Performing a physical examination on a patient when prescribing

Thomas, Neil, Yemm, Rowan ORCID: https://orcid.org/0000-0002-4678-9532 and Hodson, Karen ORCID: https://orcid.org/0000-0002-9739-5445 2024. Performing a physical examination on a patient when prescribing. Pharmaceutical Journal 312 (7981) 10.1211/PJ.2024.1.215002

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Abstract

The main purpose of patient assessment is to gather further information to confirm or refute potential differential diagnoses, or to monitor disease progression and changes in the patient’s health condition. It incorporates physical examinations, further tests and/or investigations. This article specifically discusses the physical examination component of patient assessment. It is recommended that you read this article in conjunction with these resources from The Pharmaceutical Journal: ‘Introduction to the prescribing consultation‘; ‘Principles of effective history taking when prescribing‘; ‘Introduction to clinical assessment for prescribers‘. A consultation has been described as a process for converting a problem that the patient may present with into a plan​[1]​. This will involve initial observations and a comprehensive history. It may be possible to make a diagnosis from just these initial activities but there may also be a need to conduct further patient assessments, which may include physical examinations, further tests and/or investigations​[2]​. The information gathered at each stage of the consultation will guide the practitioner on the type and amount of patient assessments required. Practitioners need to listen to the patient and be directed to which, if any, patient assessments are required. Patient assessments also provide an opportunity to identify any ‘red flags’ in a patient, which are symptoms or characteristics that would warrant further investigation or escalation of care. Observation of the patient is important throughout the physical examination. This starts the moment the prescriber sees the patient, where they can start to assess how unwell the patient is and should continue throughout the consultation. Initially, assessment involves a thorough visual examination of the patient’s body, hands and face, including skin, posture and movement. Overall appearance and body language also provide crucial information that can aid in identifying potential health issues, abnormalities, emotional distress or mental health-related problems, or potential safeguarding concerns. Sometimes these initial observations and a few minutes spent talking to the patient may reveal care needs that should be escalated or move the consultation in an unexpected direction​[3]​. The physical examination is a unique situation in which both patient and practitioner understand that the interaction is intended to be diagnostic and therapeutic.

Item Type:	Article
Date Type:	Publication
Status:	Published
Schools:	Schools > Healthcare Sciences
ISSN:	2053-6186
Last Modified:	02 Apr 2025 15:15
URI:	https://orca.cardiff.ac.uk/id/eprint/177252

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