History of Present Illness (HPI)

Obtaining an accurate history is the critical first step in determining the etiology of a patient's problem. A
large percentage of the time, you will actually be able to make a diagnosis based on the history alone. The
value of the history, of course, will depend on your ability to elicit relevant information. Your sense of
what constitutes important data will grow exponentially in the coming years as you gain a greater
understanding of the pathophysiology of disease through increased exposure to patients and illness.
However, you are already in possession of the tools that will enable you to obtain a good history. That is,
an ability to listen and ask common-sense questions that help define the nature of a particular problem. It
does not take a vast, sophisticated fund of knowledge to successfully interview a patient. In fact seasoned
physicians often lose site of this important point, placing too much emphasis on the use of testing while
failing to take the time to listen to their patients. Successful interviewing is for the most part dependent
upon your already well developed communication skills.
What follows is a framework for approaching patient complaints in a problem oriented fashion. The
patient initiates this process by describing a symptom. It falls to you to take that information and use it as
a springboard for additional questioning that will help to identify the root cause of the problem. Note that
this is different from trying to identify disease states which might exist yet do not generate overt
symptoms. To uncover these issues requires an extensive "Review Of Systems" (a.k.a. ROS). Generally,
this consists of a list of questions grouped according to organ system and designed to identify disease
within that area. For example, a review of systems for respiratory illnesses would include: Do you have a
cough? If so, is it productive of sputum? Do you feel short of breath when you walk? etc. In a practical
sense, it is not necessary to memorize an extensive ROS question list. Rather, you will have an
opportunity to learn the relevant questions that uncover organ dysfunction when you review the physical
exam for each system individually. In this way, the ROS will be given some context, increasing the
likelihood that you will actually remember the relevant questions.
The patient's reason for presenting to the clinician is usually referred to as the "Chief Complaint." Perhaps
a less pejorative/more accurate nomenclature would be to identify this as their area of "Chief Concern."
Getting Started:
Always introduce yourself to the patient. Then try to make the environment as private and free of
distractions as possible. This may be difficult depending on where the interview is taking place. The
emergency room or a non-private patient room are notoriously difficult spots. Do the best that you can
and feel free to be creative. If the room is crowded, it's OK to try and find alternate sites for the interview.
It's also acceptable to politely ask visitors to leave so that you can have some privacy.
If possible, sit down next to the patient while conducting the interview. Remove any physical barriers that
stand between yourself and the interviewee (e.g. put down the side rail so that your view of one another is
unimpeded... though make sure to put it back up at the conclusion of the interview). These simple
maneuvers help to put you and the patient on equal footing. Furthermore, they enhance the notion that
you are completely focused on them. You can either disarm or build walls through the speech, posture and
body languarge that you adopt. Recognize the power of these cues and the impact that they can have on
the interview. While there is no way of creating instant intimacy and rapport, paying attention to what
may seem like rather small details as well as always showing kindness and respect can go a long way
towards creating an environment that will facilitate the exchange of useful information.
If the interview is being conducted in an outpatient setting, it is probably better to allow the patient to
wear their own clothing while you chat with them. At the conclusion of your discussion, provide them
with a gown and leave the room while they undress in preparation for the physical exam.
Initial Question(s):
Ideally, you would like to hear the patient describe the problem in their own words. Open ended questions
are a good way to get the ball rolling. These include: "What brings your here? How can I help you? What
seems to be the problem?" Push them to be as descriptive as possible. While it's simplest to focus on a
single, dominant problem, patients occasionally identify more then one issue that they wish to address.
When this occurs, explore each one individually using the strategy described below.
Follow-up Questions:
There is no single best way to question a patient. Successful interviewing requires that you avoid medical
terminology and make use of a descriptive language that is familiar to them. There are several broad
questions which are applicable to any complaint. These include:
1

1. Duration: How long has this condition lasted? Is it similar to a past problem? If so, what was
done at that time?
2. Severity/Character: How bothersome is this problem? Does it interfere with your daily
activities? Does it keep you up at night? Try to have them objectively rate the problem. If they are
describing pain, ask them to rate it from 1 to 10 with 10 being the worse pain of their life, though
first find out what that was so you know what they are using for comparison (e.g. childbirth, a
broken limb, etc.). Furthermore, ask them to describe the symptom in terms with which they are
already familiar. When describing pain, ask if it's like anything else that they've felt in the past.
Knife-like? A sensation of pressure? A toothache? If it affects their activity level, determine to
what degree this occurs. For example, if they complain of shortness of breath with walking, how
many blocks can they walk? How does this compare with 6 months ago?
3. Location/Radiation: Is the symptom (e.g. pain) located in a specific place? Has this changed over
time? If the symptom is not focal, does it radiate to a specific area of the body?
4. Have they tried any therapeutic maneuvers?: If so, what's made it better (or worse)?
5. Pace of illness: Is the problem getting better, worse, or staying the same? If it is changing, what
has been the rate of change?
6. Are there any associated symptoms? Often times the patient notices other things that have
popped up around the same time as the dominant problem. These tend to be related.
7. What do they think the problem is and/or what are they worried it might be?
8. Why today?: This is particularly relevant when a patient chooses to make mention of
symptoms/complaints that appear to be long standing. Is there something new/different today as
opposed to every other day when this problem has been present? Does this relate to a gradual
worsening of the symptom itself? Has the patient developed a new perception of its relative
importance (e.g. a friend told them they should get it checked out)? Do they have a specific
agenda for the patient-provider encounter?
For those who favor mnemonics, the 8 dimensions of a medical problem can be easily recalled using
OLD CARTS (Onset, Location/radiation, Duration, Character, Aggrevating factors, Reliving factors,
Timing and Severity).
The content of subsequent questions will depend both on what you uncover and your knowledge
base/understanding of patients and their illnesses. If, for example, the patient's initial complaint was chest
pain you might have uncovered the following by using the above questions:
The pain began 1 month ago and only occurs with activity. It rapidly goes away with rest.
When it does occur, it is a steady pressure focused on the center of the chest that is roughly
a 5 (on a scale of 1 to 10). Over the last week, it has happened 6 times while in the first
week it happened only once. The patient has never experienced anything like this
previously and has not mentioned this problem to anyone else prior to meeting with you.
As yet, they have employed no specific therapy.
This is quite a lot of information. However, if you were not aware that coronary-based ischemia causes a
symptom complex identical to what the patient is describing, you would have no idea what further
questions to ask. That's OK. With additional experience, exposure, and knowledge you will learn the
appropriate settings for particular lines of questioning. When clinicians obtain a history, they are
continually generating differential diagnoses in their minds, allowing the patient's answers to direct the
logical use of additional questions. With each step, the list of probable diagnoses is pared down until a
few likely choices are left from what was once a long list of possibilities. Perhaps an easy way to
understand this would be to think of the patient problem as a Windows-Based computer program. The
patient tells you a symptom. You click on this symptom and a list of general questions appears. The
patient then responds to these questions. You click on these responses and... blank screen. No problem. As
yet, you do not have the clinical knowledge base to know what questions to ask next. With time and
experience you will be able to click on the patient's response and generate a list of additional appropriate
questions. In the previous patient with chest pain, you will learn that this patient's story is very consistent
with significant, symptomatic coronary artery disease. As such, you would ask follow-up questions that
help to define a cardiac basis for this complaint (e.g. history of past myocardial infarctions, risk factors
2

for coronary disease, etc.). You'd also be aware that other disease states (e.g. emphysema) might cause
similar symptoms and would therefore ask questions that could lend support to these possible diagnoses
(e.g. history of smoking or wheezing). At the completion of the HPI, you should have a pretty good idea
as to the likely cause of a patient's problem. You may then focus your exam on the search for physical
signs that would lend support to your working diagnosis and help direct you in the rational use of
adjuvant testing.
Recognizing symptoms/responses that demand an urgent assessment (e.g. crushing chest pain) vs. those
that can be handled in a more leisurely fashion (e.g. fatigue) will come with time and experience. All
patient complaints merit careful consideration. Some, however, require time to play out, allowing them to
either become "a something" (a recognizable clinical entity) or "a nothing," and simply fade away.
Clinicians are constantly on the look-out for markers of underlying illness, historical points which might
increase their suspicion for the existence of an underlying disease process. For example, a patient who
does not usually seek medical attention yet presents with a new, specific complaint merits a particularly
careful evaluation. More often, however, the challenge lies in having the discipline to continually reconsider the diagnostic possibilities in a patient with multiple, chronic complaints who presents with a
variation of his/her "usual" symptom complex.
You will undoubtedly forget to ask certain questions, requiring a return visit to the patient's bedside to
ask, "Just one more thing." Don't worry, this happens to everyone! You'll get more efficient with practice.
Dealing With Your Own Discomfort:
Many of you will feel uncomfortable with the patient interview. This process is, by its very nature, highly
intrusive. The patient has been stripped, both literally and figuratively, of the layers that protect them
from the physical and psychological probes of the outside world. Furthermore, in order to be successful,
you must ask in-depth, intimate questions of a person with whom you essentially have no relationship.
This is completely at odds with your normal day to day interactions. There is no way to proceed without
asking questions, peering into the life of an otherwise complete stranger. This can, however, be done in a
way that maintains respect for the patient's dignity and privacy. In fact, at this stage of your careers, you
perhaps have an advantage over more experienced providers as you are hyper-aware that this is not a
natural environment. Many physicians become immune to the sense that they are violating a patient's
personal space and can thoughtlessly over step boundaries. Avoiding this is not an easy task. Listen and
respond appropriately to the internal warnings that help to sculpt your normal interactions.
Vital Signs
Vital signs include the measurement of: temperature, respiratory rate, pulse, blood pressure and, where
appropriate, blood oxygen saturation. These numbers provide critical information (hence the name
"vital") about a patient's state of health. In particular, they:
1. Can identify the existence of an acute medical problem.
2. Are a means of rapidly quantifying the magnitude of an illness and how well the body is coping
with the resultant physiologic stress. The more deranged the vitals, the sicker the patient.
3. Are a marker of chronic disease states (e.g. hypertension is defined as chronically elevated blood
pressure).
Most patients will have had their vital signs measured by an RN or health care assistant before you have a
chance to see them. However, these values are of such great importance that you should get in the habit of
repeating them yourself, particularly if you are going to use these values as the basis for management
decisions. This not only allows you to practice obtaining vital signs but provides an opportunity to verify
their accuracy. As noted below, there is significant potential for measurement error, so repeat
determinations can provide critical information.
Getting Started: The examination room should be quiet, warm and well lit. After you have finished
interviewing the patient, provide them with a gown (a.k.a. "Johnny") and leave the room (or draw a
separating curtain) while they change. Instruct them to remove all of their clothing (except for briefs) and
put on the gown so that the opening is in the rear. Occasionally, patient's will end up using them as
ponchos, capes or in other creative ways. While this may make for a more attractive ensemble it will also,
unfortunately, interfere with your ability to perform an examination! Prior to measuring vital signs, the
patient should have had the opportunity to sit for approximately five minutes so that the values are not
3

