As discussed in Chapter 24, Diagnostic Reasoning in Physical Diagnosis, most of the time, the diagnosis is not clear-cut; the history is often not that of a 70-year-old man with a history of hypertension and hypercholesterolemia who presents with crushing chest pain, or that of a 43-year-old obese woman who presents with severe right upper quadrant pain radiating to her right shoulder and nausea. In most cases, there exists uncertainty as to the diagnosis, and the health-care provider must assess the relative chance that the patient is or is not suffering from a particular medical problem. There are elements of uncertainty in almost every case you will see.

Despite the technology of the twenty-first century, physicians still must use their judgment when making clinical decisions. The hard part of practicing medicine lies in knowing when it is acceptable to be cost conscious with the use of further testing and when this technology must be used. Codifying the way in which health care providers logically approach medical problems and deal with uncertainty is a difficult task. Good medicine is playing the odds after having obtained the important data. The focused history starts with uncovering the major details of the current medical problem or the reason the patient has sought medical attention at this time.

In documenting a focused history and performing a focused physical examination, you need to explore the chief complaint, the history of the present illness, the past medical history, medications and allergies, the family history and social history, the occupational history, and the sexual history that are relevant to that specific patient. It is important to recognize that focused does not mean making one diagnosis and skipping the differential diagnosis. In the focused physical examination, you need to examine specifically the body part or system directly involved with the medical problem when there is no time to perform a head-to-toe examination. Remember, however, that other organ systems may need to be evaluated as well. A patient with chest pain requires a full cardiac examination, in addition to examination of the legs for peripheral pulses and edema, carotid artery auscultation and palpation, evaluation of liver size, and evaluation of the retina for related vascular changes.

After your clinical evaluation, tests should be obtained only to corroborate your clinical impression or if the result will in some way affect your decision-making. Remember that common things are common. Uncommon symptoms are more likely to represent an uncommon manifestation associated with a common condition than with a totally uncommon illness.

Illustrative Case