First class notes

Chapter 1

The History and Interviewing Process

The history and physical examination begin, and are at the heart of, the diagnostic and treatment
process.

The techniques you will learn are orderly but are not rigid.

To prevent misinterpretations and misperceptions, you must make every effort to sense the world of
the patient as that patient sees it.

Goals

Discover information leading to diagnosis and management.

Provide information about diagnosis.

Negotiate and share in health care management.

Counsel about disease prevention.

The Ethical Context

Autonomy

Patient’s self-determination

Beneficence

Do good for the patient.

Nonmaleficence

Do no harm to the patient.

The Ethical Context (Cont.)

Utilitarianism

Appropriate use of resources for the greater good

Fairness and justice

Equitable treatment of all

Deontologic imperatives

Care delivered according to traditions and in cultural contexts

Effective Communication

Factors That Enhance Communication

Establishing a positive patient relationship depends on communication built on:

Courtesy

Comfort

Connection

Confirmation

Confidentiality

Enhancing Patient Responses

Open-ended question

Allows patient discretion about the extent of an answer

Direct question

Seeks specific information

Leading question

May limit the information provided to what the patient thinks you want to know

Enhancing Patient Responses (Cont.)

If the patient does not understand what you are asking, remember to:

Facilitate: Encourage your patient to say more.

Reflect: Repeat what you have heard.

Clarify:Ask “What do you mean?”

Empathize: Show understanding and acceptance.

Confront: Address disturbing patient behavior.

Interpret: Repeat what you have heard to confirm the patient’s meaning.

Communication Tensions

Curiosity about you

Anxiety

Silence

Depression

Crying

Physical intimacy

Emotional intimacy

Seduction
Anger

Avoidance

Financial considerations

Language

The History

Taking the history usually begins your relationship with the patient.

Setting for the Interview

Comfort for all involved

Removal of physical barriers

Good lighting

Privacy

Relative quiet

Unobtrusive access to clock

The Patient History

Identify those matters the patient defines as problems.

Establish a sense of the patient’s reliability.

Consider the potential for intentional or unintentional suppression or underreporting of information.

Remain in a constant state of subjective evaluation of the patient’s words and behaviors.

Adapt to the modifications that age, pregnancy, and physical and emotional handicaps mandate.

Structure of the History

The identifiers: name, date, time, age, gender, race, occupation, and referral source

Chief concern

History of present illness (HPI)

Past medical history (PMH)

Family history (FH)

Personal and social history (SH)

Review of systems (ROS)

Building the History

Introduce yourself.
Address patient properly.

Be courteous.

Make eye contact.

Do not overtire patient.

Do not be judgmental.

Be flexible.

Building the History (Cont.)

Avoid medical jargon.

Take notes sparingly.

Avoid leading questions.

Start with general concerns, then move to specific descriptions.

Clarify responses with where, when, what, 
 how, and why questions.

Verify and summarize what you have heard.

Approaching Sensitive Issues

Use language that is understandable.

Do not apologize for broaching the issue.

Ensure privacy.

Be direct and firm.

Do not preach.

Do not push too hard.

Sensitive Issues

Alcohol and drug use

Domestic violence

Spirituality

Sexuality

Alcohol

The CAGE questionnaire was developed in 1984 by Dr. John Ewing, and it includes four interview
questions designed to help diagnose alcoholism. The acronym “CAGE” helps practitioners
quickly recall the main concepts of the four questions (Cutting down, Annoyance by criticism,
Guilty feeling, Eye-openers).
Probing questions may be asked as follow-up questions to the CAGE questionnaire.

Alcohol (Cont.)

TACE questionnaire

T–How many drinks does it Take to make you feel high?

A–Have people Annoyed you by criticizing your drinking?

C–Have you felt you ought to Cut down on your drinking?

E–Have you ever had an Eye-opener drink first thing in the morning to steady your nerves or
get rid of a hangover?

Alcohol (Cont.)

