In dealing with patients, the physician should
avoid being judgmental of their values
and lifestyles unless it is medically relevant
(for example, smoking and alcohol or sub-
stance abuse, which should be firmly
discouraged). In the course of one's practice,
every physician can anticipate meeting patients
who evoke negative, as well as positive,
emotional reactions. Physicians need to be aware
of this possibility and should not allow
their judgment or actions to interfere with
their patients' best interests.
In order to treat a patient effectively, a good
relationship between physician and
patient must be established. This mainly
depends on the empathetic response on the part
of the physician and recognition of the
physician's caring attitude by the patient.
CLINICAL SKILLS
The basic three-step approach used by
physicians in diagnosing disease involves taking
a patient's history, performing a physical
examination, and ordering laboratory tests
and/or imaging procedures. These steps are
discussed in-depth below:
History Taking
All the facts in the patient's medical history
should be noted in the written record. The
history can be recorded in one of two ways: (1)
it can be recorded in chronological
order, in which case recent events should be
emphasized most; or (2) if a problem-ori-
ented approach is used, the problems that are
clinically most pronounced should be
noted first. The nature of the symptoms should
be in the patient's own words. In elicit-
ing the history, the physician needs to be
careful to avoid suggesting answers in the
course of guiding the patient through the
interview. It is important that careful attention
be given to all the details of the interview,
no matter how minor, since a seemingly small
detail may be important in making the
diagnosis.
More than an organized listing of symptoms, a
well-written history, elicited during
the interview, should also reveal something
about the patient, in addition to the nature of
the patient's disease. This information may be
extracted from facial expressions, voice
inflections, and the attitude that is evident
during the discussion of the illness. Taking a
history is a challenge since patients are
highly subjective in their presentation and may
also be affected by their past experience. In
addition, there is a fear of disability or even
death, as the impact of illness on one's family
inevitably influences a person's account
of the problem. Unfortunately, language or
sociological obstacles, as well as failing
mental recall, can, in some cases, very
significantly interfere with the patient giving an
adequate history. In such cases, the physician
may have to seek the help of an interpreter
or a member of the patient's family in order to
obtain an accurate history. The physi-
cian's skill, knowledge, patience, and
experience will greatly influence the quality of the
history taken.
Obtaining a family medical history can be very
helpful in short-term care and pre-
ventive health. The process of history taking
also serves to establish or strengthen the
physician-patient relationship. Patients should
be put at ease and should be allowed to
express their thoughts. The confidential nature
of the information should be emphasized.
Physical Examination
Physical signs are objective and verifiable
evidence of disease. Their significance is
enhanced when these signs confirm a structural
or functional change indicated by the
patient's history. On occasion, the physical
signs may be the only evidence of disease,
especially if the history is not
informative.
The physical exam should be carried out
methodically and thoroughly. While the
focus of the exam may be on the diseased area
or organ, in a new patient the exam
should cover the entire body. The results
should be recorded at the time they are
obtained. Skill in this area is required and
comes with time.
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