affected by the exertion required to walk to the exam room. All measurements are made while the patient
is seated.
Observation: Before diving in, take a minute or so to look at the patient in their entirety, making your
observations, if possible, from an out-of-the way perch. Does the patient seem anxious, in pain, upset?
What about their dress and hygiene? Remember, the exam begins as soon as you lay eyes on the patient.
Temperature: This is generally obtained using an oral thermometer that provides a digital reading when
the sensor is placed under the patient's tongue. As most exam rooms do not have thermometers, it is not
necessary to repeat this measurement unless, of course, the recorded value seems discordant with the
patient's clinical condition (e.g. they feel hot but reportedly have no fever or vice versa). Depending on
the bias of a particular institution, temperature is measured in either Celcius or Farenheit, with a fever
defined as greater than 38-38.5 C or 101-101.5 F. Rectal temperatures, which most closely reflect internal
or core values, are approximately 1 degree F higher than those obtained orally.
Respiratory Rate: Respirations are recorded as breaths per minute. They should be counted for at least
30 seconds as the total number of breaths in a 15 second period is rather small and any miscounting can
result in rather large errors when multiplied by 4. Try to do this as surreptitiously as possible so that the
patient does not consciously alter their rate of breathing. This can be done by observing the rise and fall
of the patient's hospital gown while you appear to be taking their pulse. Normal is between 12 and 20. In
general, this measurement offers no relevant information for the routine examination. However,
particularly in the setting of cardio-pulmonary illness, it can be a very reliable marker of disease activity.
Pulse: This can be measured at any place where there is a large artery (e.g. carotid, femoral, or simply by
listening over the heart), though for the sake of convenience it is generally done by palpating the radial
impulse. You may find it helpful to feel both radial arteries simultaneously, doubling the sensory input
and helping to insure the accuracy of your measurements. Place the tips of your index and middle fingers
just proximal to the patients wrist on the thumb side, orienting them so that they are both over the length
of the vessel.

Vascular Anatomy

Technique for Measuring the Radial Pulse

The pictures below demonstrate the location of the radial artery (surface anatomy on the left, gross
anatomy on the right).

Frequently, you can see transmitted pulsations on careful visual inspection of this region, which may help
in locating this artery. Upper extremity peripheral vascular disease is relatively uncommon, so the radial
artery should be readily palpable in most patients. Push lightly at first, adding pressure if there is a lot of
subcutaneous fat or you are unable to detect a pulse. If you push too hard, you might occlude the vessel
and mistake your own pulse for that of the patient. During palpation, note the following:
1. Quantity: Measure the rate of the pulse (recorded in beats per minute). Count for 30 seconds and
multiply by 2 (or 15 seconds x 4). If the rate is particularly slow or fast, it is probably best to
measure for a full 60 seconds in order to minimize the impact of any error in recording over
shorter periods of time. Normal is between 60 and 100.
2. Regularity: Is the time between beats constant? In the normal setting, the heart rate should appear
metronomic. Irregular rhythms, however, are quite common. If the pattern is entirely chaotic with
no discernable pattern, it is referred to as irregularly irregular and likely represents atrial
fibrillation. Extra beats can also be added into the normal pattern, in which case the rhythm is
described as regularly irregular. This may occur, for example, when impulses originating from the
ventricle are interposed at regular junctures on the normal rhythm. If the pulse is irregular, it's a
good idea to verify the rate by listening over the heart (see cardiac exam section). This is because
certain rhythm disturbances do not allow adequate ventricular filling with each beat. The resultant
systole may generate a rather small stroke volume whose impulse is not palpable in the periphery.
3. Volume: Does the pulse volume (i.e. the subjective sense of fullness) feel normal? This reflects
changes in stroke volume. In the setting of hypovolemia, for example, the pulse volume is
relatively low (aka weak or thready). There may even be beat to beat variation in the volume,
occurring occasionally with systolic heart failure.
Rhythm Simulator
Blood Pressure: Blood pressure (BP) is measured using mercury based manometers, with readings
reported in millimeters of mercury (mm Hg). The size of the BP cuff will affect the accuracy of these
readings. The inflatable bladder, which can be felt through the vinyl covering of the cuff, should reach
roughly 80% around the circumference of the arm while its width should cover roughly 40%. If it is too
small, the readings will be artificially elevated. The opposite occurs if the cuff is too large. Clinics should
have at least 2 cuff sizes available, normal and large. Try to use the one that is most appropriate,
recognizing that there will rarely be a perfect fit.

Blood Pressure Cuffs

In order to measure the BP, proceed as follows:

1. Wrap the cuff around the patient's upper arm so that the line marked "artery" is roughly over the
brachial artery, located towards the medial aspect of the antecubital fossa (i.e. the crook on the
inside of their elbow). The placement does not have to be exact nor do you actually need to
identify this artery by palpation.
Antecubital Fossa
The pictures below demonstrate the antecubital fossa anatomy (surface anatomy on the left, gross
anatomy on the right).

2. Put on your stethescope so that the ear pieces are angled away from your head. Twist the head
piece so that the bell is engaged. This can be verified by gently tapping on the end, which should
produce a sound. With your left hand, place the bell over the area of the brachial artery. While
most practitioners use the diaphragm of the stethescope, the bell is actually be superior for picking
up the low pitched sounds used for measuring BP. It's worth mentioning that a number of different
models of stethescops are available on the market, each with its own variation on the structure of
7

the diaphragm and bell. Read the instruction manual accompanying your stethoscope in order to
determine how your device works.

3. Grasp the patient's right elbow with your right hand and raise their arm so that the brachial artery
is roughly at the same height as the heart. The arm should remain somewhat bent and completely
relaxed. You can provide additional support by gently trapping their hand and forearm between
your body and right elbow. If the arm is held too high, the reading will be artifactually lowered,
and vice versa.
4. Turn the valve on the pumping bulb clockwise (may be counter clockwise in some cuffs) until it
no longer moves. This is the position which allows air to enter and remain in the bladder.
5. Hold the bell in place with your left hand. Use your right hand to pump the bulb until you have
generated 150 mmHg on the manometer. This is a bit above the top end of normal for systolic
blood pressure (SBP). Then listen. If you immediately hear sound, you have underestimated the
SBP. Pump up an additional 20 mmHg and repeat. Now slowly deflate the blood pressure cuff (i.e.
a few mm Hg per second) by turning the valve in a counter-clockwise direction while listening
over the brachial artery and watching the pressure gauge. The first sound that you hear reflects the
flow of blood through the no longer completely occluded brachial artery. The value on the
manometer at this moment is the SBP. Note that although the needle may oscillate prior to this
time, it is the sound of blood flow that indicates the SBP.
6. Continue listening while you slowly deflate the cuff. The diastolic blood pressure (DBP) is
measured when the sound completely disappears. This is the point when the pressure within the
vessel is greater then that supplied by the cuff, allowing the free flow of blood without turbulence
and thus no audible sound. These are known as the Sounds of Koratkoff.
Technique for Measuring Blood Pressure

7. Repeat the measurement on the patient's other arm, reversing the position of your hands. The two
readings should be within 10-15 mm Hg of each other. Differences greater then this imply that
there is differential blood flow to each arm, which most frequently occurs in the setting of
subclavian artery atherosclerosis.
8. Occasionally you will be unsure as to the point where systole or diastole occurred and wish to
repeat the measurement. Ideally, you should allow the cuff to completely deflate, permit any
venous congestion in the arm to resolve (which otherwise may lead to inaccurate measurements),
and then repeat a minute or so later. Furthermore, while no one has ever lost a limb secondary to
BP cuff induced ischemia, repeated measurement can be uncomfortable for the patient, another
good reason for giving the arm a break.
9. Avoid moving your hands or the head of the stethescope while you are taking readings as this may
produce noise that can obscure the Sounds of Koratkoff.
10. You can verify the SBP by palpation. To do this, position the patient's right arm as described
above. Place the index and middle fingers of your right hand over the radial artery. Inflate the cuff
until you can no longer feel the pulse, or simply to a value 10 points above the SBP as determined
by auscultation. Slowly deflate the cuff until you can again detect a radial pulse and note the
reading on the manometer. This is the SBP and should be the same as the value determined with
the use of your stethescope.
Ohio State University, Blood Pressure Simulator
Normal is between 100/60 and 140/90. Hypertension is thus defined as either SBP greater then 140 or
DBP greater than 90. It is important to recognize that blood pressure is rarely elevated to a level that
causes acute symptoms. That is, while hypertension in general is common, emergencies resulting from
extremely high values and subsequent acute end organ dysfunction are quite rare. Rather, it is the
chronically elevated values which lead to target organ damage, though in a slow and relatively silent
fashion. At the other end of the spectrum, the minimal SBP required to maintain perfusion varies with the
individual. Therefore, interpretation of low values must take into account the clinical situation. Those
with poorly functioning hearts, for example, can adjust to a chronically low SBP (e.g. 80-90) and live
without symptoms of hypoperfusion. However others, used to higher baseline values, might become quite
ill if their SBPs were suddenly decreased to these same levels.
Many things can alter the accuracy of your readings. In order to limit their impact, remember the
following:
1. Do not place the blood pressure cuff over a patients clothing or roll a tight fitting sleeve above
their biceps when determining blood pressure as either can cause elevated readings.
2. Make sure the patient has had an opportunity to rest before measuring their BP. Try the following
experiment to assess the impact that this can have. Take a patient's BP after they've rested. Then
repeat after they've walked briskly in place for several minutes. Patients who are not too
physically active (i.e. relatively deconditioned) will develop an elevation in both their SBP and
DBP. Also, see what effect raising or lowering the arm, and thus the position of the brachial artery
relative to the heart, has on BP. If you have a chance, obtain measurements on the same patient
9

3.
4.
5.

