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.’
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.
The integrated medical interview.
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
Table 5-1. Continuing the HPI/OAP |Favorite Table|Download (.pdf)
Table 5-1. Continuing the HPI/OAP
Step 6 – Obtain a Chronological Description of the HPI/OAP
Obtaining and describing data without interpreting it
Describe symptoms already introduced by the patient
Describe symptoms not yet introduced in the already identified body system (and general health symptoms)
Interpreting data while obtaining it: Testing hypotheses about the possible disease meaning of symptomsa
Describe relevant symptoms outside the body system involved in the HPI
Inquire about the presence or absence of relevant nonsymptom data (secondary data) not yet introduced by the patient
Understand the patient's perspective
- Impact (Meaning) of Illness on Self/Others
- Health beliefs
- Triggers for seeking care