Clinical practices
Medical
availability and clinical practice varies across the world due to regional
differences in culture and technology. Modern scientific medicine is highly
developed in the Western world, while in developing countries such as parts of Africa
or Asia, the population may rely more heavily on traditional medicine with limited
evidence and efficacy and no required formal training for practitioners.[8] Even
in the developed world however, evidence-based medicine is not
universally used in clinical practice; for example, a 2007 survey of literature
reviews found that about 49% of the interventions lacked sufficient evidence to
support either benefit or harm.[9]
In modern
clinical practice, physicians 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 by a medical interview[10] 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.[11] Follow-ups
may be shorter but follow the same general procedure, and specialists follow a
similar process. The diagnosis and treatment may take only a few minutes or a
few weeks depending upon the complexity of the issue.
The
components of the medical interview[10] 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 'chief concern' or 'presenting
complaint'.
- History of present illness (HPI):
the chronological order of events of symptoms and further clarification of
each symptom. Distinguishable from history of previous illness, often
called past medical history (PMH). Medical history comprises HPI and PMH.
- 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 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 for medical signs of disease, which are objective and
observable, in contrast to symptoms which are volunteered by the patient and
not necessarily objectively observable.[12] The
healthcare provider uses the senses of sight, hearing, touch, and sometimes
smell (e.g., in infection, uremia, diabetic ketoacidosis). Four actions are the
basis of physical examination: inspection, palpation (feel), percussion (tap to determine resonance
characteristics), and auscultation (listen), generally in that order
although auscultation occurs prior to percussion and palpation for abdominal
assessments.[13]
The clinical
examination involves the study of:
- Vital signs including height,
weight, body temperature, blood
pressure, pulse, respiration rate, and 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 (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.
The
treatment plan may include ordering additional medical laboratory tests and medical
imaging studies, starting therapy, referral to a specialist, or
watchful observation. Follow-up may be advised. Depending upon the health
insurance plan and the managed
care system, various forms of "utilization review", such as prior
authorization of tests, may place barriers on accessing expensive services.[14]
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.
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.