6.

with both a large and small cuff. These exercises should give you an appreciation for the
magnitude of error that can be introduced when improper technique is utilized.
If the reading is surprisingly high or low, repeat the measurement towards the end of your exam.
Instruct your patients to avoid coffee, smoking or any other unprescribed drug with
sympathomimetic activity on the day of the measurement.
Orthostatic (a.k.a. postural) measurements of pulse and blood pressure are part of the assessment
for hypovolemia. This requires first measuring these values when the patient is supine and then
repeating them after they have stood for 2 minutes, which allows for equilibration. Normally, SBP
does not vary by more then 20 points when a patient moves from lying to standing. In the setting
of significant volume depletion, a greater then 20 point drop may be seen. Changes of lesser
magnitude occur when moving from lying to sitting or sitting to standing. This is frequently
associated with symptoms of cerebral hypoperfusion (e.g.. light headedness). Heart rate should
increase by more then 20 points in a normal physiologic attempt to augment cardiac output by
providing chronotropic compensation. In the setting of GI bleeding, for example, a drop in blood
pressure and/or rise in heart rate after this maneuver is a marker of significant blood loss and has
important prognostic implications. Orthostatic measurements may also be used to determine if
postural dizziness, a common complaint with multiple possible explanations, is the result of a fall
in blood pressure. For example, patients who suffer from diabetes frequently have autonomic
nervous system dysfunction and cannot generate appropriate arteriolar vaosconstriction when
changing positions. This results in postural vital sign changes and symptoms. The 20 point value
is a rough guideline. In general, the greater the change, the more likely it is to cause symptoms
and be of clinical relevance.
If possible, measure the blood pressure of a patient who has an indwelling arterial catheter (these
patients can be found in the ICU with the help of a preceptor). Arterial transducers are an
extremely accurate tool for assessing blood pressure and therefore provide a method for checking
your non-invasive technique.

A few clinically relevant thoughts about high blood pressure:

Hypertension is very common disease (> 25% in US affected) & defined on basis of severity:
Pre-hypertension : Systolic BP 120-140 or diastolic BP 80-90.
Stage I hypertension: Systolic BP > 140-160 or diastolic BP >90-100.
Stage II: Systolic BP > 160 or diastolic BP > 100.
Ideally, several measures on different occasions should verify the finding. One time measures > 160/100
also confirms the diagnosis. It's worth mentioning that normal is 110s/70s, and cardiovascular risk rises
w/any values above these points.
Hypertension (HTN) causes & accelerates the progression of: Renal dysfunction, coronary artery disease,
systolic & diastolic heart, left ventricular hypertrophy, peripheral arterial disease, stroke, and retinopathy.
The risk of HTN induced damage correlates both w/height of BP and chronicity of elevation (ie longer
and higher =s worse). The treatment of HTN prior to the development of Target Organ Damage (aka
TOD) is referred to as "primary prevention;" while treatment to prevent &/or slow progression once
disease has already been established is called "secondary prevention." Evaluation of patients w/HTN
requires careful history, exam, labs, & other studies to search for co-morbid problems (diabetes, sleep
apnea, etc) &/or occult TOD. Most patients w/HTN are asymptomatic, at least until they develop target
organ damage, which can take years to occur.
The majority of patients w/HTN (> 60%) will require at least 2 meds for treatment. For a BP between
140-160/80-100, best initial drug treatment is typically with hydrochlorthiazide, a very mild diuretic
w/potent anti-hypertensive properties. For those w/starting values > 160/100, it's best to start w/2 meds
simultaneously. A few more thoughts:
1. Where you start isn't where you end - so expect to reassess BP in a short time (several weeks) and
make adjustments as necessary
2. Most drugs w/in the same class (e.g. any of the 8 or so ACE-Inhibitors) work equally well.
3. Effective treatment requires continual reassessment of medication adherence - a major reason for
lack of response to Rx. It helps to know the common side effects for each medication, as these can
10

affect adherence (e.g. ACE-I cough; HCTZ mild increase in urination, erectile dysfunction;
all anti-htn meds hypotension)
4. HTN is directly related to weight, inactivity, ETOH consumption, & salt intake. As such, life style
interventions are absolutely worth addressing, though they are relatively ineffective as sole
treatments (due to the inability of patients & clinicians to achieve sustained and meaningful
changes). That said, you'll never know the impact until you try to address - and readdress - and
readdress @ each visit.
5. HTN "swims" in the same vascular risk factor "soup" as diabetes, hyperlipidemia, and smoking.
These other areas must also be addressed.
6. Treatment goals vary a bit from patient to patient - those with established vascular disease are
treated w/goal of reaching BP 120s/70s. Those in primary prevention group w/o diabetes, target
BP < 140/90.
7. Most patients have primary hypertension (ie the elevation in BP is the primary disorder).
Secondary HTN (elevation in BP secondary to another, treatable condition) is rather uncommon though worth thinking about in the right situation. Secondary causes include: pheochromocytoma,
excess cortisol production, hyper adlosteronism, hypo/hyper-thyroidism, renal artery stenosis, &
chronic kidney disease.
8. Certain conditions favor particular meds - for example: Diabetes ACE-I or Angiotensin
Receptor Blockers (ARBs); Coronary artery disease B blockers.
9. The use of 3 or more meds for refractory HTN isn't uncommon - in particular w/very obese
patients.
10. Acute interventions to immediately lower BP are largely reserved for those times when there is
clear evidence of acute symptoms from acute TOD (e.g. CHF, coronary ischemia, increased intracranial pressure) secondary to very high values.

JNC 7 Express -- Summary of Guidelines for treatment HTN

New England Journal of Medicine - BP Measurement
Moser M, et al. Resistant or difficult to control hypertension. NEJM 2006; 355: 385-92.

Oxygen Saturation: Over the past decade, this non-invasive measurement of gas exchange and red blood
cell oxygen carrying capacity has become available in all hospitals and many clinics. While imperfect, it
can provide important information about cardio-pulmonary dysfunction and is considered by many to be a
fifth vital sign. In particular, for those suffering from either acute or chronic cardio-pulmonary disorders,
it can help quantify the degree of impairment.
Pulse Oxymeter

11

The Lung Exam

The 4 major components of the lung exam (inspection, palpation, percussion and auscultation) are also
used to examine the heart and abdomen. Learning the appropriate techniques at this juncture will
therefore enhance your ability to perform these other examinations as well. Vital signs, an important
source of information, are discussed elsewhere.
Inspection/Observation: A great deal of information can be gathered from simply watching a patient
breathe. Pay particular attention to:
1. General comfort and breathing pattern of the patient. Do they appear distressed, diaphoretic,
labored? Are the breaths regular and deep?
2. Use of accessory muscles of breathing (e.g. scalenes, sternocleidomastoids). Their use signifies
some element of respiratory difficulty.
3. Color of the patient, in particular around the lips and nail beds. Obviously, blue is bad!

Cyanosis of nail beds

4. The position of the patient. Those with extreme pulmonary dysfunction will often sit up-right. In
cases of real distress, they will lean forward, resting their hands on their knees in what is known as
the tri-pod position.
Patient with emphysema bending over in Tri-Pod Position

12

5. Breathing through pursed lips, often seen in cases of emphysema.

6. Ability to speak. At times, respiratory rates can be so high and/or work of breathing so great that
patients are unable to speak in complete sentences. If this occurs, note how many words they can
speak (i.e. the fewer words per breath, the worse the problem!).
7. Any audible noises associated with breathing as occasionally, wheezing or the gurgling caused by
secretions in large airways are audible to the "naked" ear.
8. The direction of abdominal wall movement during inspiration. Normally, the descent of the
diaphragm pushes intra-abdominal contents down and the wall outward. In cases of severe
diaphragmatic flattening (e.g. emphysema) or paralysis, the abdominal wall may move inward
during inspiration, referred to as paradoxical breathing. If you suspect this to be the case, place
your hand on the patient's abdomen as they breathe, which should accentuate its movement.
9. Any obvious chest or spine deformities. These may arise as a result of chronic lung disease (e.g.
emphysema), occur congenitally, or be otherwise acquired. In any case, they can impair a patient's
ability to breathe normally. A few common variants include:
o Pectus excavatum: Congenital posterior displacement of lower aspect of sternum. This
gives the chest a somewhat "hollowed-out" appearance. The x-ray shows a subtle concave
appearance of the lower sternum.

Barrel chest: Associated with emphysema and lung hyperinflation. Accompanying xray
also demonstrates
increased anterior-posterior diameter as well as diaphragmatic flattening.
13

Spine abnormalities:
Kyphosis: Causes the patient to be bent forward. Accompanying X-Ray of same
patient clearly demonstrates extreme curvature of the spine.

Scoliosis: Condition where the spine is curved to either the left or right. In the
pictures below, scoliosis of the spine causes right shoulder area to appear somewhat
higher than the left. Curvature is more pronounced on x-ray.

