Clinical Assessment and Evidence-Based Practice
The final domain tests how you gather information and convert it into a decision: focused history and examination, appropriate imaging, clinical decision rules and guideline-based care. Questions often hinge on whether the patient is stable enough for a given investigation.
History and examination
- Start with the presenting complaint, then analyse it by onset, site, radiation, character, timing, aggravating and relieving factors, and associated symptoms.
- Red flags: weight loss, dysphagia, rectal bleeding, night pain, fever with rigors, bilious vomiting.
- Examination sequence: general, hands, abdomen (inspection, auscultation before palpation, percussion, palpation), hernial orifices, rectal or vaginal examination where indicated.
- Clinical reasoning uses illness scripts; compare the case to prototypes and consciously look for features that do not fit - those are where errors hide.
Imaging and investigation choice
- Plain radiographs remain first-line for suspected perforation (erect chest) and obstruction (abdominal film), but CT is more sensitive and defines the cause.
- Ultrasound is first-line for gallstones, biliary dilatation and many scrotal or gynaecological presentations; it is operator dependent.
- CT with contrast and appropriate phases defines staging, vascular anatomy and abscesses; MRI is superior for soft tissue, liver lesions, pelvic staging and spinal disease.
- PET-CT is used for staging and recurrence, not as a first-line diagnostic test.
- Do not send an unstable patient to the CT scanner; resuscitate and use bedside imaging such as FAST.
Guidelines and decision rules
- Guidelines (WSES, NICE, Tokyo, ATLS, Surviving Sepsis) summarise evidence but must be applied to the individual.
- Clinical decision rules: Wells score for DVT and PE, Alvarado score for appendicitis, Glasgow coma scale, qSOFA and NEWS for deterioration risk.
- Shared decision-making incorporates patient values, particularly where evidence is equivocal.
Appraising evidence
- Frame the question with PICO: population, intervention, comparison, outcome.
- Prefer systematic reviews and randomised trials for therapy; cohort studies for prognosis and rare exposures.
- Check for bias: selection, performance, detection, attrition and publication bias.
- Consider applicability: were the trial patients similar to yours, and are the outcomes patient-important?
Worked example
A 60-year-old with unilateral leg swelling has a Wells score of 3 - active cancer in the past 6 months, whole-leg swelling and pitting oedema, minus an alternative diagnosis. A score of 3 means DVT is likely: proceed to compression ultrasound rather than D-dimer. If the score had been 0 or less, a D-dimer would safely exclude DVT.
Traps that lose marks
Ordering CT before resuscitation in shock; using D-dimer in a high-probability patient; applying a guideline to a patient who falls outside its population; anchoring on the first diagnosis and ignoring discordant findings.