The CRAFFT questionnaire was developed in 2002 as a screening tool for alcohol and substance
abuse in adolescents. The CRAFFT acronym helps practitioners remember the main concepts
of the six questions: Car, Relax, Alone, Forget, Friends, Trouble.

Screening vs. Assessment

There is a difference between a screening and an assessment interview.

The goal of screening is to find out if a problem exists.

This is particularly true of CAGE, CRAFFT, and TACE questionnaires.

They are effective, but they are only the start, and assessment goes on from there.

Domestic Violence

About 94% of reported victims of domestic abuse are women.

They come from every ethnic and socioeconomic group.

Domestic Violence (Cont.)

Three questions comprise a brief screening instrument to detect partner violence.

Have you ever been hit, kicked, punched, or otherwise hurt by someone within the past year?

Do you feel safe in your current relationship?

Is there a partner from a previous relationship who is making you feel unsafe now?

Domestic Violence: HITS

Verbal abuse is as intense a problem as physical violence.

The wording of the question is “In the last year how often did your partner:

Hurt you physically?”

Insult or talk down to you?”

Threaten you with physical harm?”

 Scream or curse at you?”

Spirituality

Many patients want attention paid to spirituality.

Faith can be a key factor in the success of a management plan.

Some patients may prefer that you not breach the subject.

The acronym FICA can be used as an approach.

Spirituality: FICA

Faith, belief, meaning

What is your spiritual heritage? What writings are important to you? Do these beliefs help you
cope with stress?

Importance and influence

How have these beliefs influenced how you handle stress? To what extent?

Community

Do you belong to a formal spiritual or religious community?

Address/action in care

How do your religious beliefs affect your health care decisions? How would you like me to
support you in this regard when your health is involved?

Sexuality

The sexual orientation of a patient must be known if appropriate continuity of care is to be offered.

About 10% of the persons you serve are likely to be other than heterosexual.

Trust can be better achieved if questions are “gender neutral.”

Tell me about your living situation.

Are you sexually active? In what way?

Outline of the History

Chief concern (CC) or the reason for seeking care

History of present illness or problem (HPI)

Past medical history (PMH)

Family history (FH)

Personal and social history (PSH)

Review of systems (ROS)

Chief Concern
Note all significant complaints.

Seek answer to the question “What underlying problems or symptoms brought you here?”

Determine the duration of the current illness by asking “How long has this problem been present?”

 Or “When did these symptoms begin?”

Note age, gender, marital status, occupation, and previous hospital admissions.

History of Present Illness:
 Explore the following

Chronology of events

Health state before present problem

First symptoms

Exposure to infection or toxic agents

Typical attack

Illness impact on lifestyle

Stability of problem

Immediate reason for visit

Review of involved systems

Medications list

Complementary or alternative therapies

Chronology review

Problem list

Past Medical History:
 Explore the following

Past medications

Allergies (drugs, environment, food)

Past transfusions

Recent screening tests

Emotional status

General health

Childhood illnesses

Major adult illnesses

Immunizations

Surgery

Serious injuries and resulting disability

Functional ability limitations

Family History:
 Explore the following

Blood relatives with illness similar to the patient’s illness

Blood relatives with history of major disease

Determine if any cancers have been multiple, bilateral, occurred more than once in the family, and
occurred at a young age (less than 50 years).

Note the age and outcome of any illness.

Family History:
 Explore the following (Cont.)

Note the ethnic and racial background of the family.

Note the age and health of the patient’s spouse/partner or the child’s parents.

A pedigree diagram helps illustrate the family members with a disorder.

There should be at least three generations for the pedigree.

Personal and Social History:
 Explore the following

Personal status

Habits

Sexual history

Home conditions

Occupation

Environment

Military record

Religious preference

Access to care

Review of Systems:
 Explore the following

General constitutional symptoms

Skin, hair, and nails

Head and neck

Lymph nodes

Chest and lungs

Breasts

Heart and blood vessels

Peripheral vascular
Hematologic

Gastrointestinal

Diet

Review of Systems: 
 Explore the following (Cont.)

