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Sir William Osler taught that what was not found in a history was aided by completing an appropriate physical examination. The history provides 90% of the diagnosis, the physical examination provides 9%, and diagnostic tests contribute the remaining 1% of diagnostic certainty.

In the situation of the patient who remains undifferentiated despite optimizing the history, it is paramount that the EMS clinician perform a thorough and complete physical examination [4]. This begins with ensuring that a complete set of vital signs is taken and recorded. The following strategies can be used to improve the diagnostic accuracy during the physical examination process [4, 7,9–11].

 Ensure that a complete and uninterrupted physical examination or secondary survey.

 Clarify the history while conducting the physical examination.

 Perform an environmental scan of the patient’s physical surroundings to complement the history (general surroundings, state of disarray, etc.).

 Have a structured and simple differential diagnosis or impression, based on the presenting history and physical information currently available (e.g., an altered level of consciousness can be broken down into structural, metabolic, and toxicological etiologies).