Chapter 5. The Middle of the Interview: Clinician-Centered Interviewing

Give each patient enough of your time. Sit down; listen; ask thoughtful questions; examine carefully. … Be appropriately critical of what you read or hear. … Follow the example set by William Osler: ‘Do the kind thing and do it first.’

Paul Beeson, MD

This chapter describes the steps involved in conducting the middle of the interview using clinician-centered interviewing skills. This part of the interview includes the latter part of the history of the present illness (HPI) and other active problems (OAP), continuing directly from the patient-centered HPI, and the past medical history (PMH), social history (SH), family history (FH), and review of systems (ROS).

Recall our progress to this point. During the beginning of the interview you used patient-centered interviewing skills to begin eliciting the HPI (Steps 1–5): you set the stage; obtained the chief concern and agenda; drew out the Symptom Story, Personal Context and Emotional Context; and made a transition to the middle of the interview, the point where we now find ourselves. There are five additional steps (Steps 6–10) in the middle of the interview, as shown in Figure 5-1. To illustrate each step, we will continue to follow Mrs. Jones.

Step 6 (Table 5-1) is the most important and most challenging part of the middle of the interview. The goal here is for you to develop and clarify the symptoms and secondary data that pertain to the patient's symptom story. By the end of this step, you often will be able to make a disease diagnosis or, if not, you can greatly narrow the range of possible disease explanations for the symptom(s). This will guide what to most carefully look for during the physical examination and the subsequent laboratory evaluation, if any. The companion video available on the McGraw-Hill website (http://www.mhprofessional.com/patient-centered-interviewing) demonstrates what we will now describe. Module 8 in doc.com provides additional information about developing and clarifying the patient's HPI.1

In almost all instances, you will have obtained a satisfactory overview of the HPI during Steps 2–4 but sometimes the patient's description of the personal or emotional context of the symptom was urgent enough that you will not have gotten a good symptom description in Step 4. If this is the case, you can begin Step 6 by obtaining an overview of the major symptoms, when they began, and the most pressing current issue, using both open- and closed-ended skills. The problem usually, but not always, will concern physical symptoms.

Otherwise, as presented in Chapter 4, begin by converting each of the patient's concerns to a standard symptom and further clarify it according to the seven descriptors (OPQQRST: onset and chronology, position and radiation, quality, quantification, related symptoms, setting, and transforming factors [aggravating/alleviating]). You will also need to know what other symptoms occurred before, during, or after the symptom under discussion.

As you talk with patients, you may begin to have ideas about what is causing the patient's problems, and how the symptoms may be affecting physical functioning or activities of daily life. These ideas are known as “hypotheses” and the process of asking questions that make them more or less likely is called hypothesis testing. When you first learn how to interview patients, focus on first collecting as much data as you need to comprehensively describe the patient's problem(s). Beginners often need to postpone hypothesis testing to a second interview after they have had time to read about the problems that have been described.2–4 As you become experienced and learn more about specific diseases and conditions, you will become faster, more efficient, and more accurate at gathering data and will learn to recognize patterns in the patient's story that suggest certain diagnoses.5 Chest pain, for example, has well over 20 possible disease causes, such as, angina pectoris, myocardial infarction, pericarditis, esophagitis, pneumonia, pleurisy, pulmonary embolus, costochondritis, and rib fracture. Each diagnosis has unique symptom and other diagnostic features and, often, different related symptom patterns. In the meantime, just ask the questions that will help you comprehensively describe the patient's symptoms.

As a beginning interviewer, you can still test hypotheses during the interview but comprehensive questioning gives you data from which you can generate better and more hypotheses.2 Comprehensively question only in relevant areas, do not ask the same questions of every patient, and do not simply elicit all known symptoms from the entire ROS.2 As you acquire clinical experience and your knowledge base grows, hypothesis testing will become more prominent and comprehensive questioning will be less necessary. Nevertheless, even seasoned clinicians use comprehensive questioning in challenging cases when hypothesis testing is ineffective.2

Preclinical and beginning clinical students can generate a surprisingly relevant data base with the purely “descriptive” or comprehensive questioning approach. We will explore this in more depth next and then briefly consider how the more advanced clinical student integrates the hypothesis-testing approach.

Obtaining and Describing Data Without Interpreting It—for Preclinical and Beginning Clinical Students

For beginning students, Step 6 begins with two parts: A. Expand the description of symptoms already introduced by the patient and B. Inquire about symptoms not yet introduced that are located in the same body system.

A: Expand the Description of Symptoms Already Introduced by the Patient

Begin with the patient's most important problem and identify all symptoms and secondary data starting from the onset of the concern. Group the concerns by common times of occurrence, translate each into a symptom, and then refine each symptom using the seven descriptors (see Chapter 4). At times, it is easier to first obtain the patient's symptoms, and then fill in the secondary data (see Chapter 4). In either case, make use of repeated queries for temporal connections such as, “Then what?” or “What happened after that?” or “And then?” The patient sometimes will not introduce secondary data and so you must ask about prior treatment, procedures, diagnoses, and other secondary information. Alternatively, the patient may present a host of secondary data from which you must sift out the symptoms. For example, a patient might say, “This chest pain and shortness of breath occurred before my heart catheterization but after they found my cholesterol and blood sugar to be increased; that was when I was in the hospital last October for coughing up blood.” Here, the clinician must recognize the primary data (chest pain, shortness of breath, and hemoptysis) and not confuse them with the secondary data (heart catheterization, cholesterol, blood sugar, hospitalization).

Seek to understand the temporal (time) course of all data, using calendar dates and exact times when possible, and always for recent or acute problems. More remote problems often can be marked by weeks, months, or even years.

As you will see in the next vignette, the clinician uses closed-ended questions to elicit most information and offers periodic supportive remarks, maintaining a patient-centered atmosphere of warmth and understanding.

Continuation of Mrs. Jones Visit (from Chapter 3)

B: Inquire About Symptoms Not Yet Introduced that Are Located in the Same Body System(s) (and General Health Symptoms)

Until this point, the interviewer has addressed symptoms (and related secondary data) volunteered by the patient but there often are other symptoms (“related symptoms” from Chapter 4) that have not been mentioned, which either by their presence or absence are pertinent to making a diagnosis; the absence of a symptom can be just as diagnostically important as its presence. The clinician thus needs to develop a more complete profile of the patient's problem(s).

You can often assume that symptoms in the same system are related to the same underlying disease process. You know what the patient's major concerns are and can therefore identify the body system likely involved if disease is present. At this point, from the ROS, ask the questions under the involved system heading; for example, a patient with urinary hesitancy and increased urinary frequency usually (but not always) has a disease in the urinary system and so you would use closed-ended questions to inquire about the symptoms under that heading in the ROS (dysuria, nocturia, urgency, hematuria, particulate matter in the urine, and so on until you comprehensively questioned about all possible symptoms under the urinary system heading of the ROS). At times, however, a symptom can suggest more than one system as a source of disease; for example, shoulder pain can indicate disease in the musculoskeletal system (rotator cuff injury), gastrointestinal system (cholecystitis) or the cardiopulmonary system (angina). In this case, you would inquire about all possible musculoskeletal, cardiopulmonary and gastrointestinal symptoms (joint swelling, hemoptysis, orthopnea, vomiting, diarrhea, and so on).