Endocrine

Female

Male

Genitourinary

Musculoskeletal

Neurologic

Psychiatric

Concluding questions

General Constitutional Symptoms

Fever

Chills

Malaise

Fatigability

Night sweats

Sleep patterns

Weight

Average

Preferred

Present

Change

Skin, Hair, and Nails

Rash, eruption, itching

Pigmentation or texture change

Excessive sweating

Abnormal nail or hair growth

Head and Neck: General

Headaches

Dizziness

Syncope

Head injuries

Loss of consciousness

Head and Neck: Eyes

Acuity

Blurring

Diplopia

Photophobia

Pain

Vision changes

Glaucoma

Eye medications

Trauma

Head and Neck: Ears

Hearing loss

Pain

Discharge

Tinnitus

Vertigo

Head and Neck: Nose

Sense of smell

Colds

Obstruction

Epistaxis

Postnasal discharge

Sinus pain

Head and Neck: Throat and Mouth

Hoarseness or change in voice

Sore throats

Bleeding gums

Tooth abscesses, extractions

Soreness or ulcers of tongue/mucosa

Taste changes

Lymph Nodes

Enlargement

Tenderness

Suppuration

Chest and Lungs

Pain

Dyspnea

Cyanosis

Wheezing

Cough

Sputum

Hemoptysis

Night sweats

Exposure to tuberculosis

Last chest radiograph

Breasts

Development

Pain

Tenderness

Discharge

Lumps

Galactorrhea

Mammograms

Screening

Diagnostic
Self-awareness

Self-examination

Heart and Blood Vessels

Chest pain

Palpitations

Dyspnea

Orthopnea

Edema

Claudication

Hypertension

Previous myocardial infarction

Exercise tolerance

Date of last electrocardiogram

Other cardiac tests

Peripheral Vascular

Claudication

Frequency

Severity

Tendency to bruise or bleed

Thromboses

Thrombophlebitis

Hematologic

Anemia

Blood cell abnormalities

Past transfusions

Gastrointestinal

Appetite

Digestion

Food intolerances

Dysphagia
Heartburn

Nausea/vomiting

Hematemesis

Regularity of bowels

Constipation

Diarrhea

Change in stools

Hemorrhoids

Jaundice

Previous imaging studies

Diet

Appetite

Likes and dislikes

Diet restrictions, cultural constraints

Vitamins and other supplements

Caffeine

Dietary recall

Endocrine: General

Thyroid enlargement or tenderness

Heat/cold intolerance

Weight change

Diabetes

Polydipsia

Polyuria

Changes in facial or body hair

Increased hat or 
 glove size

Skin striae

Endocrine: Female and Male

Female:

Menses
 Discharge, itching

Last Pap smear

Libido, intercourse

Birth control

Infertility, pregnancy

Menopause

Male:

Puberty onset

Erections

Emissions

Testicular pain

Libido

Infertility

Genitourinary

Sexually transmitted infections

Dysuria

Pain

Urgency

Frequency

Nocturia

Hematuria

Polyuria

Hesitancy

Dribbling

Loss in force of stream

Passage of stone

Edema of face

Stress incontinence

Hernias

Musculoskeletal
Joint stiffness, pain

Restriction of motion

Swelling, redness, heat

Bony deformity

Neurologic

Syncope

Seizures

Weakness or paralysis

Abnormalities of sensation or coordination

Tremors

Loss of memory

Psychiatric

Depression

Mood changes

Difficulty concentrating

Nervousness

Tension

Suicidal thoughts

Irritability

Sleep disturbances

Concluding History Questions

Is there anything else that you think would be important for me to know?

What problem concerns you most?

What do you think is the matter with you?

What worries you the most about how you are feeling?

Adaptations for Age, Gender, and Handicaps

Children

Pay attention to them (place equal emphasis on the child and on the accompanying adult).

Glean clues about family dynamics.

