At the start of a new year I thought it would be useful this week to take a step back from discussing clinical presentations and look more at the process a doctor particularly in the Emergency Department goes about assessing a patient to reach a diagnosis. While there has been a step forward in the number and type of investigations that can be ordered in the Emergency Department unless the doctor has an idea about what these investigations are designed to rule in or rule out it is like aiming a shotgun at a piece of sky, pulling the trigger and hoping one hits something. The purpose of an investigation is like a marksman who prepares and hits their target with a single shot without disturbing or hitting anything else.
When I was a medical student the standard text book about clinical assessment of patients was McLeods Clinical Examination. This book, with a number of new authors still exists today and the summary of a patient interaction has not changed.
That involves taking a history, undertaking an examination formulating a probably diagnosis, undertaking investigations and then treating the patient including how ongoing treatment should be given.
Emergency Medicine has constraints on it both in terms of numbers of patient and therefore the time that each patient may have with the doctor.
The principles have not altered but in Emergency Medicine the process is:
A brief relevant history
A focused examination
A probable working diagnosis
Emergency treatment and safe outcome
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