Clinical skills

A complete medical evaluation includes a medical history, a systems enquiry, a physical examination, appropriate laboratory or imaging studies, analysis of data and medical decision making to obtain diagnoses, and a treatment plan.[4]

The components of the medical history 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 (DHx): what drugs the patient takes including prescribed, over-the-counter, and home remedies, as well as alternative and herbal medicines/herbal remedies such as St John's wort. 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, 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 (taste has been made redundant by the availability of modern lab tests). Four chief methods are used: inspection, palpation (feel), percussion (tap to determine resonance characteristics), and auscultation (listen); smelling may be useful (e.g. infection, uremia, diabetic ketoacidosis).

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)

Skin

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 (spine and extremities)

Neurological (consciousness, awareness, brain, cranial nerves, spinal cord and peripheral nerves)

Psychiatric (orientation, mental state, evidence of abnormal perception or thought)

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.