14

10.
Review of Lung Anatomy: Understanding the pulmonary exam is greatly enhanced by
recognizing the relationships between surface structures, the skeleton, and the main lobes of the
lung. Realize that this can be difficult as some surface landmarks (eg nipples of the breast) do not
always maintain their precise relationship to underlying structures. Nevertheless, surface markers
will give you a rough guide to what lies beneath the skin. The pictures below demonstrate these
relationships. The multi-colored areas of the lung model identify precise anatomic segments of the
various lobes, which cannot be appreciated on examination. Main lobes are outlined in black. The
following abbreviations are used: RUL = Right Upper Lobe; LUL = Left Upper Lobe; RML =
Right Middle Lobe; RLL = Right Lower Lobe; LLL = Left Lower Lobe.

15

Anterior View

Posterior View

16

Right Lateral View

17

Left
Lateral
View

18.

19.
20.
Palpation: Palpation plays a relatively minor role in the examination of the normal chest
as the structure of interest (the lung) is covered by the ribs and therefore not palpable. Specific
situations where it may be helpful include:
1.

Accentuating normal chest excursion: Place your hands on the patient's back with thumbs
pointed towards the spine. Remember to first rub your hands together so that they are not
too cold prior to touching the patient. Your hands should lift symmetrically outward when
18

the patient takes a deep breath. Processes that lead to asymmetric lung expansion, as might
occur when anything fills the pleural space (e.g. air or fluid), may then be detected as the
hand on the affected side will move outward to a lesser degree. There has to be a lot of
plerual disease before this asymmetry can be identified on exam.
Detecting Chest Excursion

2.

Tactile Fremitus: Normal lung transmits a palpable vibratory sensation to the chest wall.
This is referred to as fremitus and can be detected by placing the ulnar aspects of both
hands firmly against either side of the chest while the patient says the words "NinetyNine." This maneuver is repeated until the entire posterior thorax is covered. The bony
aspects of the hands are used as they are particularly sensitive for detecting these
vibrations.

Assessing Fremitus
Pathologic conditions will alter fremitus. In particular:
19

Lung consolidation: Consolidation occurs when the normally air filled lung
parenchyma becomes engorged with fluid or tissue, most commonly in the setting
of pneumonia. If a large enough segment of parenchyma is involved, it can alter the
transmission of air and sound. In the presence of consolidation, fremitus becomes
more pronounced.
AA Pleural fluid: Fluid, known as a pleural effusion, can collect in the potential space
that exists between the lung and the chest wall, displacing the lung upwards.
Fremitus over an effusion will be decreased.
AA

In general, fremitus is a pretty subtle finding and should not be thought of as the primary
means of identifying either consolidation or pleural fluid. It can, however, lend supporting
evidence if other findings (see below) suggest the presence of either of these processes.
Effusions and
infiltrates can perhaps
be more easily
understood using a
sponge to represent the
lung. In this model, an
infiltrate is depicted by
the blue coloration that
has invaded the sponge
itself (sponge on left).
An effusion is depicted
by the blue fluid upon
which the lung is
floating (sponge on
right).

2.

Investigating painful areas: If the patient complains of pain at a particular site it is

obviously important to carefully palpate around that area. In addition, special situations
(e.g. trauma) mandate careful palpation to look for evidence of rib fracture, subcutaneous
air (feels like your pushing on Rice Krispies or bubble paper), etc.

Percussion: This technique makes use of the fact that striking a surface which covers an air-filled
structure (e.g. normal lung) will produce a resonant note while repeating the same maneuver over
a fluid or tissue filled cavity generates a relatively dull sound. If the normal, air-filled tissue has
been displaced by fluid (e.g. pleural effusion) or infiltrated with white cells and bacteria (e.g.
20

pneumonia), percussion will generate a deadened tone. Alternatively, processes that lead to
chronic (e.g. emphysema) or acute (e.g. pneumothorax) air trapping in the lung or pleural space,
respectively, will produce hyper-resonant (i.e. more drum-like) notes on percussion. Initially, you
will find that this skill is a bit awkward to perform. Allow your hand to swing freely at the wrist,
hammering your finger onto the target at the bottom of the down stroke. A stiff wrist forces you to
push your finger into the target which will not elicit the correct sound. In addition, it takes a while
to develop an ear for what is resonant and what is not. A few things to remember:

3.
4.

If you're percussing with your right hand, stand a bit to the left side of the patient's back.
Ask the patient to cross their hands in front of their chest, grasping the opposite shoulder
with each hand. This will help to pull the scapulae laterally, away from the percussion
field.

5.

Work down the "alley" that exists between the scapula and vertebral column, which should
help you avoid percussing over bone.

6.

Try to focus on striking the distal inter-phalangeal joint (i.e. the last joint) of your left
middle finger with the tip of the right middle finger. The impact should be crisp so you
may want to cut your nails to keep blood-letting to a minimum!

7.

The last 2 phalanges of your left middle finger should rest firmly on the patient's back. Try
to keep the remainder of your fingers from touching the patient, or rest only the tips on
them if this is otherwise too awkward, in order to minimize any dampening of the
perucssion notes.

8.

When percussing any one spot, 2 or 3 sharp taps should suffice, though feel free to do
more if you'd like. Then move your hand down several inter-spaces and repeat the
maneuver. In general, percussion in 5 or so different locations should cover one hemithorax. After you have percussed the left chest, move yours hands across and repeat the
same procedure on the right side. If you detect any abnormality on one side, it's a good
idea to slide your hands across to the other for comparison. In this way, one thorax serves
as a control for the other. In general, percussion is limited to the posterior lung fields.
However, if auscultation (see below) reveals an abnormality in the anterior or lateral fields,
percussion over these areas can help identify its cause.
21

Percussion Technique

The goal is to recognize that at some point as you move down towards the base of the
lungs, the quality of the sound changes. This normally occurs when you leave the thorax. It
is not particularly important to identify the exact location of the diaphragm, though if you
are able to note a difference in level between maximum inspiration and expiration, all the
better. Ultimately, you will develop a sense of where the normal lung should end by simply
looking at the chest. The exact vertebral level at which this occurs is not really relevant.
10.
"Speed percussion" may help to accentuate the difference between dull and
resonant areas. During this technique, the examiner moves their left (i.e. the nonpercussing) hand at a constant rate down the patient's back, tapping on it continuously as it
progresses towards the bottom of the thorax. This tends to make the point of inflection (i.e.
change from resonant to dull) more pronounced.
9.

Practice percussion! Try finding your own stomach bubble, which should be around the left costal
margin. Note that due to the location of the heart, tapping over your left chest will produce a
different sound then when performed over your right. Percuss your walls (if they're sheet rock)
and try to locate the studs. Tap on tupperware filled with various amounts of water. This not only
helps you develop a sense of the different tones that may be produced but also allows you to
practice the technique.
Auscultation: Prior to listening over any one area of the chest, remind yourself which lobe of the lung is
heard best in that region: lower lobes occupy the bottom 3/4 of the posterior fields; right middle lobe
heard in right axilla; lingula in left axilla; upper lobes in the anterior chest and at the top 1/4 of the
posterior fields. This can be quite helpful in trying to pin down the location of pathologic processes that
may be restricted by anatomic boundaries (e.g. pneumonia). Many disease processes (e.g. pulmonary
edema, bronchoconstriction) are diffuse, producing abnormal findings in multiple fields.
11.
Put on your stethoscope so that the ear pieces are directed away from you. Adjust
the head of the scope so that the diaphragm is engaged. If you're not sure, scratch lightly
on the diaphragm, which should produce a noise. If not, twist the head and try again.
Gently rub the head of the stethoscope on your shirt so that it is not too cold prior to
placing it on the patient's skin.
12.
The upper aspect of the posterior fields (i.e. towards the top of the patient's back)
are examined first. Listen over one spot and then move the stethoscope to the same
position on the opposite side and repeat. This again makes use of one lung as a source of
comparison for the other. The entire posterior chest can be covered by listening in roughly
4 places on each side. Of course, if you hear something abnormal, you'll need to listen in
more places.
22

Lung Auscultation

The lingula and right middle lobes can be examined while you are still standing
behind the patient.
14.
Then, move around to the front and listen to the anterior fields in the same fashion.
This is generally done while the patient is still sitting upright. Asking female patients to lie
down will allow their breasts to fall away laterally, which may make this part of the
examination easier.
13.

Thoughts On "Gown Management" & Appropriately/Respectfully Touching Your Patients:

There are several sources of tension relating to the physical exam in general, which are really
brought to the fore during the chest examine. These include:
o Area to be examined must be reasonably exposed - yet patient kept as covered as possible
o The need to Palpate sensitive areas in order to perform accurate exam - requires touching
people w/whom you've little acquaintance - awkward, particularly if opposite gender
o As newcomers to medicine, you're particularly aware that this aspect of the exam is
"unnatural" & hence very sensitive.. which is a good thing!
Keys to performing a sensitive yet thorough exam:
o Explain what you're doing (" why) before doing it acknowledge "elephant in the room"!
o Expose the minimum amount of skin necessary - this requires "artful" use of gown &
drapes (males & females)
o Examining heart & lungs of female patients:
Ask pt to remove bra prior (you can't hear the heart well thru fabric)
Expose the chest only to the extent needed. For lung exam, you can listen to the
anterior fields by exposing only the top part of the breasts (see picture below).
Enlist patient's assistance, asking them to raise their breast to a position that
enhances your ability to listen to the heart
Don't rush, act in a callous fashion, or cause pain
PLEASE... don't examine body parts thru gown as:
It reflects Poor technique
You'll miss things
You'll lose points on scored exams (OSCE, CPX, USMLE)!

