Visit–Revisit

Clinical Assessment Is Not a Linear Process

Ask · Examine · Think · Revisit Clerking Order ≠ Thinking Order Medicine Is Iterative
Reminder

Common diseases still require
careful — and iterative — assessment.

The misconception Students believe assessment is a sequence — history first, then examination, then thinking. This is a communication format, not a thinking process.
The reality History and examination continuously inform each other. A finding on examination sends you back to history. A new history detail changes your examination focus.
The skill Knowing when to revisit — and what to look for when you do — is one of the hallmarks of a good clinician.
The Shift

What students think vs. what actually happens

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The Student Mental Model

Incorrect
  • Take full history in perfect order
  • Examine from head to toe
  • Then think about the diagnosis
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Good Clinical Practice

Correct
  • Ask history — form early hypotheses
  • Examine — findings change your thinking
  • Return to history with new questions
  • Re-examine with a focused purpose
  • Refine hypothesis — repeat as needed
Clinical Reasoning

The Iterative Loop — not a line, a cycle

Loop repeats until clinical clarity is achieved History Initial Examine Findings emerge Hypothesis Working diagnosis Revisit New questions Refine Or re-examine or investigate
This cycle is normal medicine. The number of loops depends on clinical complexity. A straightforward case may need only one pass. An undifferentiated presentation may need several. The ability to recognise when another loop is needed is itself a clinical skill.
Principles

Six reasons assessment is iterative — not sequential

1

History and Examination Inform Each Other

A finding on examination is not the end of history — it is a trigger for new, targeted questions. What you find changes what you ask. What you ask changes what you look for.

Clinical example Child presents with wheeze. During examination you find unilateral reduced air entry. You must immediately return to history: any choking episode? Sudden onset? Playing with small objects? The examination finding has reframed the entire history.
2

History Is Not Taken in Presentation Order

The clerking format — presenting complaint, history of presenting complaint, past history, family history — is a communication structure, not a thinking sequence. If a new hypothesis arises mid-history, pursue it immediately.

Clinical example You are taking a history and begin to suspect a genetic condition. Do not wait until the "family history section." Ask the family history now. Patient safety is more important than format compliance.
3

History Is Often Taken More Than Once

Parents remember details later. Patients give incomplete information initially. Sensitive issues require trust before disclosure. Revisiting history is not a sign of failure — it is good clinical practice.

Note Good clinicians revisit history frequently — not because they forgot to ask, but because the clinical picture has evolved and new questions have become relevant.
4

Physical Examination Is Repeated

One examination is rarely sufficient in acute care. Re-examination after an intervention is part of management — it is how you know whether the intervention worked.

Clinical examples Re-check respiratory rate after nebulisation. Re-examine the abdomen after analgesia. Reassess neurological status after a seizure. Each re-examination is a decision point.
5

Clinical Reasoning Is a Loop, Not a Line

History → Exam → Hypothesis → More History → Focused Exam → Refined Hypothesis → Investigation → Reassessment. This cycle may repeat several times. That is not inefficiency — that is how diagnoses are actually made.

Why this matters The student who stops thinking after the first examination misses the diagnosis that only becomes apparent on the second. The loop is the process.
6

Focused Re-examination Is a Clinical Skill

Re-examination is not just repetition — it is purposeful reassessment with a specific question in mind. What you are looking for on the second examination is different from what you looked for on the first.

Clinical examples Suspected asthma → reassess air entry after bronchodilator. Suspected ALL → re-check for lymphadenopathy and organomegaly. Suspected nephrotic syndrome → reassess oedema distribution daily.
Important Distinction

Clerking format vs. clinical thinking — do not confuse them

OSCE / Clerking Format

A communication structure

The structured history and examination format taught in OSCE is designed for clear, reproducible communication — to ensure nothing is omitted when presenting a case or writing a note. It is a valuable tool for this purpose.

Clinical Thinking

A flexible reasoning process

Clinical thinking is priority-based, hypothesis-driven, and iterative. It follows the evidence, not the headings. The order changes based on what the patient tells you, what you find, and what hypothesis you are currently testing.

The fault is not the OSCE format — it is an excellent communication tool. The error is applying a communication format to a thinking process. Students who confuse the two become rigid clinicians who cannot adapt when the patient does not follow the textbook structure.
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Practical Rule for Students

If a new idea comes to mind — ask immediately.

Do not wait for the "correct section." Do not hold the question until you reach the right heading. Patient safety is more important than format compliance. The question that occurs to you mid-examination may be the one that makes the diagnosis.

What This Model Prevents

Common errors from linear thinking

Missing key history because the "right section" had already passed
Rigid, mechanical clerking that does not respond to new findings
Failing to re-examine after an intervention
Treating clinical assessment as a checklist to complete, not a process to repeat
Final Take-Home Message
"Clinical assessment is not History → Exam → Finish.
It is Ask · Examine · Think · Revisit · Refine."

Medicine is iterative. Good clinicians are flexible.
The loop continues until clarity is achieved.

Clerking order ≠ thinking order Revisiting is good practice The loop is the process
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