Content area
Full Text
The clinical encounter usually consists of the steps shown in fig 1. A good history is very important for making a diagnosis. Examination and investigations may help to confirm or refute the diagnosis made from the history.
The history will also tell you about the illness as well as the disease. The illness is the subjective component and describes the patient's experience of the disease.
Try to follow the sequence history, examination, investigation when you see a patient. A common mistake is to rush into investigations before considering the history or examination.
It is easy to mindlessly order a battery of tests. There are many problems with this approach: Investigations cannot be used in isolation-is the x ray finding or blood test result relevant or an incidental finding?
Investigations can be inaccurate-there can be problems with technique, reagents, or interpretation of the findings
Investigations pose risks-radiation exposure, unnecessary further procedures, and so on
Investigations can be costly, to the patient and to society.
Always remember to treat the patient and not the investigation. And remember that although we talk about "the patient," you should consider "the person."
Structure
You should use the following as a guide until you develop your own style and one that you feel comfortable with. You are at liberty to reorganise the order. For instance, you could go to the systems review after the history of the presenting complaint. Whatever order you use, however, you need to ensure that you get all components of the history (fig 2).
Introduction and details
You should always begin by introducing yourself. This should include your status as well as the educational reason for the encounter. For example, "My name is... I am a... year medical student, and I have come to talk to you to learn...