What Ever Happened to a Good History?

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By Karen Roush, MS, RN, FNP, clinical managing editor

What ever happened to a good history? We were taught as NP students that the history portion of the exam was as important as the physical. In fact, in most cases it’s what you learn in the history—from asking the right questions and really listening to the patient’s answers—that gives you the information you need to figure out what is going on. The physical findings either support what you’re thinking or lead you to ask more specific questions.

A good history isn’t just listening to the patient’s answers to your questions; it’s listening to all the information they offer. Take for example, the middle-aged construction worker who takes his lunch hour to come in to the clinic complaining of a cold. He lists the usual symptoms, cough, fatigue, a little shortness of breath, and then as you’re starting the exam he casually mentions that he hasn’t been to a doctor in 15 years.

Someone who’s managed to stay out of a doctor’s office for 15 years and now shows up, on his lunch hour, because of a simple cold? So, you ask some more questions and learn about some chest pressure he attributes to the coughing he’s been doing and about […]