Introduction to Solving Clinical Cases
Steps in a Clinical Encounter
Information gained by a healthcare professional by asking
specific questions, with the aim of obtaining information useful in
diagnosis and providing medical care.
Identification and demographics: name, age, sex, height, weight
the major health problem or concern, and its
History of pre
details about the complaints enumerated in
History of past illness
I) (including major illnesses, any previous
surgery/operations, any current ongoing illness, e.g., diabetes, sickle cell)
Review of systems
Systematic questioning about different
including living arrangements, occupation, drug use (including
tobacco, alcohol, other recreational drug use), recent foreign travel and
exposure to environmental pathogens through recreational activities or pets.
r medications (including those prescribed by doctors, and others
obtained over the counter or
, obstetric/gynecological history
and so on as appropriate.
Process by which a healthcare professio
the body of a patient for
A physical examination usually starts with first observation of the patient and
systematically covers the patient
mobility, awareness, color, hydration, etc
height, weight, pain
temperature, blood p
ressure, pulse, respiratory rate
cardiovascular, lungs, breast, abdomen, genitalia,
musculoskeletal, nervous, including mental status, HEENT (head, eyes, ears,
nose, throat), skin
History + Physical Examination
(a working theory)
(in our case,
a list of
associated with the presumptive diagnosis).
Presumptive + differential will guide your investigation, development of a
that will allow you
to eliminate (or not) the most likely candidates. Always start
with the idea that this is a “horse” and not a “zebra”.