o
o

23

Remember - Don't examine thru clothing or "snake" stethoscope down shirts/gowns

Good exam options

A few additional things worth noting.
o Ask the patient to take slow, deep breaths through their mouths while you are performing
your exam. This forces the patient to move greater volumes of air with each breath,
increasing the duration, intensity, and thus detectability of any abnormal breath sounds that
might be present.
o Sometimes it's helpful to have the patient cough a few times prior to beginning
auscultation. This clears airway secretions and opens small atelectatic (i.e. collapsed) areas
at the lung bases.
o If the patient cannot sit up (e.g. in cases of neurologic disease, post-operative states, etc.),
auscultation can be performed while the patient is lying on their side. Get help if the
patient is unable to move on their own. In cases where even this cannot be accomplished, a
minimal examination can be performed by listening laterally/posteriorly as the patient
remains supine.
o Requesting that the patient exhale forcibly will occasionally help to accentuate abnormal
breath sounds (in particular, wheezing) that might not be heard when they are breathing at
normal flow rates.
o A healthy individual breathing through their mouth at normal tidal volumes produces a soft
inspiratory sound as air rushes into the lungs, with little noise produced on expiration.
These are referred to as vessicular breath sounds.
24

Wheezes are whistling-type noises produced during expiration (and sometimes inspiration)
when air is forced through airways narrowed by bronchoconstriction, secretions, and/or
associated mucosal edema. As this most commonly occurs in association with diffuse
processes that affect all lobes of the lung (e.g. asthma and emphysema) it is frequently
audible in all fields. In cases of significant bronchoconstriction, the expiratory phase of
respiration (relative to inspiration) becomes noticeably prolonged. Clinicians refer to this
as an increased I to E ratio. Normal is approximatley 1:2 (i.e. expiration twice as long as
inspiration) though actual timed measurements are neither practical nor reliable. Focus
instead on simple observation, noting whether E seems >> I. The greater the difference, the
worse the obstruction. Occasionally, focal wheezing can occur when airway narrowing if
restricted to a single anatomic area, as might occur with an obstructing tumor or
bronchoconstriction induced by pneumonia. Wheezing heard only on inspiration is referred
to as stridor and is associated with mechanical obstruction at the level of the trachea/upper
airway. This may be best appreciated by placing your stethescope directly on top of the
trachea.
Rales (a.k.a. crackles) are scratchy sounds that occur in association with processes that
cause fluid to accumulate within the alveolar and interstitial spaces. The sound is similar to
that produced by rubbing strands of hair together close to your ear. Pulmonary edema is
probably the most common cause, at least in the older adult population, and results in
symmetric findings. This tends to occur first in the most dependent portions of the lower
lobes and extend from the bases towards the apices as disease progresses. Pneumonia, on
the other hand, can result in discrete areas of alveolar filling, and therefore produce
crackles restricted to a specific region of the lung. Very distinct, diffuse, dry-sounding
crackles, similar to the noise produced when separating pieces of velcro, are caused by
pulmonary fibrosis, a relatively uncommon condition.
Dense consolidation of the lung parenchyma, as can occur with pneumonia, results in the
transmission of large airway noises (i.e. those normally heard on auscultation over the
trachea... known as tubular or bronchial breath sounds) to the periphery. In this setting, the
consolidated lung acts as a terrific conducting medium, transferring central sounds directly
to the edges. It's very similar to the noise produced when breathing through a snorkel.
Furthermore, if you direct the patient to say the letter 'eee' it is detected during auscultation
over the involved lobe as a nasal-sounding 'aaa'. These 'eee' to 'aaa' changes are referred to
as egophony. The first time you detect it, you'll think that the patient is actually saying
'aaa'... have them repeat it several times to assure yourself that they are really following
your directions!
Secretions that form/collect in larger airways, as might occur with bronchitis or other
mucous creating process, can produce a gurgling-type noise, similar to the sound produced
when you suck the last bits of a milk shake through a straw. These noises are referred to as
ronchi.
Auscultation over a pleural effusion will produce a very muffled sound. If, however, you
listen carefully to the region on top of the effusion, you may hear sounds suggestive of
consolidation, originating from lung which is compressed by the fluid pushing up from
below. Asymmetric effusions are probably easier to detect as they will produce different
findings on examination of either side of the chest.
Auscultation of patients with severe, stable emphysema will produce very little sound.
These patients suffer from significant lung destruction and air trapping, resulting in their
breathing at small tidal volumes that generate almost no noise. Wheezing occurs when
there is a superimposed acute inflammatory process (see above).

Most of the above techniques are complimentary. Dullness detected on percussion, for example,
may represent either lung consolidation or a pleural effusion. Auscultation over the same region
should help to distinguish between these possibilities, as consolidation generates bronchial breath
sounds while an effusion is associated with a relative absence of sound. Similarly, fremitus will be
increased over consolidation and decreased over an effusion. As such, it may be necessary to
repeat certain aspects of the exam, using one finding to confirm the significance of another. Few
25

findings are pathognomonic. They have their greatest meaning when used together to paint the
most informative picture.
The Dynamic Lung Exam:
Pulse Oxymeter

Oftentimes, a patient will complain of a symptom that is induced by activity or movement.

Shortness of breath on exertion, one such example, can be a marker of significant cardiac or
pulmonary dysfunction. The initial examination may be relatively unrevealing. In such cases,
consider observed ambulation (with the use of a pulse oxymeter, a device that continuously
measures heart rate and oxygen saturation, if available) as a dynamic extension of the cardiac and
pulmonary examinations. Quantifying a patient's exercise tolerance in terms of distance and/or
time walked can provide information critical to the assessment of activity induced symptoms. It
may also help unmask illness that would be inapparent unless the patient was asked to perform a
task that challenged their impaired reserves. Pay particular attention to the rate at which the
patient walks, duration of activity, distance covered, development of dyspnea, changes in heart
rate and oxygen saturation, ability to talk during exercise and anything else that the patient
identifies as limiting their activity. The objective data derived from this low tech test can aid you
in determining disease and symptom severity, helping to create a list of possible diagnoses and
assisting you in the rational use of additional tests to further delineate the nature of the problem.
This can be particularly helpful in providing objective information when symptoms seem out of
proportion to findings. Or when patients report few complaints yet seem to have a cosiderable
amount of disease. It will also generate a measurement that you can refer back to during
subsequent evaluations in order to determine if there has been any real change in functional status.
The Oral Presentation
The purpose of the oral presentation is to provide other clinicians with patient information. This must be
done in such a way that it tells the patient's story in a logical, clear and complete fashion yet is neither
cumbersome nor too long. It is a difficult skill to master and is made more complicated by the fact that
different clinical situations demand different types of presentations. For example, presentations given
during morning work rounds (the time when the medical team briefly visits with each patient to review
their clinical course and determine the plan for the day), are not the same as those given at formal patient
management conferences. The first situation requires a focused presentation, with emphasis placed on
reviewing new facts and data (e.g. test results, vital signs, changes in clinical course, etc.) and outlining
the care plan. The second example calls for a much more detailed discussion. The presenter, then, must
take into account the "environmental" factors which determine the type of presentation that is required.
These include:
26

1. The audience to which you are presenting. A group of cardiologists, for example, are going to be
most interested in the cardiac history.
2. The purpose of the presentation (e.g. is it for work rounds, teaching conference, clinic etc.?).
3. Time available to give the presentation. The longest, most complete presentation should take no
longer then 5-7 minutes while shortened versions can be given in as little as 15 to 30 seconds.
4. Your familiarity with the case as well as associated pathophysiology.
For the purposes of this discussion, we will focus on the formal/complete presentation as it is probably
the form which is most complicated and intimidating. You will find, however, that once you grasp the
logic and organization of this process and have an opportunity to practice, your presentations will become
both more effective and less anxiety provoking. Tips for presenting during work rounds are provided in
the "Inpatient Medicine" section of the Clinical Guide.
In the discussion that follows, illustrative examples are frequently included and have been set off from the
text by means of quotation marks and italics.
The Formal Presentation
Chief Complaint/Chief Concern:
The presentation begins with a one sentence description of the patient and the reason prompting their
evaluation (i.e. the Chief Complaint). This is a teaser that sets the tone for the information to follow. It
should not be too inclusive.
"Mr. H is a 50 year old male with AIDS who presents for the evaluation of fever, chills and
a cough over the past 3 days."
History of Present Illness (HPI):
The HPI is presented in both a problem based and chronological fashion. That is, the dominant
problem/complaint serves as the centerpiece of the history. If there is more then one problem, the
presenter may try to link them together when appropriate. Information related to this main theme is
presented in chronological order. This requires that the presenter go back far enough in time to cover any
historical data that is relevant to the patient's main complaint. Your ability as a presenter to know which
past information is important and which superfluous will be based on both your clinical experience and
understanding of pathophysiology. At the current time, this might be quite limited. For the above patient,
a thorough description would include:
"Mr. H has been HIV + since 1987; his CD4 count in June of '97was 150 and viral load
approximately 50,000. Past opportunistic infections have included: PCP pneumonia
12/95; CMV retinitis 1/96; and Kaposi's Sarcoma first noted on his skin 1/96. He currently
takes 3TC, AZT, and Indinavir, all of which he has been receiving for approximately one
year. He also takes Bactrim Single Strength tablets on a daily basis, along with
Fluconazole troches PRN for thrush. He claims to be 100% compliant with all of his
medication. He is homosexual though he is currently not sexually active. He has never
used intravenous drugs."
This information is not, in a strict sense, part of the present illness. However, it providescritical
information that will have a direct bearing on the listener's interpretation of this patient's active problem.
Your ability to determine which background to incorporate into your HPI will improve with time and
exposure. The details of the patient's acute problem are then presented:
"Until 1 week ago, Mr. H had been quite active, walking up to 2 miles a day without
feeling short of breath. Approximately 1 week ago, he began to feel dyspneic with
moderate activity. This progressed to the point that, 1 day ago, he was breathless after
walking up a single flight of stairs. 3 days ago, he began to develop subjective fevers and
chills along with a cough productive of rust-colored sputum. There was associated nausea
but no vomiting. He has spent most of the last 24 hours in bed. He denies head ache,
photophobia, stiff neck, focal weakness, chest pain, hemoptysis, abdominal pain, diarrhea
27

or other complaints. There is no know history of asthma, COPD or chronic pulmonary