Be sensitive to their needs.

Play with them.

Children: Explore following issues

Mother’s gestational history, pregnancy, and birth

Child’s neonatal period, feeding, and developmental milestones

Child’s school adjustment, habits, and home conditions

Review systems for child-specific conditions.

Adolescents

Respect need for confidentiality.

Respect impending adult status.

Do not force conversation.

Establish an alliance.

Be flexible in approach.

Adolescents (Cont.)

Factors impacting history taking

Self-esteem, acceptance by peers, tension with parents

Cover issues of special concern.

(Hint: Use mnemonic HEEADSSS or PACES to zero in on issues.)

Adolescents: Explore following issues

HEEADSSS

Home environment

Education

Eating

Activities, affect, ambitions, anger

Drugs

Sexuality

Suicide/depression

Safety

PACES

Parents, peers
 Accidents, alcohol/drugs

Cigarettes

Emotional issues

School, sexuality

Pregnant Women

Consider health needs of mother and fetus.

Explore effects of pregnancy on health status.

Use interview as time for teaching health care practices.

Pregnant Women: Explore following issues

Current pregnancy and obstetric history

Exposure to environmental/occupational hazards

Family genetic conditions/congenital abnormalities

Personal and social issues of pregnancy and parenting

Reproductive, cardiovascular, endocrine, respiratory system focus

Risk factors that threaten mother and fetus

Older Adults

Watch for age-related changes that may impede interview.

Sensory loss, visual impairment, cognitive impairment, or memory loss

Draw on person’s cumulative lifetime experience, wisdom, and perspective.

Older Adults: Explore following issues

Multiple overlapping health problems

Chronic symptoms

Complete drug assessment

Assessment of functional capacity

Patients With Disabilities

Adapt interview approach to fit needs.

Involve the patient to the limit of emotional, mental, and physical abilities.

Family members are often available to make the patient more comfortable and provide further
information.

Types of Histories
A “complete” history is not always necessary.

You may know the patient well and be considering the same problem over time.

Adjust your approach to the need at the moment.

Types of Histories (Cont.)

Complete history

Most often recorded the first time you see the patient

Inventory history

Related to but does not replace the complete history

Touches on major points without complete detail

Entire history will be completed in more than one session

Types of Histories (Cont.)

Problem (or focused) history

Taken when a problem is acute so that only the need of the moment is given full attention

Interim history

Designed to chronicle events that have occurred since your last meeting with the patient

Substance determined by nature of problem and need of the moment

Should always be complemented by the patient’s previous medical record

The Next Step

Physical examination

The laying on of hands

Question 1

A health history that is designed to chronicle events that have occurred since the patient’s last visit is
called a:


A. Interim history

B. Problem history

C. Inventory history

D. Complete history

Question 2

The CAGE screening test for alcoholism is suggestive of the disease if there are two positive
responses. What does the A stand for?


A. Annoyance by criticism
B. Alcohol in the AM

C. Abnormal drinking habits

D. Alert after excessive alcohol

Question 3

The chief concern:


A. Requires step-by-step evaluation of the circumstances

B. Explores the patient’s overall health

C. Is a statement about why the patient is seeking care

D. Is a detailed inquiry of possible concerns

Question 4

The history of present illness includes which of the following:


A. Unique concerns that explain the prevention needed

B. Presence or absence of health-related issues

C. Chronologic ordering of events

D. General health and strength

Question 5

Which of the following is initially appropriate in the management of a patient’s diagnosed problem?


A. Inform the patient of the treatment plan.

B. Give the patient detailed written instructions regarding the treatment plan.

C. Inform the patient that the plan has been tailored to his or her needs.

D. Inform the patient of treatment options and possible results.

Question 6

Which question would be considered a “leading question”?


A. “What do you think is causing your headaches?”

B. “You don’t get headaches often, do you?”

C. “On a scale of 1 to 10, how would you rate the severity of your headaches?”

D. “At what time of the day are your headaches the most severe?”