Questioning in this way often uncovers symptoms the patient may have forgotten or not thought important, and can at times provide crucial diagnostic information; for example, in the preceding patient with urinary concerns, discovering the periodic presence of particulate matter in the urine in association with bloody urine suggests renal calculi. Frequently, however, the patient will deny most symptoms on the list, this is also diagnostically important; for example, the absence of gross hematuria in this patient would weigh against renal calculi as well as some bladder or renal diseases.

Inquiring about symptoms of general health (see the review of systems) fills out the symptom profile. Ask about appetite, weight, general feeling of well being, pain, and fever in most patients, whatever system their symptoms reside in. Many diseases, especially more serious ones, exhibit one or more of these general symptoms. In our vignette, the clinician relies predominantly on closed-ended questions, and continues to intersperse supportive remarks.

Continuation of Mrs. Jones Visit

With experience, you will base the extent of this review of systems upon clinical acumen, and it almost always can be considerably shortened; for example, an experienced clinician might be comfortable already with a diagnosis of migraine and inquire only about “Have you ever had a stroke? Head injury? Recent fevers?” For beginning students, however, systematically going through all the possibilities is the best way to learn them.

Interpreting Data While Obtaining It: Testing Hypotheses About the Possible Disease Meaning of Symptoms—for Clinical Students and Graduates

From the gathering/describing interview, you now have a complete profile and chronology of symptoms. But, you have not interpreted or grouped them in a way that points to specific diseases that could cause them. Just recounting symptoms usually does not identify a disease. Nor have you accounted for potentially significant symptoms in other systems. Inquiring about all symptoms outside the involved system is not feasible, would take too long, is intellectually unsound, and is boring.2

More advanced clinical students should therefore, after completing parts A and B of Step 6, add two additional parts: C—Ask about relevant symptoms outside the body system involved in the HPI, and D—Inquire about the presence or absence of relevant nonsymptom data (secondary data) not yet introduced by the patient, before concluding with the third part, understand the patient's perspective.

C: Ask About Relevant Symptoms Outside the Body System Involved in the HPI

Ask about symptoms outside the involved body system if they are pertinent to a diagnosis you are considering. For example, in a patient with advanced rheumatoid arthritis who is feeling fatigued, asking about gastrointestinal bleeding symptoms (“any black stools?”), while outside the musculoskeletal system, is still warranted if you suspect gastrointestinal bleeding due to nonsteroidal anti-inflammatory drug (NSAID) therapy is causing the fatigue. In patients with more than one problem, you will need to inquire in multiple systems during the HPI.

D: Inquire About the Presence or Absence of Relevant Nonsymptom Data (Secondary Data) Not Yet Introduced by the Patient

It is important to know about any medications taken to relieve the symptom, diagnoses given for the symptom in the past, prior treatments, and clinician visits or hospital stays for the symptom. This is especially true for complementary and alternative medicine treatments. Research shows that patients, as a rule, will not volunteer information about complementary and alternative treatments, therefore you must ask specifically and concretely about their use and do so in a nonjudgmental way.6 Also, asking relevant questions about possible etiological explanations for the diagnoses being entertained may help narrow the differential diagnosis. For example, if pulmonary embolism is a concern, ask about recent long car rides or air travel; if lung cancer is a hypothesis, ask about cigarette smoking.

How do you test hypotheses during the interview? Based on unique symptom(s) characteristics and secondary data suggesting one diagnosis over the others, and based on knowledge of what diseases are most common, you rank-order disease possibilities in your mind starting from the opening moments of the interview.2,5,7 Then, as noted earlier, seek additional diagnostic data (primary and secondary) to support the current best choice, almost always via extensive closed-ended questioning. If complete data have already been obtained descriptively, the new data will be largely outside the involved system. If not supported, another disease hypothesis becomes the best choice (“next best choice”) to explain the symptom(s) and you will similarly explore it. By following this process of testing multiple, ever-changing best hypotheses, you will eventually arrive at the best diagnostic possibility, the “current best hypothesis”—which is the best fit of our patient's primary data (and secondary, if available) with a known disease.

It is not uncommon to start with one disease hypothesis (angina) and, based on symptom descriptors and associated symptoms, end with a quite different one (esophagitis). For example, because of substernal chest pain radiating into the arms, the student's first hypothesis was angina. But, she or he knew esophagitis also was a possible cause of chest pain radiating to the arms and asked about descriptors and other symptoms associated with this diagnosis and they were present (precipitation of pain by coffee or recumbence, relief by belching and antacids, poor appetite) and other descriptors expected with angina were not present (no relationship of pain to exertion, no dyspnea or diaphoresis). When a hypothesis is well supported, it becomes a “diagnosis.” A diagnosis can often be made from the history alone (eg, angina) but sometimes additional data from the physical examination (eg, elevated jugular venous pressure for a diagnosis of congestive heart failure) or the laboratory (eg, low hemoglobin for a diagnosis of anemia) are needed before you can establish a diagnosis.2

The more knowledge and experience you gain the more facile and efficient you will become in formulating the diagnosis and knowing the proper questions to ask in real time rather than in a subsequent interview. Nevertheless, virtually all beginning clinical students will find themselves fully synthesizing the diagnosis only after the interview—when they have read about the problem, talked again with the patient to clarify issues they overlooked, and discussed the problem with faculty and more senior team members. Although this vast topic of clinical diagnostics8 is outside the scope of this text, and you will study this material extensively during your clinical years of training, the process of clinical problem solving is illustrated in Table 5-2. The table shows how a clinician tests hypotheses while obtaining the HPI.

Continuation of Mrs. Jones Visit

Understand the Patient's Perspective

By this point, you have elicited a detailed description of the patient's symptom, performed a targeted ROS and, if you are a clinical student, sought symptoms in relevant body systems and obtained pertinent nonsymptom (secondary) data. Regardless of your clinical level, the patient's history of present illness is not complete until you have a good understanding of the patient's perspective on his or her illness. This is key to making an accurate diagnosis and being of the most help to the patient. Much of this information may have been elicited during Steps 3 and 4, particularly if you used indirect emotion-seeking skills in Step 4. The patient may also have related some of this data while answering your questions thus far in Step 6. Ask about each of the remaining areas now.

Impact (Meaning) of Illness on Self/Others

Ask, “How is this symptom affecting your life/work?,” “How has it impacted your family/spouse/coworkers?” [How an illness affects the patient and his or her family is important psychosocial information and it can have practical implications, eg, need for home services.]

Health Beliefs (See Also doc.com Module 99)

Ask about the patient's “explanatory model” of illness, “What do you believe is causing your (symptom)?” because it is critical to understanding how the symptom is affecting the patient and what is important to her or him;10 it can also give you an opportunity to correct misconceptions and address fears with an empathic response. It is useful to normalize this question by saying something like, “Many patients already have ideas about what's causing their problems so I ask this question of everyone. It really helps me help them.” Occasionally, in eliciting a patient's belief or attribution a patient will say, “You're the clinician, you tell me!” Don't get flustered by this response. Calmly explain, “I find that it helps to share each of our perspectives so that we can come up with the best treatment plan for you.” If the patient persists in saying that you're the clinician and it's your job, you can switch to a more clinician-centered interviewing style, having learned about a strong patient preference at the same time.

