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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?”