General Considerations

The focused history and physical examination constitute a modality that is important to master to explore a patient’s needs and to educate the patient within a short period. It is a great skill and takes time to master. Only after becoming comfortable and confident with the complete history and physical examination can the clinician master the focused history and physical examination, because it relies on extracting the components that are most relevant.

It would be wonderful if clinicians were able to spend 45 minutes to 1 hour with each new patient, but time restraints generally allow the health care provider only about 10 to 15 minutes for each new patient encounter at most. Thus, taking a focused history and performing a focused physical examination are critical skills. It is extremely important to learn to become focused and efficient in documenting a medical history and in performing the physical examination, even though most medical schools do not teach these focused clinical skills.

Always start with open-ended questions and determine why the patient sought medical attention today. At some point in the interview, it would be helpful to ask the patient, “What do you think is going on?” There may be conflict or hidden anxiety, and this question may help the patient to open up to the actual problem. Let the patient speak without interruption, if possible. Always avoid leading or biased questions.

The focused history and physical examination is a complex activity comprising several different skills. It is, however, difficult to teach. Scientific knowledge must be integrated with excellent communication and hypothetical-deductive reasoning to produce a series of pertinent questions about the health of the patient.

In documenting a focused history and performing a focused physical examination, you need to explore the chief complaint, the history of the present illness, the past medical history, medications and allergies, the family history and social history, the occupational history, and the sexual history that are relevant to that specific patient. It is important to recognize that focused does not mean making one diagnosis and skipping the differential diagnosis. In the focused physical examination, you need to examine specifically the body part or system directly involved with the medical problem when there is no time to perform a head-to-toe examination. Remember, however, that other organ systems may need to be evaluated as well. A patient with chest pain requires a full cardiac examination, in addition to examination of the legs for peripheral pulses and edema, carotid artery auscultation and palpation, evaluation of liver size, and evaluation of the retina for related vascular changes.

After your clinical evaluation, tests should be obtained only to corroborate your clinical impression or if the result will in some way affect your decision-making. Remember that common things are common. Uncommon symptoms are more likely to represent an uncommon manifestation associated with a common condition than with a totally uncommon illness.

Illustrative Case