Triggers for Seeking Care

Another indirect emotion-seeking skill which, if not asked about in Step 4, should be elicited here is to understand the reason(s) why the patient came at this time: “What made you decide to see me today for this (symptom)?” This often provides a window on the patient's personal life, important relationships and health beliefs (eg, a coworker with similar symptoms is recently told of a serious diagnosis, or a worried spouse insists that the patient seek care). Asking, “What else is going on in your life?” can uncover interpersonal crises or other sources of distress that can cause or amplify symptoms.11

In the case of Mrs. Jones, we learned in Step 3 and 4 that her headache is related to her work and a bit about the impact on her relationship with her husband. The student now asks several questions to learn more about her perspective:

Continuation of Ms. Jones Visit

Procedural Issues

When the patient presents more than one concern, you will need to evaluate each one in much the same way. For example, Mrs. Jones also had colitis and a recent cough. These now could be systematically explored. If these are not currently active health problems, though, they can be explored instead as part of the PMH, in less depth. And when not contributing to current problems, as in Mrs. Jones' situation, they are included in the PMH portion of the written report. When they are contributing to the patient's current problems, they are included as OAP at the end of the HPI.

This is a lot to assimilate, and it will require much practice before you feel competent and confident interacting with patients. Review the demonstration video to get a better sense of the flow of the interview (see video at http://www.mhprofessional.com/patient-centered-interviewing). Once you learn the parts of the ROS and the symptom-defining skills in their clinical context, this process becomes quite reflexive. Typically, it does not take a seasoned clinician very long to obtain diagnostic and therapeutic information. With advancing skills and knowledge of diseases, you will learn which are the most pertinent questions and how to ask them efficiently rather than needing to ask all of them. In order to learn all the components of the interview, you will initially need to practice most of them in most encounters, which obviously will take time. (See the end of Chapter 7 for a discussion of how much time the interview will take for a beginning clinical student.)

Because you use predominantly closed-ended inquiry in the middle of the interview, two important issues must be raised: (1) Poorly conducted closed-ended inquiry can lead to considerable bias of the data. Table 5-3 lists important ways to avoid this. (2) Because you are in the middle of the interview and using clinician-centered skills, you can ask direct questions that insert new information into the conversation where necessary. This is especially helpful in testing hypotheses; for example, in a patient with a chronic cough, it is perfectly appropriate to introduce these thoughts: “Are you a cigarette smoker?,” “Have you lost weight?,” or “Have you ever been tested for TB?”

The HPI/OAP concludes when you have addressed all the patient's presenting symptoms. At this point you will, after some experience, understand the problem and have the best possible disease explanation in mind if not the actual diagnosis. This will determine what corroborating data to look for on the physical exam and in the laboratory evaluation. You will also more fully recognize the close interaction of symptoms and secondary data with the personal data obtained in the beginning of the interview.

At this time, you will make a statement about changing the conversation to some topics “we haven't yet talked about, such as your past health issues,” as the clinician did with Mrs. Jones earlier, inquiring if she thought her story has been completely discussed, summarizing, and asking if there was anything further to add.

Addressing a Predominantly Psychological Problem

In patients with psychiatric diseases or other serious psychological problems, the personal contextual data you obtained during the beginning of the interview usually are not sufficient for complete evaluation. Steps 1–5 are just the beginning. In step 6, you pin down details about the psychological problem, just as you would with a physical symptom. Elicit the patient's symptoms and test hypotheses about the underlying diagnosis by selectively testing different diagnostic possibilities. For example, a patient's depression may have become apparent during Steps 1–5, but it now is your task to explore its possible disease causes, potential complications, and treatment options. Using open-ended inquiry and “coning-down” to closed-ended questions you differentiate, for example, major depression, bipolar disorder, schizophrenia, medication side-effects, and medical diseases as causes of depression. You will gain much more experience with the medical interview questions needed to diagnose both medical and psychiatric diseases during your clinical clerkships, but we use depression as an example here, because depressed mood can be a normal emotion or a symptom of a psychiatric disorder, major depressive disorder is so prevalent, and validated questions help make the diagnosis. Major depressive disorder can be screened for by asking two questions:12

Over the last 2 weeks, how often have you been bothered by:

1. Having little interest or pleasure in doing things?

2. Feeling down, depressed or hopeless?”

   If the patient answers, “more than half the days” or “nearly every day” to one or both questions, the sensitivity to rule in the diagnosis of depression is 83% and the specificity is 90%. In this case you would follow up with seven more questions to confirm the diagnosis. The patient needs to answer “more than half the days” or “nearly every day” to a total of at least five of the nine questions (the 2 screening questions and the seven follow-up questions) to meet diagnostic criteria for major depressive disorder.13 The questions are:

   Over the last 2 weeks, how often have you been bothered by:

3. Trouble falling or staying asleep, or sleeping too much?

4. Feeling tired or having little energy?

5. Poor appetite or overeating?

6. Feeling bad about yourself—or that you are a failure or let your family down?

7. Trouble concentrating on things, such as reading the newspaper or watching television?

8. Moving or speaking so slowly that other people could have noticed, or the opposite—being so fidgety or restless that you have been moving around a lot more than usual?

9. Thoughts that you would be better off dead, or of hurting yourself in some way?”

Most medical patients are like Mrs. Jones and have no apparent over-riding psychological problem or diagnosis. That may surprise you after everything we have heard about Mrs. Jones' job stresses and interpersonal conflicts. While it is important for you to understand your patients at this level, life stresses such as these are not necessarily symptoms of disease. Indeed, these types of problems occur in everyone's personal lives and are not outside the realm of normal. Simply feeling heard and understood by a caring person is often enough to help. Indeed some patients express, “I feel better just having come to see you!” You will gather additional personal details for patients like Mrs. Jones in the SH.

General Comments About the Remainder of the Interview

You now have completed the most important part of the middle of the interview. Step 6 is where you will spend most of your time. The remaining steps (Steps 7–10) are very straightforward, consisting of lists of questions on various topics you ask one by one. In many practice settings, patients complete a questionnaire beforehand and the clinician uses it to efficiently guide this part of the interview. While continuing to be on the lookout for clues to hypotheses, most hypothesis testing should have been completed.

You will note that the questions are extensive and to completely ask and answer all of them could literally take several hours! We present all of this material in order to provide you with an idea of the magnitude of potentially important information about the patient and what may be necessary to understand her or him fully. Note that the experienced clinician rarely obtains all of this information, certainly not at one sitting; pertinent but nonurgent information often is obtained over many visits. Information in Steps 7–10 is gathered selectively according to the individual patient's needs. As you proceed through these steps, consider which might be more important in, for example, older patients, women, men, children, crisis situations, and high-risk patients. As a beginning student, you should initially obtain complete information in all areas as a way of learning the categories and beginning to appreciate the rich diversity of your patients. When you have learned and memorized all the categories you should become more selective also.