condition. His current problem seems different to him then his past episode of PCP."
This section documents the course of the patient's most active problem. It concludes with a list of
"pertinent negatives" that are meant to exclude, on the basis of history, other possible diagnoses that are
known to have a similar symptom complex. In a patient with an HIV related illness, this review might
actually be much more extensive than that provided above due to the diffuse, multi-organ system
involvement that occurs with this disease. Note that the patient's baseline functional status is described,
allowing the listener to gain some sense of the degree of impairment caused by the acute medical
problem. If a patient is a poor historian, confused or simply unaware of all the details related to their
illness, state this and move on. Historical information can be obtained from family, friends, etc. If this is
the case, make sure that you note the source.
If, for example, a patient complains of both chest pain and shortness of breath, they may well be
secondary to a single underlying process such as myocardial ischemia resulting in heart failure. When the
problems are completely unrelated, the "dominant issue" (as determined by the presenter) is treated first,
followed by a discussion of the secondary complaint. This can get quite complicated when multiple
problems exist in parallel.
Review of Systems: The critical positive and negative findings discovered during a review of systems are
generally incorporated at the end of the patient's history, as was done above. These questions are designed
to uncover illnesses which might "travel with" the main problem and attempt to identify commonly
occurring complications (e.g. hemoptysis can be a sequelae of pulmonary infection). The listener needs
this information to help them put the remainder of the history in appropriate perspective. Any positive
responses to a more inclusive ROS that covers all of the other various organ systems are then noted. The
extent to which this is repeated is left to the discretion of the presenter. If it is completely negative, it is
generally acceptable to simply state, "ROS negative."
Past Medical History: Note is made of any other past medical problems which the patient has that are
not related to the current complaint. Those items mentioned above are not repeated.
"The patient's past medical history includes:
1. Hypertension x 10 years
2. Gastro-Esophageal Reflux Disease
3. Degenerative Joint Disease of the Right Knee"
Past Surgical History: Any prior surgeries (along with the year in which they occurred) are noted.
"Past surgical history is remarkable for:
1. Status Post Cholycystectomy 1990
2. Status Post Appendectomy 1985
3. Status Post open repair and internal fixation of left femur fracture, 1983"
Medications/Allergies: All current medications (along with dose, route and frequency) are mentioned:
"The patient takes the following medications:
AZT 300 mg, 1 PO, BID
Indinavir 750 mg, 2 PO, TID
3TC 150 mg, 1 PO, BID
Lansoprazole 20 mg, 1 PO, BID
Lopressor 50 mg, 2 PO, BID
Clotrimazole Troches 100 mg, 1 PO TID PRN
Naprosyn 250 mg, 1-2, PO, BID PRN
He has no allergies"
28

Smoking and Alcohol (and any other substance abuse): Cigarettes and alcohol are highlighted because
their use is so widespread and the deleterious effects associated with prolonged exposure well
documented. Any additional substance abuse (e.g. cocaine use, intravenous drugs, etc.) should also be
mentioned.
"Mr. H smokes 1 pack of cigarettes per day and has done so for 20 years. He drinks
approximately 1 glass of wine per week. He denies any other drug use."
Social/Work History: This includes a brief description of the patient's work and home environments.
Sexual history, if relevant to the oral presentation would also be presented here. Any unusual work-related
exposures should be noted.
"Mr. H works as an accountant for a large firm in Boston. He lives alone in an apartment
in the city."
Family History: Emphasis is placed on the identification of illnesses within the family (particularly
among first degree relatives) that are known to be genetically based and therefore potentially inherited by
the patient. This would include: history of coronary artery disease, diabetes, certain neoplasms, etc.
"Both of the patient's parents are alive and well (his mother is 78 and father 80). He has 2
brothers, one 45 and the other 55, who are also healthy. There is no family history of heart
disease or cancer."
Physical Exam: This begins with a one sentence description of the patient's appearance along with their
vital signs. In general, only '+' findings are noted. It is also reasonable to mention the absence of certain
things that the listener will find helpful in excluding particular diagnoses. If, for example, a patient has
shortness of breath secondary to asthma, the presenter might mention that rales, elevated jugular venous
pressure and an S3 were not present, indicating that congestive heart failure is an unlikely diagnosis.
Some listeners expect the entire physical examination to be recounted, including "normal findings,"
particularly if the presenter is a student. The following exam is listed in more detail then is necessary.
However, it should give you an idea of how abnormalities as well as "normal findings" are reported.
"Mr. H was seated on a gurney in the ER, breathing comfortably through a face mask
oxygen delivery system. Breathing was unlabored and accessory muscles were not in use.

Vital signs were: Temp 102 Pulse 90 BP 150/90 Respiratory Rate 20 O2 Sat (on
40% Face Mask) 95%
Head, Eyes, Ears, Nose, Throat: Pupils equal, round and reactive to light;
Tympanic membranes pearly gray with cone of light well seen; Sclera anicteric;
No thrush was noted; Mucosa was dry and without lesions; There was no
appreciable adenopathy; Thyroid non-palpable; JVP was less then 5 cm.
Lungs: Crackles and Bronchial breath sounds noted at right base. E to A changes
present. No wheezing or other abnormal sounds noted over any other area of the
lung. Dullness to percussion and increased fremitus was also appreciated at the
right base.
Cardiac: Rhythm was Regular. Normal S1 and S2. No murmurs or extra heart
sounds noted.
Abdomen: Symmetric appearing; soft, flat, non-tender; no palpable masses; well
healed Right upper and lower quadrant incisions at sites of prior apppendectomy
and cholycystectomy.
Rectal Exam: Brown stool in rectal vault, guiac negative; no masses; prostate
small, smooth and non-tender.
GU: Testes descended bilaterally; no masses; no hernia; penis without lesions.
Extremities: No evidence of clubbing, cyanosis or edema; Dorsalis Pedis and
Posterior Tibial pulses 2+ and equal bilaterally.
29

Skin: a 2x3 cm raised, purplish, non-tender, non-blanching area noted on left midshin; no other skin abnormalities identified.
Neurologic Exam:
Mental Status: Awake, alert, appropriate and completely oriented.
Cranial Nerves: 2 thru 12 tested and intact.
Motor: Strength 5/5 all extremities.
Cerebellar: Finger to nose well done.
Reflexes: 2+ at ankles, knees, biceps and triceps
Sensation: Intact to light touch and pin prick bilaterally;
proprioception normal; vibration normal.
Ambulation: Normal gait; negative Romberg."

Lab results, Radiological Studies, EKGs: In general, only lab values which are abnormal are
mentioned. Similarly, if the interpretation of radiological studies and EKGs are directly relevant to the
case, they are discussed.
"Mr. H's lab work was remarkable for: White count of 18 thousand with 10% bands;
Normal Chem 7 and LFTs. Room air blood gas: pH of 7.45/ PO2 of 55/PCO2 of 30.
Sputum gram stain remarkable for an abundance of polys along with gram positive
diplococci. CXR showed a dense right lower lobe infiltrate without effusion."
Impression and Plan: This is your opportunity to summarize the important aspects of the history,
physical exam and supporting lab tests and formulate a differential diagnosis as well as a plan of action
that addresses both the diagnostic and therapeutic approach to the patient's problems.
"Mr. H is an HIV + male with a low CD 4 count and high viral load who presents with an
acute pulmonary process. The rapid progression, focality of findings on lung exam and
radiography, along with the sputum gram stain suggest a bacterial infection, in particular
Streptococcal pneumonia. Other pathogens to consider include H Flu and, less commonly,
Legionella. While he is certainly at risk for PCP, his presentation, compliance with PCP
prophylaxis and statement that his current illness seems different then past PCP infection
would argue against this as the etiologic agent. Mycobacterial infection also seems
unlikely. Viral infections and neoplastic processes like CMV or Kaposi's Sarcoma of the
lung do not generally give this clinical presentation. Furthermore, the data does not
support the existence of either a primary cardiac or noninfectious pulmonary process.
The Current plan then is:
1.
2.
3.
4.
5.

Follow up on cultures of sputum and blood.

Obtain sputum for silver staining to r/o PCP
Begin treatment with IV cefuroxime; Hold off on empiric treatment for PCP.
Continue O2,with goal to keep sats greater then 92%
IV fluid replacement with Normal Saline at 125cc/H for next 24 hours to correct
mild hypovolemia, with plan to reassess volume status at that time
6. If patient does not show improvement (or worsens) and cultures are unrevealing,
consider bronchoscopy as a means of making more definitive diagnosis."
A Few Practical Tips:
1. Practice, Practice, Practice. Mastering the oral presentation takes time and experience. This will
not occur overnight. Early on in your careers, try to avoid presenting "on-the-fly" as it is
obviously quite difficult to rapidly assimilate all of the relevant data and present it in a clear and
cogent fashion. It's O.K. to use notes, though with practice and experience, this will eventually
become unnecessary.
2. Prior to presenting, think about what sort of picture you are trying to paint and then practice
(while at home, walking to the hospital, in front of friends, etc.) doing this. Ask yourself and those
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3.
4.

5.
6.

listening to you whether the information that you have provided is in synch with the impression
that you are trying to create. Are your listeners able to generate an accurate mental image along
with a reasonable list of diagnostic possibilities?
Listen to others when they present. Try to identify which elements distinguish concise
presentations from those that are confusing or ineffective.
Think about the clinical situation in which you are presenting so that you can provide a summary
that is consistent with the expectations of your audience. Work rounds, for example, are clearly
different from conferences and therefore mandate a different style of presentation. Some services,
in particular, general surgery and surgical sub-specialties, have very regimented presentation
formats that are used for all patients. This is driven by the time constraints and high patient
volumes seen on these services. Alternatively, some listeners demand that the presenter,
particularly if that person is a student, recount the history in exquisite detail. They may, for
example, expect you to list the entire physical exam, including both normal and abnormal
findings, as well as the results of an extensive ROS. The only way for you to know what is
expected is to ask beforehand.
Try to be thorough without at the same time being long-winded or too detail oriented. Knowing
what constitutes the "right amount" of relevant information will obviously take some practice and
experience.
Ask for feedback from your listeners. This will allow you to correct errors and improve
subsequent presentations.

