The importance of patient history alongside an effective physical examination

Getting to the root of the problem with a patient takes time, skill and practice. Getting the basics right is vital, like greeting your patient warmly and professionally, and making your consulting room comfortable. But what about the less obvious stuff, and what makes a consultation between a healthcare professional and their patient truly effective?

The answer lies in a combination of good communication, applied professional knowledge and a thorough understanding of the patient’s history. These work in harmony with skilled examination techniques to provide the best chance of accurate diagnosis. As a competent healthcare professional, it’s important to realise that consultation skills go way beyond basic questions like “does asthma run in your family?” or “have you hurt this leg before?”

A good history is one that reveals the patient's concerns, ideas, opinions and expectations which can go a long way towards disclosing the less obvious causes behind their symptoms. It may, for example, give you an idea of their emotions and frustrations. Healthcare professionals should try to avoid dominating the history taking and let the patient speak openly. At the heart of any good communication is the ability to listen - and sometimes, to read between the lines. Without the ability to see life through the eyes of your patient, their history is likely to be much less revealing and less useful to you in attempting an accurate diagnosis.

Sometimes, history is all that’s needed to diagnose. A good example is if someone comes to you with a headache, and describes the headache to you in detail. They may mention certain triggers they’ve noticed previously, together with other symptoms like nausea or visual disturbances. This information on its own could be enough for you to diagnose migraines for example, with no further investigation needed. Other times however, a physical examination will be required alongside a patient’s history, and this is where the two can work together.

How physical examinations can bring out more about a patient’s history

There are certain things you can do during a physical examination, such as being gentle in your approach and explaining to your patient what you’re doing and why. This can go a long way towards putting their mind at ease, and when people relax they tend to chat – and when they chat about their health, history often comes out with it.

Discovering the core of a patient’s worries, and how those worries have evolved over time, takes lots of practice. A consultation can allow them to unburden themselves and let you into other parts of their life such as money worries or family issues. It’s only through finding the perfect combination of history and physical examination that healthcare professionals will have the greatest chance of diagnosing a patient effectively – and offering them the best solution.

Are you a healthcare professional looking to develop your patient assessment skills?

If so, why not sign up for our Five-day patient assessment skills workshop? Offering practitioners the chance to enhance their skills in clinical decision making and diagnostic proficiency through CPD, it’s ideal for nurses, pharmacists, paramedics and physiotherapists in particular.

All course material and refreshments are provided, as well as a certificate of attendance. Multiple dates are available between September 2019 and April 2020 and the course takes place at St. Bart’s hospital in London.

*Article and image contributed by a third party. 

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