While much of the information in Steps 7–10 is quite routine, continue to watch your patient's response, particularly fatigue and impatience with a long process. Periodically ask how the patient is responding to the interview itself. It can be tiring and you may need to ask if the patient needs a break or if it would be appropriate to continue at a later time. At the other extreme, while these may appear to be very standard questions, they often strike an emotional chord in patients and you may need to return to patient-centered inquiry, particularly empathy skills (NURS); for example, when asking a spouse's age, the patient becomes sad because of a recent divorce. It is also essential in this more routine part of the history to maintain the respectful, patient-centered atmosphere you have previously established and not become hurried. Finally, normalize the situation by telling patients that the questions you are asking are indeed customary and that they do not suggest something you have recognized or suspected about them; for example, a patient might get insulted when asked about drug use or sexual practices if you do not explain the reason for asking.

In the past medical history (PMH), you elicit information about significant past medical events unrelated to HPI/OAP. Events occurring in the past that are related to the HPI/OAP, however, are elicited as part of the HPI/OAP. For instance, in a patient presenting with chest pain, the prior history of myocardial infarction usually is obtained in the HPI rather than the PMH; it would also be reported there in the written and oral presentation of the history and physical (H and P). Similarly, because of the close association of diabetes and coronary artery disease, if this patient also were a diabetic of 20-years duration, this fact would be elicited and recorded in the HPI. On the other hand, if the same patient presented with diverticulitis or hip fracture, the cardiovascular history would be obtained and presented in the PMH as long as it was not an active problem. These distinctions are not always clear, and there are no evidence-based guidelines to determine where you should obtain or record historical data. And, of course, you will sometimes elicit data pertinent to the HPI while obtaining the PMH (or other parts of the history); you will relocate it to the HPI when writing up or presenting the H and P.

Ask about each major area shown in Table 5-4 with a focused, open-ended screening question, for example, “How was your health as a child?” and “Tell me about any previous hospitalizations/other medical problems/surgeries.” This is followed with enough closed-ended questions to get the necessary details for all items mentioned. Simple closed-ended inquiry suffices in obtaining much data within these categories (“Ever had any broken bones?”).

We now will expand upon the outline shown in Table 5-4. When a problem with significance for the patient's health is found in any of the areas listed, review the symptoms and make your own diagnosis, examining outside records to be certain. You can accept as provisional, but not final a patient's understanding of diagnoses or interpretations of treatments. Follow the already described procedure: convert concerns to symptoms from the ROS and refine them with the seven descriptors, and then organize relevant primary data (symptoms) and secondary data (doctor visits, hospitalizations, tests) into chronologic sequence.

For PMH problems with little significance to present health (appendectomy or tonsillectomy many years ago), little detail is needed other than getting the patient's version of diagnosis, complications, and statement that there have been no subsequent problems. Indeed, time constraints and patients' comfort discourage acquiring unnecessary data, such as the details of an uncomplicated appendectomy 30 years earlier.

As listed in Table 5-4, identify significant past problems by inquiring in the following areas.

Screen for Major Diseases

Screen for problems that might not yet have been identified. Begin with childhood illnesses by asking “Tell me about any illness you had as a child.” Then inquire about specific childhood illnesses (eg, measles, mumps, German measles, chickenpox). Continue with adult illnesses by asking, “Other than (chief concern), how is your health? What significant illnesses have you had?”, followed by specific inquiry about common adult illnesses (hypertension, heart attack, stroke, heart murmur, other heart disease, diabetes, tuberculosis, sexually transmitted infections, cancer), blood transfusions and visits to healthcare providers during the last year. Similarly, ask about prior treatment, such as cortisone, insulin, blood transfusions, and anticoagulants, that suggests serious problems. Finally, inquire about all health visits to the doctor or others during the last year.

Other Medical, Surgical, or Psychological Problems

Inquire about injuries, accidents, illnesses requiring several visits, unexplained problems, procedures, tests, psychological problems and psychotherapy.

Hospitalizations

Hospitalizations may identify the most serious problems patients have experienced: surgical, medical, psychiatric, obstetric, rehabilitation, and any other type. The more recent and the more serious a hospitalization, the more data are required, sometimes more extensive than the HPI; for example, in a patient who is admitted with a hip fracture as the primary problem but who had a history of three heart attacks, you would need to elicit extensive details of all primary and secondary cardiovascular data. Hospitalizations usually are presented in chronological order.

Immunizations

Ask about childhood (measles, mumps, rubella, polio, Haemophilus influenza type b, hepatitis B, tetanus/pertussis/diphtheria, HPV, varicella, meningococcal, rotavirus) and adult (diphtheria booster, tetanus boosters, measles/mumps/rubella boosters, hepatitis A, hepatitis B, influenza, pneumococcal, herpes zoster, meningococcal) immunizations. The most recent Centers for Disease Control and Prevention vaccination recommendations can be found at www.cdc.gov/vaccines/recs/schedules/default.htm.

Screening

There are a number of recommended health-screening procedures (varying by age, circumstance, and gender) that you will want to ensure are up to date. These might include screening for tuberculosis, hyperlipidemia, hypertension, cervical cancer, breast cancer, colon cancer, etc. Screening recommendations change as new knowledge is discovered. You can find the latest US Preventive Services Task Force health screening recommendations applicable to your patient at http://www.ahrq.gov/clinic/pocketgd.htm.

Women's Health History

Essential information to obtain from women and girls about menses is age at onset (“How old were you when you had your first period?”), cycle length (“How often do you get your period?”), duration (“How long does your period last?”), discomfort or pain with menses, number of pads or tampons daily, and age at menopause. Use of contraceptives, including birth control pills or other hormonal preparations also is sometimes elicited here (“Do you or your partner[s] use birth control? What type? How often?”). The sexual history, sexually transmitted infection history, and intimate partner violence questions found in the Social History can be asked here in the PMH if you prefer.

The obstetric history includes number of pregnancies (“Have you ever been pregnant?” How many times?”), deliveries of living children and their outcome, other deliveries and reason for adverse outcome, any complications of pregnancy, spontaneous abortions (“Have you had any miscarriages?”) and induced abortions. You can elicit breast-feeding history and problems here. The women's health history often is elicited and reported as part of the HPI when genitourinary problems are the focus. Many women's health questions are also found in the ROS because some clinicians ask about women's health history there instead of in the PMH or SH. You will learn from your teachers which section you are expected to record and report the women's health history in.

Medications and Other Treatments

List all prescribed and other medications with dose, duration of use, reason for use, and any adverse reactions. Also obtain a listing of medications used during the last year but which are not presently being taken. Specific inquiry about agents sometimes not considered to be medications is necessary as well: inhalers, laxatives, tonics, hormones, birth control pills, and vitamins. Inquire about agents obtained over-the-counter, from alternative healers, or from other sources such as a friend. In order to identify all the patient's medicines, you may need to contact the pharmacy or ask the patient to bring in the actual medications so that they can be definitively identified, particularly when all the patient knows is that “I'm taking a brown pill for my circulation.” Sometimes it helps to consult the Physicians' Desk Reference which has color photographs of many commonly used brand name medications.14 An online resource is Pillbox from the National Library of Medicine (http://pillbox.nlm.nih.gov/), which allows for rapid identification of pills based on color, shape, and size.

