A complete medical evaluation includes a medical history, a physical examination, appropriate laboratory or imaging studies, analysis of data and medical decision making to obtain diagnoses, and treatment plan.
The components of the medical history are:
- Chief complaint (CC) - the reason for the current medical visit.
- History of present illness (HPI) - the chronological order of events of symptoms. A mnemonic PQRST is sometimes helpful in obtaining the history:
- Provocative-palliative factors - what makes a symptom worse or better.
- Quality - description of the symptom
- Region - which part of the body is affected
- Severity - what is the intensity of the symptom; using a scale of 0-10 (10 worst)
- Timing - what is the course of the symptom
- Current activity - occupation, hobbies, what the patient actually does.
- Medications - what drugs including OTCs, and home remedies. Drug allergies are important
- Past medical history (PMH) - other medical diagnoses, past hospitalizations and operations, injuries, past infectious diseases and/or vaccinations
- Review of systems (ROS) - an outline of additional symptoms to ask which may be missed on HPI, generally following the body's main organ systems (heart, lungs, digestive tract, urinary tract, etc.)
- Social history (SH) - birthplace, residences, marital history, social and economic status, habits including diet, drugs, tobacco, alcohol
- Family history (FH) - listing of diseases in the family that may impact the patient. A family tree is sometimes used.
The physical examination is the examination of the patient from head to toe looking for signs of disease. The doctor uses his senses of sight, hearing, touch, and sometimes smell (taste has been replaced by modern lab tests). Four chief methods are used: inspection, palpation, percussion, and auscultation; smelling may be useful (e.g. infection, uremia, diabetic ketoacidosis).
- Vital signs include height, weight, body temperature, blood pressure, pulse, respiration rate, hemoglobin oxygen saturation
- General appearance of the patient
- Skin
- Head, eye, ear, nose, and throat (HEENT)
- Cardiovascular - heart and blood vessels
- Respiratory - lungs
- Abdomen and rectosigmoid
- Genitalia
- Spine and extremities - musculoskeletal
- Neuropsychiatric
Laboratory and imaging studies results, if any.
Medical decision making (MDM) process involves the analysis and synthesis of all the above data to come with a list of possible diagnoses (the differential diagnoses) and what needs to be done to come up with a final diagnosis which would explain the patient's problem.
Treatment plan may include ordering additional labs and studies, starting therapy, referring to a specialist, or watchful observation. Follow-up may be needed.
This process is used by primary care providers and well as specialists. It may take only a few minutes if the problem is simple and straightforward. Or it may take weeks for a patient who has been hospitalized with multiple system problems involving 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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