Clinical Decision Making

Clinical decision making is the process by which we determine who needs what, when. While not exactly
arbitrary, this exercise can be quite subjective. Each clinician compiles their own data (hence the
emphasis on learning to perform an accurate H&P) and then constructs an argument for a particular
disease state based on their interpretation of the "facts." The strength of their case will depend on the way
in which they gather and assemble information. There may then be no single, right way of applying
diagnostic and therapeutic strategies to a particular case. Of course, not every situation is a clinical
quandary. A patient with a known history of coronary artery disease presenting with 3 hours of crushing
chest pain, an EKG with 4mm ST segment elevations across the precordial leads, and an initial TroponinI of 50 is having a myocardial infarction. That is a diagnostic slam dunk. More commonly, however, there
exist elements of uncertainty. Medicine involves playing the odds, assessing the relative chance that a
patient is/is not suffering from a particular illness. Codifying the way in which clinicians logically
approach problems and deal with this uncertainty is a difficult task. What follows is my take on diagnostic
and therapeutic decision making. It incorporates the following series of questions in a more or less stepwise fashion:
1. Does this particular clinical situation, on the basis of the H&P, seem familiar to me (i.e. does it fit
any pattern of disease that I have seen/read about)? Is there a single answer which explains even a
multitude of complaints/findings? Referred to as Occam's Razor this, in essence, is the search for
the simplest possible explanation.
2. What other explanations exist? This is known as the "differential." Rather then long, it should be
logical. The list is arranged from most to least likely and highlights those conditions that I
absolutely do not want to miss (i.e. conditions that would result in significant morbidity/mortality
if not promptly identified). When searching for explanations, remember that common things occur
commonly. While patients do contract unusual illnesses, these are rather rare events. Thus, strange
symptoms and findings are still more likely to represent an uncommon presentation of a common
problem then to be due to an altogether uncommon illness. I didn't make this up, but have found it
to be a clinical truism. However, fear not Great Lupus Hunters, unusual illnesses do occur. Simply
make sure that you really rule out the more run-of-the-mill stuff first!
3. What (if anything) do I need to do to rule out the "really bad things" and how quickly does this
need to be done? Can it be achieved as an outpatient or will hospitalization be required? This type
of evaluation frequently produces a list of things that the patient does not have without ever
reaching a definitive diagnosis, which is quite acceptable.
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4. Of the remaining potential explanations, do I need to make use of additional tests or am I

comfortable enough with the available information to make a presumptive diagnosis and proceed
on that basis alone?
Note: A test should only be obtained if the result will in some way affect your decision making.
That is, if you are going to embark on a particular strategy regardless of the results, why obtain it
in the first place? Furthermore, if you don't understand the operating characteristics of a test (e.g.
it's sensitivity and specificity and thus how the results will affect your view of the candidate
diagnosis), don't order it.
5. If the diagnosis is still unclear, can I use the passage of time as a diagnostic test (i.e. perhaps with
time the process will more closely resemble a pattern of disease that will be recognizable to me...
or simply fade away without explanation)? I like to think of every patient as living on their own
curve, with "wellness" measured along the Y axis, and time on the X axis. Curves, of course,
cannot be plotted on the basis of a single point. Similarly, it may take several observations
separated by time before I can begin to determine a patient's clinical direction (i.e. getting better,
worse or staying the same).
6. Does this condition require specific therapy? If so, do I first need to have an established diagnosis
(see above)? Can the patient wait for this diagnosis to be made before initiating treatment or does
their clinical situation mandate the beginning of empirical therapy while a diagnosis is
simultaneously being sought? Can the treatment be administered as an outpatient or will it require
hospitalization (either because of its complexity, compliance issues, patient's compromised
clinical condition, need to assess efficacy on a frequent basis, etc.)? What will I do if the treatment
fails to have the desired effect?
7. Is the patient on board with this plan? Do they understand the rationale for the approach that I
have chosen as well as their role?
Elements of uncertainty are wound into almost every case that you will see. Students and the public are
surprised (and perhaps disappointed) to learn that, despite the abundance of technology that currently
exists, physicians are still "reduced" to using their judgment when making clinical decisions (e.g. is a cold
viral or bacterial? Should antibiotics be administered or withheld? etc.). The trick lies in knowing when
its OK to be parsimonious with the use of testing and which situations demand a no-holds-barred pursuit
of an answer. Lets look at a few examples:
Case 1: A 24 year old otherwise healthy male presents with a 3 day history of cough productive of green
sputum, fever, chills and slight shortness of breath associated with right sided chest pain. Exam is
remarkable for a temperature of 102 F with otherwise normal vital signs. The patient looks well (i.e. not
distressed). A few crackles are noted in the right base on lung exam. No other abnormalities are apparent.
Discussion: Following the above question template, we can reason through the case as follows:
1 & 2: This clinical situation seems most consistent with a well compensated bacterial
pneumonia. Other possibilities might include:
viral infection
asthma flair
pulmonary embolism (P.E.)
other
Each, however, either cannot explain all of the findings present or is not supported by the
objective data. A viral infection, for example shouldn't cause a focal lung exam; asthma
can cause a cough and shortness of breath, but wheezing should be present; while a
pulmonary embolism can cause shortness of breath, cough and chest pain, it should not
result in fever, chills or sputum production. Furthermore, P.E.s generally occur in patient's
who have risk factors for this illness, none of which were present in this case. "Other"
includes the list of unlikely diagnoses (e.g. eosinophilic pneumonitis, histoplasmosis,
malignancy etc.) that would only be considered if the patient's course deviated markedly
32

from expected and/or could not be explained on the basis of those things higher on the
differential.
3&4: Many clinicians would feel comfortable enough at this point (based on their clinical
impression) to proceed without obtaining any additional tests to either support the
candidate diagnosis or rule out other possibilities. Other approaches would also be
acceptable. For example, another clinician may have seen a similar case in the past, treated
the patient for a bacterial process, and found out later that they had actually had a P.E.
Because of this experience, they might be uncomfortable proceeding without first
obtaining a CXR (to confirm the presence of an infiltrate), CBC (to identify a leukocytosis
c/w a bacterial infection), D-Dimer (clot breakdown product elevated in DVTs/PEs), and
an EKG (to look for stigmata of a P.E.). This approach would not necessarily be incorrect.
It's driven by a particular provider's anecdotal experience, which for obvious reasons has a
powerful impact on future decision making. This is generally helpful, as long as it is based
on logic and not fear. You might then wonder, "Why not obtain confirmatory tests
whenever possible?" Remember, tests come at a cost (in terms of dollars, time and patient
discomfort). You need to be able to justify, at least in your own mind if not that of the
insurance company, the expense. Furthermore, the expected value of any test is dependent
on the situation in which it is being applied. In general, as few tests in medicine have
100% sensitivity and specificity (i.e. correctly identify those with and without disease all
of the time), the likelihood that a result is correct is dependent on how strongly you already
feel about the candidate diagnosis. That is, if you are certain that someone is suffering
from a particular disease (on the basis of history, exam and other findings) and you order
an additional test "just to make sure" then the results of the test aren't likely to have a
significant impact on your decision making (i.e. if it confirms your suspicions, so what; if
it conflicts, you'll ignore it, treating the result as a false negative). The same principles
apply in the reverse situation (i.e. if you are certain that someone does not have a particular
illness). Tests have their greatest value when applied to situations where you're truly on the
fence about a particular diagnosis. An in depth discussion of this subject can be found in
any text under Baysean Analysis.
5: In this setting, I would probably not be comfortable waiting for the process to "play out"
any further without initiating therapy. Bacterial processes tend to worsen unless they are
treated, even in otherwise healthy 23 year olds.
6: Therapy in this case could be initiated on an outpatient basis with an antibiotic directed
against Strep and H. Flu, the pathogens most commonly associated with respiratory
infections in this age group. Treatment would last for a total of 7 days (a somewhat
arbitrary number) and the patient instructed to return for re-evaluation on the last day of
therapy to insure that the infection was completely treated and that the antibiotics could be
discontinued. In addition, they would be told to contact me if they felt worse. If this, in
fact, occurred I would have to consider why things did not go as I had anticipated. Did the
patient have an atypical infection (e.g. Legionellosis)? Were they non-compliant with
medications? Had they developed a complication (e.g. empyema)? Were they suffering
from a particularly virulent strain of bacterium? Or was the initial diagnosis (e.g. infectious
process) correct in the first place? The only way to make this determination (and catch the
rare zebra) would be through re-evaluation of the patient, applying additional tests in a
logical and ordered fashion.
Example 2, by design, is a bit more murky.
Case 2: A 55 year old male with history of Chronic Obstructive Pulmonary Disease (COPD), Coronary
Artery Disease (CAD), and past Pulmonary Embolism (P.E.) presents with several hours of chest pain
radiating to his left arm associated with shortness of breath and diaphoresis. This is somewhat reminiscent
of his past myocardial infarction, but is also similar to past admissions for COPD and his P.E. ... he's just
not sure. Exam is remarkable for a pale gentleman who looks quite distressed, sweating profusely. Vital
signs remarkable for Temp 99 P 110 BP 180/100 RR 30 Sat 91%. JVP is at 8cm. Lung exam is
remarkable for diffuse wheezing. Patient has bilateral lower extremity edema (1+ to the mid shin) with
33