Ask about nonpharmacologic forms of treatment, whether administered by self or others, including physical therapy, massage, biofeedback, relaxation techniques, yoga, acupuncture, psychotherapy of any type (eg, individual, group), diet, and exercise. Specifically inquire about complementary and alternative treatment (eg, homeopathy, herbal medicine, chiropractic) since these often are not mentioned out of embarrassment or fear of disapproval by the clinician.15

Allergies and Drug Reactions

If not already ascertained, ask about asthma, hay fever, hives, and atopic eczema because they are common allergic disorders; asthma and these patients also may be more sensitive to certain medications (eg, aspirin in asthmatics).

Drug reactions can be allergic/immunological (rash due to penicillin) or nonimmunological (candida vaginitis due to an antibiotic). Patients seldom make this distinction but you must because true allergic reactions usually preclude subsequent use of the medication while alterations in dosage and frequency can sometimes allow continued use following a nonallergic drug reaction. List all allergic or other drug reactions, dose and duration of use of the agent, specific symptoms (eg, hives, anaphylaxis, rash) and secondary data (eg, desensitization, skin tests, cortisone), recurrence, history of reexposure, and final outcome.

We now pick up again with Mrs. Jones:

Continuation of Mrs. Jones Visit

Also called the psychosocial history, the psychosocial ROS or the patient profile, the social history (SH) is where you learn about the patient's behaviors and other personal factors that may impact disease risk, severity, and outcome; it also helps you to get to know the patient better. As with other parts of the history, you may uncover aspects of the social history during different parts of the encounter. Regardless of where in the history you obtain the data, when you do an oral or written case presentation, you will place those parts of the social history not involved in diagnosing the chief concern under the heading Social History, to help organize the information.

Start with a transition statement (“Now I'd like to ask you some questions about your life and things you do to stay healthy”) and initiate each major SH area in Table 5-5 with a focused open-ended request or question (“Can you tell me about your work?”), then follow up with enough closed-ended questions to get the necessary details. Because the social history addresses many sensitive areas, be especially careful to be patient, courteous, nonjudgmental and understanding as a way of ensuring continuation of the patient-centered atmosphere. Patients often are reassured when you state that the questions are routine and asked of everyone. Address tension-laden areas delicately with considerable use of open-ended and empathy skills; you may need to use patient-centered interviewing skills if significant issues or emotions develop, or if a previously reticent patient begins to open up. It is not uncommon to go back and forth between patient-centered and clinician-centered skills many times. The interviewing strategy for obtaining very sensitive information, such as sexual or drug use history, is expanded upon in Chapter 7.

The list of potential topics of inquiry in the SH is extensive and may not seem relevant to the reason the patient is seeking health care. However, understanding these aspects of the patient's life can aid you in diagnosing the chief concern, helping the patient recuperate after hospital discharge, and keeping the patient healthy by addressing harmful behaviors. As you gain experience, you will learn which questions are most important to ask for a particular patient encounter. The bold items in Table 5-5 should be addressed in most encounters; these topics will identify targets for risk factor modification and assist in building the doctor–patient relationship. These issues, although rarely brought up by patients, should be discussed openly and in a nonjudgmental fashion to both garner trust and obtain accurate information. You may need to obtain this type of information over multiple encounters with the patient.

Ask about the unbolded items in Table 5-5 if time allows or when directed by the patient's illness. For example, you would ask about travel and pets if the patient presented with acute fever.

We recommend that you begin with less sensitive topics first, generally following the order listed in Table 5-5. Make a transition statement between topics and assure the patient that you ask these questions of all your patients.

Recommended questions for some important topics are listed in the following sections, followed by the rationale [in brackets].

Occupation

Ask, “Do you work outside the home? Tell me about your work. How long have you done this work? What other jobs have you had? Have you ever been exposed to fumes, dust, radiation, or loud noise at work? Do you think your work or environment is affecting your symptoms now?” If so, ask, “Do your symptoms improve away from work?” and “Are others at work having similar symptoms? Tell me about stress at work.” If the patient does not work outside the home, ask what a typical day is like.

[A patient's occupation can affect health through toxic exposures, injuries, and stress.16 For example, auto body workers can develop asthma, woodworkers have an increased incidence of nasopharyngeal carcinomas, and clinicians can be exposed to tuberculosis, HIV and viral hepatitis.]

Health Promotion

Diet (See Also doc.com Module 2517)

Ask for a 24-hour dietary recall, “Tell me what you've eaten in the past 24 hours, starting with just before you came here and working backward.” Avoid asking, “Tell me about your diet.” because for some patients a “diet” is something one goes on to lose weight. A 24-hour dietary recall (assuming the day is typical) gives you a more accurate understanding of actual dietary practices than asking about what the patient eats on an average day.

Screen for bulimia by asking, “Are you satisfied with your eating habits?” If the patient answers no, then follow-up with, “Do you ever eat in secret?”18

Depending on the clinical scenario, you may need to explore some additional areas:

• Sodium: Reducing sodium can decrease blood pressure as much as starting a medication, and it can relieve heart failure symptoms, so ask about salt use in patients with hypertension and congestive heart failure. Does the patient add salt during cooking and/or at the table? Ask about hidden sodium, found in prepared foods such as cold cuts, bacon, ham, canned soups and vegetables, and in restaurant meals.
• Fat: Dietary fat intake can significantly affect cholesterol levels. Inquire about intake of dairy products, eggs, red meat, and organ meats.
• Caffeine: Can cause nervousness, tremor, palpitations, and insomnia. Ask about intake of caffeinated beverages (eg, coffee, tea, cola, mountain dew, energy drinks) and caffeine pills (eg, No-Doz).
• Fiber: Low fiber diet can lead to constipation, hemorrhoids, and diverticulosis.
• Dairy products: For patients who might have lactose intolerance.
• Wheat: For patients who might have gluten enteropathy.

[Understanding your patient's dietary choices and relationship to food is increasingly important because of the increasing incidence of obesity and eating disorders. Diet also plays an important role in many common diseases such as hypertension, diabetes and hyperlipidemia. Symptoms can also be caused by foods, such as diarrhea and bloating in patients with lactose intolerance who consume dairy products, and in patients with gluten enteropathy who eat wheat. Malnutrition can exist even if the patient is obese.]

Exercise (also see doc.com Module 2517)

Ask, “Tell me what you do for physical activity or exercise.”

[A sedentary lifestyle contributes to many illnesses including obesity, Type 2 diabetes, and heart disease. The US Department of Health and Human Services in its 2008 Physical Activity Guidelines for Americans (www.health.gov/paguidelines) recommends that adults get at least 2½ hours per week of moderate intensity, or 1 hour and 15 minutes a week of vigorous-intensity aerobic physical activity, or an equivalent combination of moderate- and vigorous-intensity aerobic activity. It also recommends that adults should do muscle-strengthening activities that are moderate or high intensity and involve all major muscle groups on 2 or more days a week. Understanding the details of a patient's exercise and physical activity can allow you to counsel the patient appropriately.]

