Medical History and Physical Examinations: Tools for early diagnosis and Means to avoid unnecessary investigations

Abstract

Background: Medical history and physical examination is one of the essential skills for clinicians. Detailed and adequate history taking and physical examination usually lead to a timely and accurate diagnosis of the disease. Depending on the acquired patient history and examination findings, physician can decide to do further investigations to confirm the initial diagnosis. The primary goal of this article is to emphasize on the importance of patient history taking and physical examination during the diagnosis stage. Material and Methods: Present study highlights the importance of patient history taking and physical examination via multiple medical cases apprehended by the author over a period of 2 years. Some systematic approaches are summarized as a means to use efficient history taking and proper physical examination as a strong tool of disease diagnosis. Finally, some common hinders and challenges regarding these two powerful tools in context of Bangladesh are discussed and some viable solutions are provided. Conclusion: If done precisely, adequate history taking and proper physical examination can certainly protect patients from the risks of unnecessary testing. Hence, this process is cost-beneficiary, which is a great plus for the people of developing countries. Accordingly, it is of paramount importance to keep proper documentation of Patient’s history and physical examination findings as well as tests and investigations done previously. Good documentation is a great resource to learn from past clinical incidents and avoid future adverse ones, hence greatly aiding in ensuring patient safety. Informative and detailed medical history along with inclusive physical examination followed by proper documentation can determine the correct diagnosis at an early stage and pave the way for an effective treatment plan.