Clinician: If it's OK then, I'd like to shift gears and ask you some different types of questions about your headaches and colitis. I'll be asking a lot more questions about specifics.
Patient: Sure, that's what I came in for.
Clinician: I know the headache is the biggest problem now (chief concern). [The clinician will now elicit the descriptors of the symptom, recognizing that some were heard in Steps 3 and 4. If, however, the clinician somehow had not yet heard about the headache and other physical problems (because the patient expressed a pressing personal concern in the beginning of the interview), he would first obtain a detailed description in the patient's own words.]
Patient: Yeah, it sure is.
Clinician: When exactly did it begin? [The interviewer wants to reaffirm the time frame of the headaches and uses a closed-ended question.]
Patient: Oh, just a few weeks after I got here. That's about 4 months ago now, so the headaches have been about 3 months. [Time of onset]
Clinician: How long does each headache last, the shortest and the longest they might last?
Patient: At least a couple hours. When they get bad, they'll last up to 12 hours or so. [Further characterizing the onset and chronology by identifying the duration]
Clinician: What happens to the symptom when it's there?
Patient: Well, it's not so bad at first but it just keeps getting worse and then the nausea comes. [Time course of symptom]
Clinician: How many do you have in a week or a month?
Patient: I can have 2 to 3 a week when they're bad. You know, every 2 to 3 days. [Symptom periodicity and frequency]
Clinician: How long have they been that often?
Patient: Since things got bad in the last month, especially the last couple of weeks. Before that they were only once or twice a week. [Total number can be calculated if important]
Clinician: You said the headache was in the right temple; can you point to it for me? [Having gotten a good story of the onset and chronology, the interviewer shifts to understanding the position (location), referring to the patient's description of the headache location in the beginning of the interview.]
Patient: (puts hand over much of right side of head) It's all over here, sometimes larger than others. [Sounds more diffuse than specifically in one location]
Clinician: Is it always in the same spot? [The clinician asks a closed-ended question, focusing away from the personal dimension and on the symptom itself, now getting the precise position.]
Clinician: Does it move any place else? [Another of what will be many closed-ended questions as the clinician asks about radiation, another descriptor of the symptom. Note that the clinician is introducing new topics and is also leading the conversation, appropriate for the middle of the interview.]
Patient: No, it stays right there. [No radiation]
Clinician: Does it feel like it's inside your head or outside on the surface; you know, does it hurt to comb your hair or touch it?
Patient: No, it doesn't hurt to touch it. It's down inside I think. [A deep rather than superficial pain]
Clinician: Could you give me a description of what it feels like; such as aching, burning, or however you'd describe it. [It's appropriate to give examples, if necessary, but provide more than one, with no particular emphasis, so as not to influence the patient.]
Patient: Oh, it's more throbbing or pounding, like you feel each pulse beat. [Quality of the pain identified, and the patient offers no bizarre description]
Clinician: How do they begin, gradually or all of a sudden?
Patient: Oh, pretty much out of the blue. [Onset is sudden]
Clinician: Now I want to get an idea of how severe these headaches are. On a scale of 1 to 10, with 1 being no pain and 10 being the worst pain you can imagine, like labor pains, what number would you give these headaches?
Patient: Well, they're sometimes worse than having a baby! I'd give them a 10, especially when they get bad. And I've missed work a few days but not very often. [Quantifying the intensity and noting some disability]
Clinician: They sound pretty bad. You've really had a lot of trouble with this! [A respect statement. Empathic comments and behaviors are used during the middle of the interview.]
Patient: You're telling me!
Clinician: Do you know of anything that brings them on? [The clinician asks about precipitating factors. He is not inquiring about the setting because he already knows that from the beginning of the interview.]
Patient: Well, just what I've told you, getting upset. Once or twice it seemed like having some wine did it but I was stressed then too. [Perhaps another precipitant]
Clinician: Anything that worsens them once they've begun?
Patient: No, they're bad enough already! Well, bright lights sure do, now that I think about it. [A transforming (aggravating) factor identified]
Clinician: They sure have been bad. What seems to help them once they occur?
Patient: Just lying down in a dark room, and an ice bag on my head. Well, the narcotic shot they gave me in the emergency room took it away too. [Another transforming (relieving) factor elicited. Also, secondary data, the narcotic and the emergency room visit, are introduced by the patient.]
Clinician: What about the nausea? When did it start? [With a full description of the headache symptom, the clinician is moving now to better define a related symptom, staying with primary data for the moment. Notice that a non-pain symptom has fewer appropriate descriptors; for example, one usually does not try to identify location or radiation of nausea.]
Patient: I've had it for about 2 months now, just when the headaches are bad.
Clinician: Help me understand better what the nausea is like. [A focused open-ended request]
Patient: Like I'm sick to my stomach and could vomit if it got worse. [Quality of nausea]
Clinician: And how does it begin? [A closed-ended question, as many of the subsequent inquiries will be]
Patient: Oh, it just kind of gradually comes on after the pain has been there awhile. [Gradual Onset]
Clinician: How bad is it, how severe?
Patient: It's minor compared to the pain. It's never really been the problem the pain is. [Not very severe or disabling]
Clinician: How often does the nausea occur?
Patient: Just when the pain gets bad. I've probably had it each time with the headache in the last month; that's when the pain has been worse. [Number of episodes identified]
Clinician: You said this began about a month after the pain, so that means the nausea has been there about 2 months? [Ms. Jones has previously indicated the time of Onset]
Patient: Yeah, but it's been worse in the last month.
Clinician: How long does the nausea last once it begins?
Patient: Oh, about a couple hours, when the headache finally goes away. [Duration of nausea and Transforming (relieving) factor]
Clinician: Anything else that relieves it?
Patient: Not that I know. I tried some antacid but it made me worse. [Other Transforming (aggravating and relieving) factors explored. Secondary data also introduced (antacid).]
Clinician: And what's the time between each episode?
Patient: Same as the headaches, you know, every couple of days. [Intervals identified. Chronology of symptom and setting also can be inferred from what Ms. Jones has said already since the nausea is linked to headaches.]
Clinician: Ever throw up with them?
Patient: Just once. That's when I went to emergency. [Related symptom]
Clinician: How much did you vomit?
Patient: Oh, just enough to soak a hankie. [The clinician has obtained pertinent descriptions of the nausea and now has discovered another symptom, vomiting, which would now be similarly explored. It can take considerable time to obtain appropriate details of each symptom for complicated patients.]
Clinician/Patient: [Not recounted here, the clinician and patient now develop details of the patient's vomiting and cough. As you gain experience, you will recognize that the headache, nausea, and vomiting go together. This allows you to develop the symptoms simultaneously and avoid repetition.]
Clinician: It sounds like you went to the emergency room once when it was bad. What's been the time course of the headaches and nausea; you know, better, worse, or about the same?
Patient: They are getting worse. They last longer and are more often in the last 2 weeks. [The overall course of the primary data is learned.]
Clinician: Have you seen anyone for them? [A good description of symptoms and their course to the present has been obtained, and the clinician is beginning to move away from symptoms to associated secondary data.]
Patient: Nobody, except the emergency room a week ago. I thought the aspirin would help.
Clinician: Have you taken anything else?
Patient: Nothing except that one shot; a narcotic of some sort I think.
Clinician: Did they do any tests on you in the emergency room?
Patient: Yeah, they did a blood count and a urine test.
Clinician: Any scans or any X-rays of your head? [Recent inquiry is aimed at understanding pertinent secondary data. Notice the repeated use of closed-ended questions to obtain a more precise description of the symptoms.]