Safety

Say, “Now I want to ask you about some personal safety issues. Do you wear seatbelts? How often? Do you use a bicycle helmet? How often? Do you ride a motorcycle? (If so) Do you wear a helmet? How often? Do you have smoke detectors in your home? How often do you change the batteries? Can children get at medications or toxic substances like cleaning products? Is there a gun in your home? (If so) How is it stored?”

[Asking patients about their day-to-day safety practices provides an opportunity for counseling that may be lifesaving.19,20 For example, in recent years about 60% of the approximately 30,000 annual fatal motor vehicle accidents have been due to failure to use seatbelts. The National Highway Traffic Safety Administration estimates that seatbelt use saves about 13,000 lives a year. Accidents are the leading cause of death of young adults. If a clinician can convince a healthy young patient to use a seat belt, it is possible to have more impact on that patient's lifespan than any other medical intervention. Even if a young adult states that they use seat belts it may be advantageous to reinforce the fact that seat belt use saves thousands of lives every year. Bicycle helmets reduce the risk of head injury by 85%; motorcycle helmet use reduces the risk of fatal head injury by 27%.20 Ensuring that firearms in the home are safely handled and stored may reduce the risk of homicide or suicide: homicide risk has an odds ratio of 2.7, and suicide risk has an odds ratio of 4.8 in households with handguns compared to households without a handgun.19,21–24 Smoke detectors reduce the risk of death from residential fires by 80%.19

Substance use (see also doc.com Modules 24,25 29,26 and 3027)

Ask about tobacco use, including forms of tobacco (eg, pipe, snuff, chewing tobacco) and number of pack-years for cigarette use (packs smoked per day multiplied by number of years of smoking, eg, smoked 2 packages of cigarettes daily for 8 years [16 pack-years]).

Determine whether the patient consumes alcohol and whether it may be a health problem. Ask “Do you drink alcohol, including beer, wine and hard liquor? How much alcohol do you drink? Has alcohol ever been a problem in your life? When was your last drink?” A response of “less than 24 hours ago” to this last question has a positive predictive value of 68% and a negative predictive value of 98% for alcohol abuse.28 Then, you can follow-up with the “CAGE” questions:29,30

“Have you ever:

• felt the need to Cut down on your drinking?
• felt Annoyed by criticism of your drinking?
• had Guilty feelings about your drinking?
• taken a morning Eye opener?”

An affirmative answer to 2 or more has a sensitivity and specificity of >90% for alcohol dependence.28

Determine whether the patient uses or abuses either “street” drugs or prescription drugs, and quantify the amount. Also determine if the patient shares drug equipment, such as needles and straws. Prescription drug abuse is now the most common form of drug abuse.31–34

Patients often minimize their use of drugs or alcohol, in an attempt to delude themselves more than you. Maintain a respectful and nonjudgmental approach in order to win the patient's trust. You might ask if the patient has had problems from using addicting substances (divorce, job loss, delirium tremens with alcohol withdrawal, emphysema from cigarettes), attempted to quit or decrease the habit; whether she/he was successful in stopping before and if not, why not; and if she or he is interested in getting help to quit. As well, ask about problems with the legal system, and with other substance abuse problems in the patient's life. Finally, particularly with drug and alcohol abuse, be alert for psychiatric issues that commonly attend these problems; such as anxiety and depression. You will often find that, when alcohol or drug abuse exists, it often relates to the major problem the patient has and almost always has a significant impact on the patient's health. In such cases, you will present this information in the HPI, even if you obtain it as part of the social history. Examples include a patient who presents with chest pain suggesting angina and also a history suggesting alcoholism, or a patient who presents with progressive shortness of breath who also has a 40 pack-year smoking history.

Personal

Living Arrangement and Personal Relationships

A good way to inquire about home life is to ask, “How are things at home? Does anyone else live at home with you? Tell me about him or her.,” “Tell me about your support systems in your life. Who do you count on?”

[Most students are uncomfortable inquiring about patients' personal lives. It can feel intrusive or voyeuristic to ask intimate questions about a stranger's private life. This is understandable. It is helpful to keep in mind some of the reasons you are asking these questions. As a clinician, you are interested in public health issues like the spread of communicable diseases; you are also interested in patient safety, including falls and intimate partner violence; risky behaviors such as unprotected sex; inherited and inheritable genetic diseases; etc.

As a beginning clinical student, you may not feel that you can do anything helpful with the information you have gotten. Once you are on clinical rotations, you will be a key member of the team caring for the patient and the history you obtain may be the most important and complete on the patient will undergo. For example, knowing a patient's personal relationships allows the team to know the next of kin to contact and when it is time to discharge the patient, the team will know the potential support systems (or lack thereof)—this may mean the difference between sending the patient home, arranging for visiting nurse, or sending the patient to a rehabilitation center. Regardless of your clinical level, be honest with patients that you are learning about medical interviewing; most patients will be very willing to help you learn by answering all your questions. In fact, your encounter with the patient may be the high point of the patient's otherwise boring day.]

Sexuality (See Also doc.com Module 1835)

A transition statement such as, “In order to provide healthcare that is right for you, it is helpful for me to understand your lifestyle” may provide a comfortable segue into asking about sexuality36 Also, stating that “these are questions I ask all of my adult patients,” may be helpful. After the transition, the following questions can then be asked:

• Is there someone special in your life? Are you and this person having sex?”
• Are there any other sexual relationships that I should know about?”
• Do you have sex with men, women, or both?”
• Do you have sex with people who might be at risk for having sexually transmitted diseases or HIV (intravenous drug users, cocaine users, prostitutes, unknown partners or gay or bisexual men)?
• (For persons having sex with men) Are you using condoms to prevent disease? What percent of the time?
• (For women) Do you have a need to discuss birth control?, Have you ever had a Pap smear? When was your last one? What were the results? Have you ever had an abnormal Pap smear? Have you ever had a biopsy or other procedure on your cervix because of an abnormal Pap smear?
• Have you ever had Gonorrhea? Syphilis? HIV? Chlamydia? Herpes? HPV? Genital warts? Hepatitis?
• Do you have any other questions or concerns about sex? I'm happy to discuss any concerns you have.

To detect sexual problems, ask:

• Have you noticed any recent changes or problems with your sexual functioning?
• Men: Do you have any problems having or maintaining an erection? Any trouble having an orgasm?
• Women: Do you have pain during intercourse? Any problems with lubrication or becoming aroused? Do you have difficulty having an orgasm?
• Has your illness affected your sexual functioning?

[Do not make assumptions about a patient's sexual orientation or practices and do not assume that orientation determines practices. For example, some men who have sex with men do not consider themselves to be gay or bisexual. Avoid questions such as “Are you married or single?” or (to a woman), “Do you have a boyfriend?” Gender-neutral language (eg, “partner”) communicates to gay, lesbian, bisexual, and transgendered patients that it is safe for them to be themselves with you.37 Seek to understand both a patient's sexual orientation and the sexual activities she or he engages in. This will allow you to screen appropriately for sexually transmitted infections, give relevant health education and provide personalized healthcare. For example, gay and lesbian patients receive less preventive care the heterosexual patients, primarily because of dissatisfaction with the clinician–patient relationship.38 Also, gay and lesbian teens are six times more likely to attempt or commit suicide than the national average.39 A trusting relationship with the clinician may help establish trust and uncover and respond to extreme distress and suicidal thoughts.

