (and pregnancy if the patient is or could be pregnant)
- Musculoskeletal (including spine and extremities)
- Neurological (consciousness, awareness, brain, vision, cranial nerves, spinal cord and peripheral nerves)
- Psychiatric (orientation, mental state, evidence of abnormal perception or thought).
It is to likely focus on areas of interest highlighted in the medical history and may not include everything listed above.
Laboratory and imaging studies results may be obtained, if necessary.
The medical decision-making (MDM) process involves analysis and synthesis of all the above data to come up with a list of possible diagnoses (the differential diagnoses), along with an idea of what needs to be done to obtain a definitive diagnosis that would explain the patient's problem.
The treatment plan may include ordering additional laboratory tests and studies, starting therapy, referral to a specialist, or watchful observation. Follow-up may be advised.
This process is used by primary care providers as well as specialists. It may take only a few minutes if the problem is simple and straightforward. On the other hand, it may take weeks in a patient who has been hospitalized with bizarre symptoms or multi-system problems, with involvement by several specialists.
On subsequent visits, the process may be repeated in an abbreviated manner to obtain any new history, symptoms, physical findings, and lab or imaging results or specialist consultations.
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