The importance of the first clinical orientation


Author : Guillermo Ojeda Burgos. Internal Medicine. January 2016

You can read this Post in spanish/ leer en español en:

guilleThe clinical approach to a patient is something that we often speak in clinical settings but it is not easy to define. A good initial clinical approach determine the clinical course of the diagnostic process . I would like to consider some reflections about this subject.

There are several ways to explain what we understand as a clinical approach. A first image is to express this idea with similarities to the blurred vision that a short-sight person has about a landscape. Another definition is the process of focus the clinical problem in a context that allows to start an action with predictable results.

This definition is close to the concept of diagnostic accuracy what is based in the recognition of signs and symptoms to reach a diagnosis. But in practice there are usually distractions that can direct the attention of the physician to a point without considering the peripheral area (tunnel vision). The importance of the initial diagnostic approach is crucial because if it is not correct can be a delay in the whole diagnostic and therapeutic process and the outcome can be worst the longer will take to get the proper diagnosis. This concept of time spend to reach a diagnosis is not taking account usually in Medicine.
The environment where you work largely determines the “tempo” to detect a disease. In primary care , for example predominate slow tempo (chronic diseases ) , while in the emergency room fast tempo ( acute illness ) . As an hospitalist myself I have the opportunity to witness diseases with different tempos.  An error in the initial clinical approach can divert the course of the disease at a point of no return in which none of the measures taken could be effective.

Some recommendations for a good approach might be

  1. Conduct a methodical obtention of information
  1. The pathophysiological framework that is chosen must explain most of the findings  and symptoms  of the patient
  2. You must consider the tempo of the disease
  1. Change your initial assessment of the problem , if new signs or symptoms should be evaluated and integrated.