As with the rest of the medical interview, tailor questions to the particular encounter. For example, it would not be appropriate to take a detailed sexual history from a person in acute congestive heart failure in a crowded emergency department. Once the patient is stabilized and in a more private setting, you could return to these questions as indicated.]

Intimate Partner Violence/Abuse (See Also doc.com Module 2840)

An estimated 2–4 million US women are physically abused each year, with domestic violence occurring in as many as one of every four US families. Although it may feel uncomfortable, you must learn to sensitively inquire about intimate partner violence, since patients are unlikely to broach this important issue themselves.41 One suggested approach42 is “Have you ever been hit, slapped, kicked, or otherwise physically hurt by someone? Has anyone ever forced you to have sexual activities?” If the patient answers yes to either question, learn more about the situation, using open-ended questions. You can then follow-up with the “SAFE” questions:43

• Stress/Safety: What Stress do you experience in your relationships? Do you feel safe in your relationships/marriage? Should I be concerned for your safety?
• Afraid/Abused: Are there situations in your relationships where you have felt afraid? Has your partner ever threatened or abused you or your children? Have you been physically hurt or threatened by your partner? Are you in a relationship like that now? Has your partner forced you to engage in sexual intercourse that you did not want? People in relationships/marriages often fight; what happens when you and your partner disagree?
• Friends/Family: Are your friends, parents or siblings aware that you have been hurt? Do you think you could tell them, and do you think they would be able to give you support? (Assess the degree of social isolation.)
• Emergency plan: Do you have a safe place to go and the resources you (and your children) need in an emergency? If you are in danger now, would you like help in locating a shelter? Would you like to talk with a social worker/counselor/me to develop an emergency plan?

Stress

Stress is ubiquitous in life. Unmanaged, it can negatively affect mental and physical health through chronic activation of the hypothalamic-pituitary adrenal access and suppression of the immune system.44 If not disclosed earlier in the interview, ask, “Can you tell me about the kinds of stress you're under?,” “Have you had any recent changes or losses at home? At work?”

Mood (See Also doc.com Module 2745)

You might get clues to a mood disorder in the beginning of the interview and you could choose to pursue your hypothesis while you are completing the HPI in Step 7. Alternatively you can inquire about the patient's mood here, or as part of the ROS (Step 10). Begin by asking, “How has your mood been?” or “How are your spirits?” To screen for depression, the most common mood disorder, ask, “Over the past 2 months, have you been bothered by little interest or pleasure in doing things? Feeling down, depressed, and hopeless?” If the patient answers yes to either question, there are more in-depth questionnaires such as the PHQ-9 to confirm the diagnosis and its severity (see "Addressing a Predominantly Psychological Problem").13

Spirituality/Religion (See Also doc.com Module 1946)

One suggested mnemonic for asking about spiritual and religious beliefs is FICA:47

• Faith and belief: “Do you consider yourself to be a spiritual or religious person?” “What is your faith or belief?” “What gives your life meaning?”
• Importance and influence: “What importance does faith have in your life?” “Have your beliefs influenced that way you take care of yourself and your illness?” “What role do your beliefs play in regaining your health or coping with illness?”
• Community: “Are you a part of a spiritual or religious community?” “Does the community support you? If so, how?” “Is there a group of people you really love or who are important to you?”
• Address in care: “Would you like me to address these issues in your health care?”

[Spirituality and religious beliefs are important to many patients, especially in times of illness. Beliefs can be a source of comfort and support. Some studies show an association between spiritual beliefs and improved health.48,49 Religious belief can also result in poorer health outcomes through avoidance of care.50 Additionally, belief that illness is a punishment from God can lead to increased mortality.51 Depending on the severity of the illness and time available, seek to understand what is ultimately meaningful for patients, how this relates to their suffering, what their belief and faith are, who and what they love, their meditation or prayer practices, their orientation to giving and forgiving, and the patient's actual worship practices; that is, the integration of mind, body, and spirit.52

While most patients welcome their clinicians knowing about their religious beliefs, the number is highest in cases of serious illness and lowest for routine office visits, so, as always, be sensitive to patient preferences.53

Health Literacy (Also See doc.com Module 99)

Health literacy is defined as the capacity of a person to obtain, process and understand health information to make decisions regarding illness prevention or treatment.54 Ask the screening question “How confident are you filling out forms by yourself?” to identify patients with low health literacy.55

[Examples of behaviors where health literacy is required include reading the instructions on a medication bottle, understanding an appointment slip, filling out health forms, participating in an informed decision discussion before an operation, managing a chronic health condition and enrolling in a health insurance plan. Patients with low health literacy have worse health outcomes and incur higher costs than patients with adequate health literacy. Low health literacy is more prevalent among older people, those with less educational attainment, those with limited English proficiency, those in minority groups, and the medically underserved. It is estimated that one-third of patients in the United States have low health literacy. Patients may try to hide their low literacy by avoiding reading (“I forgot my glasses.”); they may have few questions and may not be able to explain how to take their medications.]

Other Issues

Ask about the following areas as time permits and as indicated by the clinical situation.

Advance Directives (Also See doc.com Module 3256)

In patients who are severely ill, disabled, or elderly, inquire about advance directives (eg, “do not attempt resuscitation” wishes, living will, use of a ventilator to sustain life), power of attorney, and whom to contact in the event of serious health problems. This document makes the patient's end-of-life wishes known in the event of incapacitation. Experts in bioethics use and recommend advance directives, but they are not being used nearly often enough, leaving patients biased toward choosing cardiopulmonary resuscitation when they don't understand its ramifications. Research data show that addressing advance directives improves elderly patients' satisfaction,57 which can be enhanced by using patient-centered skills when necessary.58

Functional Status (See Also doc.com Module 2359)

Especially in the elderly and those with disabling problems, it is important to know what their functional status is; for example, how well they can dress and bathe themselves, use the toilet, transfer from bed to chair, walk, shop, cook, clean, drive, take medications, and keep track of their bank account. Indeed, the American College of Physicians has asked that patient histories be standardized to include routine functional status and well-being assessments.60 In addition, make an assessment of how much a disability interferes with the patient's life and wishes; for example, one may no longer be able to climb stairs but this does not interfere with what the patient wants to do or, alternatively, the same disability results in great hardship by preventing the patient from attending baseball games.

Continuation of Mrs. Jones Visit

The family history (FH) is another rich source for completing the personal database, as well as for understanding familial health risks, both genetic61 and environmental. The FH can provide information about contagious (pinworms, tuberculosis, varicella), toxic (carbon monoxide, lead), familial (breast cancer, coronary artery disease, alcoholism, depression), and heritable (hemophilia, sickle cell anemia) diseases. Also ask if anyone in the family has similar physical problems to the patient's, or if anyone at home has been ill lately with similar concerns.

With families, the complexities of multiple interpersonal interactions come to the forefront.62 You most want to know who is who, who is available to the patient and in what way. In general, obtain information for at least two generations preceding the patient, as well as for any subsequent generations, and include parents, siblings, and children for each generation. Although not significant for familial or heritable disorders, this includes spouses, adoptees, and other significant members of the family outside the bloodline, because shared environmental factors may contribute to illness, and these relationships can have importance for the patient's health that transcend genetics.

