Clinical Examination Skills for Healthcare Professionals

2nd Edition

Hannah Abbott, Mark Ranson

• Publisher: M&K Update
• Year: 2017
• ISBN:
  9781907830761
• Topic: Medicine
• Subtopic: Nursing

Today, an increasing number of healthcare professionals (including nurses, midwives and members of many allied professions) have to conduct the vital first stage in a patient's journey – taking a clinical history and conducting an effective physical examination. This book offers clear, practical guidance on the fundamentals of clinical examination for any practitioner who wishes to understand their patient's specific needs and to plan appropriate care. Recognising that readers will come from a diverse range of clinical backgrounds and roles, the opening chapter (on consultation and the skills needed to take an accurate clinical history) underpins the systems-based approach. This, combined with the use of case study examples, allows healthcare professionals to focus on the principles of examining the system or systems that are most relevant to their specific area of practice. The book also includes a helpful glossary and list of abbreviations.This new, updated edition contains revised chapters on genitourinary assessment, obstetric assessment and mental health assessment. There is also a completely new chapter on eye, ear, nose and throat assessment, covering the EENT conditions most commonly encountered in primary healthcare.

Chapter 1

Consultation and clinical history-taking skills

Susan Blainey

History-taking does not exist in isolation; rather it occurs in the context of a consultation. It is a competency-based activity requiring key communication skills to gather information about the patient. It can arguably be seen as the most important element in any clinical encounter. The ability to take a clinical history is certainly fundamental to developing and establishing an effective practitioner–patient relationship.

The word ‘taking’ suggests that this process is dominated by the clinician and this idea perhaps derives from early teaching methods, whereby medical students were taught a two-part approach to case management: firstly the interrogation of the patient; and secondly the physical examination (Armstrong 1985). Most practitioners will be familiar with the traditional concept of medical history-taking, in which the junior doctor on the ward clerks a patient by gathering information using an easily recognised standard framework. However, interrogation in medicine has long been integrated with consultation in history-taking (Neighbour 2007, Pendleton 1993), which constitutes a far more holistic approach.

Although it is often perceived as particular to medicine, where the long-established standard medical model is used (see Box 1.1, page 2), the actual process of history-taking is also undertaken by nursing and allied health professionals to gather information about the patient’s health status.

Box 1.1: Medical model for history-taking

•Presenting complaint

•History of presenting complaint

•Past medical history

•Drug history

•Family history

•Social history

•Systems enquiry

The specific history-taking framework used by a particular professional group may vary according to the intended outcomes relating to that professional group but the skills required for effective history-taking are common to all healthcare professions.

Traditionally, nursing staff members take a psychosocial or humanistic approach, largely aimed at identifying patient problems and needs, as opposed to a medical diagnosis (Young et al. 2009). Models developed by nursing theorists as far back as 1966 (Henderson) and as recently as the 1990s (Roper et al. 1990, Orem 1995) have been well established for this purpose.

The modernisation agenda within the NHS Plan (2002) and Making a Difference (2002) has led to continuing policy initiatives (Department of Health 2001, 2011) to encourage new ways of working to help improve services and enhance the quality of patient care. Traditional role boundaries have been challenged and professional responsibilities have changed, enabling nurses and other allied health professions to work in different ways. Their enhanced roles require practitioners to take on responsibilities in areas that have traditionally been viewed as belonging to the medical domain. These include medical history-taking, diagnostic and physical assessment, and prescribing.

Good history-taking skills are acquired through practice, using a variety of techniques and building on past experiences. The suggestion by Tierney and Henderson (2012) that the ability to take a good history cannot be achieved by reading books rings true. It is of course an experientially acquired art, learned over time, with each patient. Through practice, a healthcare practitioner learns what to ask, what to ask next, what to emphasise, what to prioritise, what to discard and what areas to investigate. A history is more than just information gathered from the patient. Done well, it should reveal the nature and extent of the problem, the context of the problem, the impact of the problem, and the patient’s concerns, ideas and expectations.

Structure is important and an ordered framework can be helpful in order to guide the process. But successful history-taking ultimately relies on communication skills, applied in the right manner and context to achieve a successful encounter for the patient and practitioner. It is this skill set that will enable the patient to tell the story of their illness.

The aims of history-taking

When taking a history, it is worth thinking about your overall aims. What are you trying to achieve? For example, are you trying to make a diagnosis? Are you establishing fitness for surgery? Or are you identifying risk-taking behaviour?

Goals for history-taking may alter or expand within consultations in the light of a changing context or an unfolding clinical situation. A patient history may commonly be taken to:

•establish the system(s) responsible for the symptom(s)

•make a diagnosis

•identify a differential diagnosis

•gather information about the patient’s overall health status

•clarify the nature of the disease process

•establish fitness for surgery/anaesthetic

•understand the patient’s individual circumstances, and their concerns, ideas, expectations and beliefs.

Effective history-taking is vital in order to arrive at an accurate diagnosis. Practitioners undertaking new roles may initially focus on mastering new physical assessment skills but equal emphasis should be placed on the ability to obtain an accurate history. The physical examination and any subsequent investigations are important but they should help to confirm or refute the differential diagnosis you have already made, based on the history.

Furthermore, the history should not only tell you about the likely disease process, it should also inform you about the subjective nature of the illness – in other words, the patient’s experience of the disease, and its effect on their life, their concerns and ideas. In an acute or life-threatening situation, the emphasis will clearly switch to physical assessment skills, as recognising and interpreting clinical signs will take priority. Nonetheless history-taking will still be important, as key information will be required from records or relatives, for example.

The standard medical approach to history-taking

The standard framework widely used for medical history-taking provides an established seven-point credible structure. For practitioners in new roles, it offers a helpful common language that can facilitate communication across inter-professional groups. Figure 1.1 shows the complete framework, with expansion of the key areas pertinent to each of the seven components. Additionally, two parallel panels, adapted from Kurtz et al. (2003) and Bickley (2008), are embedded to demonstrate some of the key underlying factors and processes that contribute to effective history-taking.

The seven components of the comprehensive health history provide a structure for the patient’s story and a standardised format for the written record. However, the order shown should not necessarily dictate the sequence of the interview. Whilst several papers and texts discuss the need to follow this approach systematically (Douglas et al. 2011, Crumbie 1999), others encourage flexibility (Shah 2005, Bickley 2008). In the Bates’ Guide to Physical Examination and History-Taking, Lynn Bickley talks about the need for clinicians to be flexible in their interview approach to history-taking, advocating the need to change style as befits the particular or changing situation. In other words, be ready to use a focused, or problem-oriented, approach, when it best suits the patient or the situation. Like a tailor fitting a garment to an individual customer, the practitioner should adapt the scope of the health history to the individual patient. This approach will need to take into account co-factors such a...

Table of contents

• Cover Page
• Title Page
• Copyright
• Contents
• List of figures
• List of tables
• List of boxes
• About the editors
• About the contributors
• Foreword
• List of abbreviations
• Chapter 1: Consultation and clinical history-taking skills
• Chapter 2: Respiratory assessment
• Chapter 3: Cardiovascular assessment
• Chapter 4: Gastrointestinal assessment
• Chapter 5: Neurological assessment
• Chapter 6: Genitourinary assessment
• Chapter 7: Musculoskeletal assessment
• Chapter 8: Obstetric assessment
• Chapter 9: Mental health assessment
• Chapter 10: Perioperative assessment
• Chapter 11: Eye, ear, nose and throat assessment
• Glossary
• Index