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General/Systematic Patient Assessment
A complete patient assessment is the foundation of clinical medicine. Even in the modern era of advanced diagnostics, history and physical examination contribute at least 75% of the information that informs diagnosis - Goldman-Cecil Medicine notes that symptoms unexplained by initial comprehensive evaluation rarely represent serious disease.
1. Chief Complaint (CC)
The opening statement, in the patient's own words, that prompted them to seek care. It sets the focus for the entire encounter. Record it briefly and directly (e.g., "chest pain for 2 hours").
2. History of Present Illness (HPI)
Systematically characterize every symptom using the OLD CARTS or SOCRATES framework:
| Element | What to Elicit |
|---|---|
| Onset | When did it start? Gradual or abrupt? |
| Location | Where exactly? Does it radiate? |
| Duration | How long does each episode last? |
| Character | Sharp, dull, burning, crampy, colicky? |
| Aggravating/Alleviating | What makes it worse or better? (food, position, activity) |
| Radiation | Does it spread anywhere? |
| Timing | Constant vs. intermittent? Pattern? |
| Severity | 0-10 scale; how does it affect daily function? |
Per Goldman-Cecil Medicine, also elicit:
- Acuity (steady vs. colicky; abrupt vs. gradual)
- Relationship to meals, bowel movements, activity
- Recent dietary intake, medication history, travel, and infection exposures
- Systemic symptoms: fever, weight loss, fatigue, night sweats, arthralgias, rash
3. Past Medical History (PMH)
- Known chronic illnesses (diabetes, hypertension, heart disease, thyroid disease, renal/hepatic disease, HIV)
- Prior hospitalizations and surgeries
- Previous similar episodes
- Immunosuppression (iatrogenic, infectious, or inherited)
- Obstetric/gynecologic history (pregnancies, LMP)
- Psychiatric history
4. Medication History
- All prescription medications (name, dose, frequency, duration)
- Over-the-counter drugs, vitamins, dietary supplements, herbal remedies
- Recent changes or new starts
- Allergies: medications, foods, environmental antigens, and contactants - document reaction type (rash vs. anaphylaxis)
5. Family History (FH)
- First-degree relatives' major diseases (cancer, heart disease, diabetes, genetic disorders, atopy)
- Age at diagnosis and cause of death in parents/siblings
6. Social History (SH)
Per Fitzpatrick's Dermatology and Goldman-Cecil:
- Occupation and workplace exposures
- Hobbies and leisure activities
- Tobacco use (pack-years), alcohol (units/week), illicit drug use
- Sexual history (partners, practices, STI risk factors)
- Living situation (alone, family, housing stability)
- Diet and exercise habits
- Travel history (endemic disease areas)
- Cultural or religious practices that may affect care
7. Review of Systems (ROS)
A systematic organ-by-organ screen to catch symptoms the patient may not have volunteered. May be focused (guided by the CC) or comprehensive:
| System | Key Symptoms to Screen |
|---|---|
| Constitutional | Fever, chills, weight change, fatigue, night sweats |
| HEENT | Headache, vision changes, hearing loss, nasal discharge, sore throat |
| Cardiovascular | Chest pain, palpitations, dyspnea, orthopnea, PND, edema, syncope |
| Respiratory | Dyspnea, cough (productive/dry), hemoptysis, wheezing |
| GI | Nausea, vomiting, dysphagia, abdominal pain, bowel habit changes, rectal bleeding, jaundice |
| GU | Dysuria, frequency, hematuria, discharge, sexual dysfunction |
| MSK | Joint pain/swelling, stiffness, muscle weakness |
| Neuro | Headache, dizziness, weakness, paresthesias, seizures, changes in cognition |
| Skin | Rashes, lesions, pruritus, hair/nail changes |
| Endo | Polyuria, polydipsia, heat/cold intolerance, menstrual irregularity |
| Psych | Depression, anxiety, sleep disturbance, suicidal ideation |
| Heme/Lymph | Easy bruising, bleeding, lymphadenopathy |
8. Physical Examination
General Impression
Observe before touching: Does the patient look well or ill? Comfortable or in distress? Obese, cachectic, or normal weight? Skin color (pallor, jaundice, cyanosis)? Skin temperature and turgor?
Vital Signs
| Parameter | Normal Adult Range |
|---|---|
| Temperature | 36.1 - 37.2 °C (97 - 99 °F) |
| Heart rate | 60-100 bpm |
| Respiratory rate | 12-20 breaths/min |
| Blood pressure | <120/80 mmHg |
| O2 saturation | ≥95% (SpO2) |
| Pain score | 0-10 (NRS) |
Weight, height, and BMI are part of a complete set.
Head-to-Toe Examination
Head/Face: Normocephalic, atraumatic; facial symmetry, temporal wasting.
Eyes (PERRL): Pupils equal, round, reactive to light; conjunctivae, sclerae (jaundice, anemia), fundoscopy when indicated.
Ears: Hearing, external canal, tympanic membranes.
Nose/Mouth/Throat: Mucous membranes (moisture = hydration status), dentition, tonsils, pharynx.
Neck: Lymphadenopathy, thyroid size and consistency, carotid bruits, JVD, tracheal position.
Chest/Respiratory: Chest wall shape, respiratory effort, percussion (dullness = fluid/consolidation; hyperresonance = pneumothorax), auscultation (air entry, crackles, wheeze, pleural rub).
Cardiovascular: Apex beat, heart sounds S1/S2, extra sounds (S3/S4, murmurs), peripheral pulses (rate, rhythm, volume), ankle-brachial index (ABI) for vascular assessment when PAD is suspected.
Abdomen: Inspection (scars, distension), auscultation (bowel sounds), percussion (liver/spleen size, ascites), palpation (tenderness, guarding, rebound, organomegaly). Assess relationship of symptoms to food/bowel movements.
Genitourinary/Rectal: Indicated by clinical context.
Musculoskeletal: Range of motion, joint swelling/tenderness, deformities, muscle strength (MRC grading 0-5), gait.
Neurological: Mental status (GCS or orientation x3), cranial nerves, motor/sensory testing, reflexes (DTRs), coordination (finger-nose, heel-shin), cerebellar signs.
Skin: Describe lesions by morphology (primary vs. secondary), color, distribution, and configuration. Per Fitzpatrick's Dermatology, describe whether lesions are localized, grouped, regional, symmetrical, sun-exposed, flexural, or dermatomal.
9. Functional Assessment
- Ability to perform activities of daily living (ADLs) and instrumental ADLs
- Metabolic equivalents (METs) - ≥4 METs (e.g., climbing a flight of stairs) indicates adequate functional capacity for perioperative risk stratification per ACC/AHA guidelines
- Social support and home environment
10. Problem List and Impression
After gathering the above data:
- List all active problems
- Formulate a differential diagnosis for each problem (ranked by probability)
- Outline the diagnostic plan (labs, imaging, procedures)
- Develop a management plan
Key Principle
As Goldman-Cecil Medicine emphasizes: "The fundamental basis of internal medicine is that diagnosis should elucidate the pathophysiologic explanation for symptoms and signs so that therapy may improve the underlying abnormality, not just attempt to suppress the abnormal symptoms or signs." History and physical examination remain the most powerful diagnostic tools available - they provide the context within which all test results must be interpreted.
Sources consulted:
- Goldman-Cecil Medicine International Edition (2 Vol Set)
- Fitzpatrick's Dermatology, Volumes 1 & 2
- Current Surgical Therapy, 14th Edition
- Bailey and Love's Short Practice of Surgery, 28th Edition
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