Once again, use open-to-closed coning inquiry to obtain the information in Table 5-6. After announcing the transition and explaining your rationale (“Now I'd like to ask about the health of your family members, because sometimes diseases can run in families.”), begin with a screening open-ended question (“Tell me about any illnesses or other problems that run in your family”). Then ask open-ended questions about the age and health of the patient's immediate family as well as the causes of death and ages of first-degree relatives (“How is your father's health?” “Your mother's health?,” etc.). Patients with recent losses may exhibit emotion, which you should address with “NURS.” Then list specific diseases, for example, tuberculosis, diabetes, colon cancer, breast cancer, prostate cancer, heart disease, bleeding problems, kidney failure or dialysis, alcoholism, drug and tobacco use, weight problems, asthma, and mental illness (depression, schizophrenia, multiple somatic concerns, suicide, violence) (“Thinking now about all of your relatives, does anyone have diabetes? Tuberculosis?,” etc.). In the case of genetic diseases, determine if the affected family member is a blood relative; obviously this doesn't apply for infectious or environmental diseases.

Some clinicians construct a genogram to organize these data.62–64 Genograms can identify conditions that might be amenable to genetic testing, and help identify dysfunctional family patterns and high medical utilization. As demonstrated by Mrs. Jones' genogram in Appendix D, this graphic form depicts myriad features in the family. Ages, gender, state of mental and physical health, and current status are obtained for each; when deceased, the age and cause of death are noted. Depending upon time, data can profitably be extended to include education, work, psychological style, and a host of other features for each member.

Given time and need, learn also about dominant and nondominant family members, and their specific styles; for example, controlling, passive, caring. In addition to individual psychological profiles, the interactions among family members (eg, direct, indirect, conflicted, close) are equally important. You can also ascertain the gestalt of the family and its unique persona; for example, the patient came from a happy family or a fighting family.

Many patients report diseases in the family and their disorder (“my father had a heart attack and I've got a murmur” likely refers to different problems). Finally, especially following the death of a relative, patients worry about being at increased risk because of familial connections. To illustrate a healthy 21-year-old woman presents with chest pain and worries about having a heart attack 10 days after her grandfather died suddenly of a myocardial infarction. Most of these symptoms relate to the patient's understandable concern. While not the intent of the FH, if emotional material arises you must be supportive and address it; for example, in discussing the dates of death of her grandfather, the patient becomes sad and tearful. As before, your patient-centered interviewing skills may be called upon.

With the large amount of potential data, the FH focuses on family data relevant to current problems. Beginning students, however, again are urged to obtain all FH data during initial interviews in order to learn the categories themselves and the richness and variability of the FH in different people. Busy clinicians often must acquire these data over many visits, often aided by questionnaires patients can complete beforehand.

Continuation of Mrs. Jones Visit

The review of systems (ROS) is less important than other parts of the history;65,66 we already have discussed the ROS in Chapter 4 as a resource that lists most symptoms; Table 4-1 has a detailed list. Indeed, by this point, the interviewer ordinarily knows everything of significance. The ROS is not used for obtaining pertinent HPI/OAP, SH, or PMH data and, rather, serves only as a final screening tool. Recall that the HPI and OAP are elicited after repeated inquiries of “What other concerns do you have?” and “Is there something else?” during agenda-setting (Step 2)—which means that little if any new, important, or active information should arise here. Nonetheless, relevant data are sometimes acquired; you must then fit them into the appropriate section (HPI/OAP, SH, or PMH) during the write-up or oral presentation.

The ROS concerns primary and secondary data from systems not yet considered. Here you return to the ROS and inquire about still unaddressed symptoms and any secondary data, including specific diseases such as psoriasis or cataracts.

Some patients may attempt to list each cold and upper respiratory illness they have had over the last 20 years when you are asking about nasal symptoms. Rather than obtaining details, you want to know only if the problem has caused any disability, represents a significant issue, or has not completely cleared. Refocusing patients helps, with comments such as “I don't need all the details, but I do want to know if there have been any major problems.” Do not probe for, or encourage, symptoms except in pediatrics (see Chapter 7). Most frustrating is the patient who answers positively to most questions, exhibiting a “positive system review.” If this persists following clarification, it suggests still unrecognized diseases or, more likely, a psychological disorder known as somatization in which patients present with multiple physical concerns that have no disease explanation. This represents the patient's expression of psychological distress through physical symptoms.

The ROS proceeds almost entirely by rapidly paced, brief closed-ended questioning after an initial, orienting question such as “I need to ask you now about any other important or current problems or symptoms you might have had, so we don't miss something. Say yes only if the symptom has been significant problem.” For example, if the gastrointestinal system had not yet been addressed, the interviewer might begin open-endedly with “Any trouble with your digestion or bowels?” and then inquire “Have you ever had trouble with your appetite” (No); “Weight loss?” (No); “Weight gain?” (No); “Difficulty swallowing?” (No); “Nausea?” (No); and so on until all of this system has been explored. Questions of course are asked and answered individually. When the more advanced clinical student has memorized all symptoms on the review of systems list, she or he is urged to obtain the ROS when performing the physical examination—as a time-saving device. For example, while examining the nose, ask questions about nasal symptoms, while examining the eyes, ask questions about eye symptoms, and so on. Always remain attentive to the patient's responses and needs, and tells her or him that questions are “routine” and that you have not noticed something to make you suspicious.

When the ROS is concluded, summarize briefly, ask if the patient has any questions, and indicate that the physical examination will follow. Continue a patient-centered atmosphere of courtesy, respect, and support throughout the encounter.

Continuation of Mrs. Jones Visit

Begin the clinician-centered HPI/OAP by converting the patient's concerns to symptoms from the ROS and then refining them with the seven descriptors. Then organize primary and secondary data into chronological sequence, progressively learning to test disease hypotheses as you proceed. Use the PMH to elicit important but not current problems. The SH and FH complete the personal and, to a lesser extent, the primary and secondary data base. Finish by screening for still undetected primary and secondary data using the ROS. (This order-with minor variation-is used by clinicians throughout the world to present [in writing and verbally] the patient's history. Obtaining it in the same order will help you organize your presentations.)

By the repeated coning-down process of brief open-ended screening followed by closed-ended acquisition of necessary details, you will better understand previous personal and symptom data from the beginning of the interview and, in addition, acquire other essential parts of the data base to complete the interview. Although not now as prominent, intermittently use patient-centered interviewing skills by making supportive comments and inquiring about how the patient is doing with the process of the interview, more extensively using these skills when the patient becomes emotional or presents important, new personal data, in order to draw out the story, seek out the emotion and respond empathically (NURS).

This completes the middle of the interview. You can now make a complete biopsychosocial description of the patient using integrated patient-centered and clinician-centered interviewing skills. By fully appreciating the patient's disease problems and the personal/emotional illness context in which they occur, you are using a scientific approach, which will benefit the patient. After obtaining further information from the physical examination, you will be ready to end the interview, as we will discuss in the next chapter.