Rather than sitting across the table from the patient, arrange for the patient and yourself to sit either side of one corner. This way means there is no barrier to communication and you will more easily be able to observe signs.
With young children, leave the child on the mother’s lap. Ask the mother to undress them so you can look at the breathing, count the breathing rate and pulse or examine the abdomen. In this way the child is more likely to feel secure and not cry which makes the examination much more easy. Leave unpopular actions like looking in the ears to the end of the examination.
Good communication skills are essential for making a correct diagnosis, and for explanation or counselling on the illness, its treatment and prevention of future illness.
Open questions: are those with no fixed answer and the patient can therefore answer the question in his/her own way. Always start taking a history by using open questions and only move onto more closed questions later.
Closed questions: are phrased very specifically and require a ‘yes’ or ‘no’ answer. If they are used at the beginning of an interview patients tend to answer quickly without thinking, and say what they think you want to hear. Only use specific closed questions later in the consultation if the patient hasn’t already mentioned something. Eg. In a patient with diarrhoea, ask ‘Is there blood in the stool?’
Leading questions: are phrased in such a way that leads the patient to give a particular answer. Therefore avoid them as they can result in misleading information.
Eg. If you ask a leading question, such as ‘You have been coughing for more than 3 weeks?’ the patient may answer quickly without proper consideration and not give the correct ‘yes’ or ‘no’ answer.
The ‘Golden Minute’
This first period of contact with the patient (which may be less than half a minute) is the key first stage of any primary care consultation and includes:
Asking the patient about the presenting problem
Listening to the patient’s interpretation of this
Allowing the patient to express any fears about the cause of the illness
When asking about the presenting problem, give the patient time to tell you about the symptoms they have.
Do not interrupt to ask questions about specific symptoms yet - but encourage them to tell you more about the presenting and other problems they have. Often, when given the chance, the patient will tell you the symptoms you need to know about, eg. the duration of the symptom, the characteristics, such as whether a chest pain is sharp or tight. They may tell you some of the other key symptoms such as "hot body" (fever).
It is also important for the patient that you hear and know about their interpretation of the cause of the illness and their fears about what is going to happen. This helps them ‘get off their chest’ the ideas about the cause of the symptoms (such as HIV, cancer, witchcraft, etc) which they may have been discussing with family and friends before coming to the health centre. This is so that they know you will take these interpretations into account in your assessment.
Also, later you can explain your diagnosis and treatment in the light of the pat ient’s own level of understanding and you may be able to reassure them about (false) interpretations of the cause.
