History and Physical Examination

Most consultant physicians allow up to an hour for new patient consultations whereas General Practice generally allocates a total of 10 minutes for history, examination and explanation - so it is important to be efficient and focused. It is permissible to take a little over 10 minutes but if a consultation is taking much longer than this, it may be preferable to ask the patient to return, perhaps with a longer appointment.

Secondary Care has more time and a referral letter. You have a "virgin" patient from whom you have to extract a clear and concise story in a brief duration.

The consultation is a very complex issue and matters that are discussed elsewhere include consultation analysis, clinical negligence and the electronic patient record and telephone consultations. Most articles on clinical topics will include the relevant aspects of history and examination for that subject.

This is a frequently neglected area, but it can be very important. Clear your mind of the last patient as you wash your hands to prepare for the next. It is like a tennis player who has to focus on each current point and not think back to the mistake that cost him the last one.

Glance through the records before seeing the patient. Because they know that you have the records, patients expect you to know their past medical history, even if it is the first time that they have consulted with you. It is certainly worth noting the last consultation and the major problems as displayed on the screen.

The patient will be anxious. Be relaxed and smile to radiate confidence. Try to let the patient speak without interruption but there will be times when he tends to meander and needs to be brought back. There are also times when it is necessary to delve deeper into certain matters. Stay focussed. Try to ask open questions and try to avoid leading questions.

Sometimes the patient will deviate but it is an important issue that will need to be addressed. Do not be diverted but it may be helpful to make a note or you will forget until after the patient has left.

Ask yourself, "Why did this patient come?" There may be hidden anxiety. There may be concern about cancer that needs to be explored and addressed. Patients sometimes open the consultation with, "I hope I'm not wasting your time," that really means, "I hope I am wasting your time and this is not serious but I am worried". If the patient enters anxious and leaves reassured, the doctor's time was not wasted.

Sometimes, but less often nowadays, a patient may present with what he regards as an acceptable opening gambit such as a cold, although the doctor may think otherwise, but really he wants to discuss his erectile dysfunction or fear of cancer. This is usually introduced with, "While I'm here doctor." Life would be simpler if they did not waste the first 5 minutes but came straight to the point.

The consultation is an opportunity to explore the patient's needs and expectations and to educate, and all this inside 8½ minutes (1 minute for patient changeover, 30 seconds for hand-washing). Deciding what can safely be omitted for each patient as the consultation is truncated from an hour to 10 minutes and what must be included is a matter at great art and skill. Such matters as the patient's real agenda and health promotion within the consultation are discussed in the article on consultation analysis.

Certain presentations are so common that the doctor should have a protocol to follow for such consultations. This includes presentations of chest pain, breathlessness, dysuria, vaginal discharge and abdominal pain. It is focused and efficient. There are standard questions for rheumatology conditions or wheezing in children or diagnosing asthma in adults.

In recent years, nurses have shown themselves able to provide a great range of safe care by following protocols. Doctors sometimes deride protocols as "painting by numbers". Much of clinical work is following protocols, even if subconsciously. Protocols are a swift, efficient and effective way to cover the ground with risk management in that they reduce the chance of forgetting or overlooking something important. Doctors need to embrace protocols and to engage in their formulation and implementation.

Patients assume that the doctor has their medical records and is fully conversant with their past medical history. Although major events should be displayed on the screen some may be incomplete and it is worth checking both for completeness and to assure the patient of one's thoroughness. The habitual loss of medical records means that most records are of remarkably short duration. As mentioned above, unless you are familiar with the patient, it is worth looking at past history and recent consultations before the patient enters.

Patients also assume that their family doctor is aware of their family history. Many conditions do have a genetic component, including coronary heart disease, diabetes, atopic eczema, autoimmune disease and some cancers. Obesity is far more environmental rather than genetic but runs in families because they eat together and develop common attitudes to food. Patients may need reassurance that diseases such as schizophrenia, Alzheimer's and Parkinson's disease do not have a significant genetic component. The fact that a family member had a disease makes the patient more aware of it and more likely to be concerned about contracting it.

Similarly, patients assume that their doctor knows their social situation. It may be relevant such as the middle-aged spinster caring for disabled and demanding parents, the single mother with a handicapped child or the child with asthma who lives in a smoky, damp and overcrowded environment. Occupation may be very relevant to the aetiology of the disease and its management. It also indicates the person's level of education and hence ability to comprehend certain issues.

Note current medication. Drugs may contribute to the current problem or influence choice of medication for it. The constipated patient may be taking co-codamol. The computer will record if medication is over or underused and the date of last issue. Enquire about OTC remedies and possible herbal or other treatments. The latter are just as likely as POMs to have toxic effects or drug interactions, perhaps more so as they have not be so thoroughly tested.

Note the health template on the screen. It should be complete and reasonably contemporary. Just mentioning smoking, alcohol consumption or BMI will remind the patient and make him think about the issue. Health promotion may also affect your practice's performance under the Quality and Outcomes Framework.

Examination needs to be as focused as history. Try to learn and apply good technique. Quite simply, good technique is more likely to give a correct result than poor technique. The yield from examining systems that are not obviously relevant is too low to justify in such limited time.

The first part of any examination is to observe. Learn to observe. Look before you lay on hands. Examination of the cardiovascular or respiratory systems does not start with the stethoscope.

The doctor should have a protocol for each system. Many forms of examination have their own dedicated article. All general practitioners should have competence in:

• Examination of the cardiovascular system, including auscultation of the heart
• Examination of the respiratory system
• Examination of the abdomen
• Checking for hernia and lumps in the groin and scrotum
• Examining lumps
• Neurological history and examination
• Competence at orthopaedic examination should include back examination, the knee history and examination, shoulder examination, hip history and examination and assessment of ankle injuries.
• Examination of tender, hot swollen joints
• Gynaecological history and examination
• Breast lumps and examination
• Peripheral pulses
• ENT examination
• Mental state examination

The ophthalmoscope is a difficult instrument to master. Attending a few ophthalmology clinics may be useful but most of all, use it and eventually you will become proficient. Become proficient with the otoscope too.

In the 1980s, handing over a prescription indicated the end of the consultation. Nowadays you are expected to discuss the illness and options for treatment with the patient. Management is more than just a prescription. It includes health education and advice. This is not simply a move away from paternalism but aids compliance and may reduce unnecessary attendance. Twin-tray laser printers enable printed PILs to be given to the patient to take away.

In the 1950s history, examination and medication seldom exceeded one line of Lloyd George records. Be concise but do not skimp. Record thoughts such as "could be psychosomatic" or "may need endoscopy" and plans such as "if not better soon, refer". The notes may be a useful tool for yourself later or for someone else but they may also be subject to scrutiny in the case of complaint or litigation. The quality of notes can be fundamental to the defensibility of a case.

Never record derogatory statements that would cause embarrassment if the patient were to read them or they were to be read out in a formal situation but do not avoid factual statements such as "smells of urine". Patients now have right of access to their notes.

Use abbreviations, but only those that other doctors would readily recognise.

Poor keyboard skills may tempt some to be more brief when moving from paper to electronic records. Avoid the temptation. Typing errors are easily corrected but even if missed they are more comprehensible that neat doctor's handwriting, and not all doctors have neat writing.