the right leg slightly more swollen then the left, which he says has been present since his DVT and
subsequent PE several years ago.
Discussion: We will approach this case in the same way as the previous example.
1&2: An exacerbation of any of this patient's underlying conditions could explain his
presentation. On the basis of the history and examination, recurrent cardiac ischemia, a
flair of his COPD or another P.E. are all possible. Additionally, this could represent new
Congestive Heart Failure (CHF), perhaps associated with ongoing cardiac ischemia.
Although he has never had this before, I know that CHF tends to occur in patients with
CAD (which this patient does have) and can cause a clinical picture similar to that
presented above. A bacterial infection (either bronchitis or pneumonia) is usually
accompanied by additional symptoms (e.g. fever, chills, sputum production), but remains a
possibility, particularly as I know that COPD flairs usually occur in association with such
an infection. Bringing up the rear would be "other" which would include, but not be
restricted to, the initial presentation of a lung cancer or a pneumothorax. These processes
do occur in patients with COPD but tend to present with other exam/historical findings
(e.g. malignancy is often associated with weeks-to-months of weakness, fatigue, weight
loss and a focal lung exam; pneumothorax causes decreased/absent breath sounds on the
affected side). Ordering these possibilities from most to least likely, I would put coronary
ischemia/CHF and P.E. 1 and 2, followed by COPD flair, pneumonia and "other." In this
case, I am impressed by the acuity of the presentation, which has increased my suspicion
for the first 2 processes. The others, however, remain reasonable diagnostic possibilities
which cannot be ruled out on a clinical basis.
3&4: All of the above conditions carry significant morbidity and/or mortality. In addition,
treatment strategies for each are quite different, and may themselves carry risk. Anticoagulation with heparin, for example, would be useful in patients with PEs but has no role
in the treatment of a COPD flair, and would unnecessarily expose the patient to the risk of
bleeding. There is also a sense of urgency that surrounds the need to make the diagnosis
and begin treatment as:
a. the patient appears ill, with clear potential for further deterioration
b. some of the treatments are only effective if applied within a narrow window of
opportunity (e.g. thrombolytics can open an occluded coronary artery and save
downstream myocardium only if they are given soon after the onset of ischemia).
The following tests, essentially performed simultaneously, are necessary in order to rapidly
make a diagnosis:
a. EKG... to assess for evidence of acute myocardial infarction or stigmata of PE
b. CXR... to evaluate for signs of CHF, PE, infiltrate... will also identity
pneumothorax or evidence of malignancy
c. CBC... to asses for anemia which could be a precipitant for cardiac ischemia or
shortness of breath; might also suggest a bacterial process if the white blood cell
count is elevated.
d. Chem 7 (includes electrolytes, BUN, Creatinine, Glucose)... might be helpful in
determination of volume status; also useful if patient will need diuretic therapy if
diagnosed with CHF.
e. Arterial Blood Gas... to define Alveolar-arterial gradient and degree of gas
exchange abnormality
f. CK-MB, Cardiac Troponins... will be elevated if patient has suffered a myocardial
infarction.
g. D-Dimer... elevated in cases of DVT/PE
h. BNP (B-type naturetic peptide)... elevated in cases of CHF
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The test results are as follows:

EKG remarkable for sinus tachycardia at 110, non-specific ST segment changes in the
inferior and precordial leads.
CXR consistent with moderate emphysema; no evidence infection, pneumothorax or
malignancy; ? upper zone vascular redistribution consistent with CHF
Chem 7 and cardiac enzymes all normal.
CBC... mildly elevated White Blood Cell Count (14 thousand) with normal differential;
normal hematocrit
ABG... PO2 50, PCO2 30, PH 7.5... c/w hypoxemia and acute respiratory alkalosis
D-Dimer...600 (moderately elevated)
BNP 300 (mildly elevated)
The diagnosis still remains in doubt. The data does not support an acute myocardial
infarction, though unstable angina without myocardial necrosis is still a possibility. There
is nothing to suggest a pneumonia, pneumothorax or malignancy, which we thought were
unlikely. I would now re-order my differential, placing pulmonary embolism at the top
followed by COPD exacerbation, CHF and unstable angina. I still need to press on and
make use of additional tests in order to identify the correct diagnosis and institute
appropriate therapy. In this case I would obtain a radiologic test known as a CT-angiogram
of the chest to assess for evidence of a pulmonary embolism. If this were negative, I would
then be left with a diagnosis of COPD, CHF or unstable angina. Further treatment would
be based on the clinical course, response to therapy, and if, in fact, there were any
additional means of distinguishing between these possibilities.
5&6: Because this patient is rather ill, treatment should occur in concert with the
diagnostic evaluation and would include:
a. Oxygen: The patient is hypoxemic and would benefit from oxygen, regardless of
the underlying cause.
b. Heparin: As it may take some time before the CT scan is performed, I would elect
to begin therapy with heparin while waiting to obtain the study. This decision is
based on my high clinical suspicion that the patient has had an embolous. Because
he already appears pretty sick and compromised, I would be uncomfortable
withholding therapy that could prevent additional (and perhaps catastrophic)
emboli. Furthermore, anti-coagulation would also be used as first-line treatment for
unstable angina, which is #2 on my differential. Only in the setting of COPD flair
(#3) would heparin be inappropriate. In this case, I have decided that the potential
benefit of heparin out weighs the short term risk of bleeding.
c. Aerosolized Albuterol (a beta-2 agonist): I would also give the patient a breathing
treatment with nebulized albuterol to see if it relieved any of his bronchospasm.
d. Lasix: This would help improve hypoxemia in the event that some component of
the patient's illness is caused by CHF. While I have no way of knowing definitively
that he does have pulmonary edema and would therefore benefit from diuresis,
there are few other therapeutic options that would have a rapid, dramatic impact on
his gas exchange. He certainly does not appear intravascularly depleted, a situation
where Lasix would be dangerous. By my calculations then, the potential benefits of
this treatment outweigh its risks.
e. Steroids: Another therapeutic option would be to give him a dose of intravenous
steroids for his possible COPD. A single dose of steroids has little downside. I also
know that it takes a while (at least several hours) to have an effect. Thus,
particularly if it will take some time to get the V/Q scan, I would probably opt to
initiate steroid therapy, which could always be discontinued if the results were
consistent with a P.E.
f. Antibiotics: Since COPD remains high on my list, and COPD flairs are most
frequently precipitated by bacterial infections, it's logical to treat for this potential
problem as well.

35

Thrombolytics are not indicated. Nor would I initiate therapy with any of the more potent
platelet inhibiting agents (the 2a/3b receptor antagonists), as these carry a higher risk of
bleeding (at least until that point when unstable angina was more clearly the leading
diagnosis). As additional data became available, I would need to continually re-evaluate all
of these decisions.
There are a few themes that are common to both cases and help guide decision making in general:
1. Patient substrate along with the clarity of presentation will have a significant impact on our
willingness to accept clinical uncertainty. Healthy patients who present with "classic"
complaints/findings can generally be managed comfortably on the basis of data acquired from the
H&P alone. These patients have significant physiologic reserves and can tolerate incorrect
treatments/diagnoses, affording us the opportunity to redirect our efforts in the event of a
diagnostic/therapeutic misstep without having them suffer significantly. As patients accrue
baseline illnesses, however, there is a marked increase in "background chatter," making it difficult
to pinpoint the etiology of an illness solely on the basis of the history and physical. Furthermore,
the patient's ability to tolerate additional insults becomes quite limited. Thus, we become both less
capable of making diagnoses on clinical grounds alone and less comfortable proceeding without
the utilization of diagnostic tests. That is, our willingness to accept uncertainty diminishes
dramatically.
2. Therapies that carry significant risk are generally reserved for more serious illnesses. They are
administered only when there is some reasonable certainty that the patient is suffering from the
disease or are doing so poorly that it's felt to be worth the risk. Treatments that carry less risk are
initiated with relative impunity, although obviously even these options have downsides.
3. Patients with significant baseline organ dysfunction often have little reserve and therefore tolerate
additional insults poorly. This imparts a sense of urgency to the process which is generally absent
when caring for healthier patients. While tests are being obtained to define the nature/extent of a
clinical problem, empirical therapies directed against several of the most likely illnesses are
initiated in an effort to prevent further deterioration. If no tests are available that can accurately
distinguish between several diagnoses, a number of different therapeutic strategies may be
pursued in parallel. These patients frequently require very close monitoring (i.e. in-hospital
treatment) so that appropriate adjustments can be made and clinical down-turns rapidly addressed.
This everything-but-the-kitchen-sink mentality is certainly less appealing and elegant then focused
therapy where interventions are initiated individually, enabling the clinician to clearly gauge their
efficacy and minimize any associated therapeutic risk. Unfortunately, it is often impossible to
identify the exact limb of the system that is broken, forcing the use of multi-modality approaches.
4. Clinicians listen, ask, examine and then try to use the information obtained to put patients into
known diagnostic categories. The differential diagnosis is a list of these possibilities and can be
thought of as a group of boxes of various shapes and sizes. The quantity and variety of these
containers is a function of the way in which providers combine historical information and exam
findings with clinical experience and their understanding of pathophysiology. Frequently there is
an imperfect fit between what we find and what we know. Instead of trying to cram patients into
ill suited spaces we should recognize that these instances indicate a need to either expand our
knowledge base, change our approach to a patient's complaint, or gather additional data.
Remember also that there is no shame in admitting that we can't explain a particular finding or
symptom. In fact, knowing what something is not has as much value as providing a specific label
for a complaint or condition.
5. Clinical decision making is based on the expectation that the human body will respond to illness
in a predictable way. Disease states which alter this behavior wreak havoc on logical decision
making. Illnesses which decrease normal immune function (e.g. HIV infection), medications that
blunt the response to infection (e.g. steroids, chemotherapy), or advanced age (which frequently
leads to an impaired physiologic response to stress) are a few examples. When caring for these
patients, providers are forced to cast a wide net, relying on the initiation of empirical therapies
while multiple diagnostic avenues are pursued.
6. There will always be some element of non-modifiable uncertainty in clinical medicine (unless, of
course, someone actually invents Star Trek-type Tricordors!). Technological advances have
36

succeeded in improving both diagnostic and therapeutic accuracy. However, they are almost never
correct all of the time. Reliance on the less-then-perfect information that these tests provide
without in some way taking into account clinical judgment can have serious consequences for the
patient.

37