Historia

CLINICAL SKILLS. THE HISTORY

Apuntes. La Historia Clínica. Móduo I PROPEDÉUTICA CLINICA Y FISIOPATOLOGÍA.
Dr. José B. Moreno.


The practice of clinical medicine depends on theeffective application of the clinical skills of interviewing, history taking, physical examination, and data recording. Rational diagnosis and treatment require accurate identification and definition of apatient’s problem through the history and physical examination. Long term management involves a high level of trust and communication between the patient and the health professional.
Even the mostdramatic advances in scientific knowledge have not decreased the importance of such skills. In fact, as science has become more complex, the role of history taking and physical diagnosis has taken onan even greater importance.

Clinical skills are mastered through practice. Contact with patients should begin early and continue throughout your education. Every patient encounter offers anopportunity to develop clinical skills. Early in your training, the techniques of communication and medical interviewing can be practiced even while your knowledge of disease is limited.
Common medicalproblems can be identified and the data base defined long before you have become expert in differential diagnosis. The techniques and sequence of a basic physical examination can also be learned at anearly point in your training. Then, as your knowledge increases, more advanced techniques of physical diagnosis can be added.

The goals and content of any medical interview vary according to theneeds or problem of the patient and the specialty interest of the physician. The history can be limited to the description of a single illness or involve a lengthy discussion of the patient’s presentand past medical history. Doctors are more than just nice, interested, empathic, they are also experts in collecting and interpreting the medical history. This expertise does not just happen. It...