Importance of history and physical examination in complex patients

Dr Brian Garibaldi is an associate professor in the Division of Pulmonary and Critical Care Medicine and director of the Biocontainment Unit at Johns Hopkins Medicine (USA).

It has become proverbial that when laboratory testing fails to determine a diagnosis in a complex patient, we should once again take a thorough history and perform physical examination. Could you comment on that?

Brian Garibaldi, MD: I would turn that question on its head and would say that the key to a diagnosis in a complex patient is the history and physical examination.

Oftentimes, particularly in complex patients, it is important to switch from type 1 thinking to type 2 thinking, slow yourself down, ask more complete questions, do a more focused physical examination, and try to find the answer, rather than waiting for the laboratory test to not give us the answer and then having to go back and repeat those.

We oftentimes talk about something called the hypothesis-driven physical examination, which means using your history to help guide what physical examination maneuvers might be most helpful. But sometimes in a complex patient, particularly in the intensive care unit (ICU), for example, they may not be able to give you a complete and thorough history. At that point the directed physical examination becomes more of a head to toe approach, to look for the common things that can cause life-threatening conditions in the ICU.

But again, even in the day of technology, the vast majority of our diagnoses we can make with a good history and physical exam at the bedside.