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INTRODUCTION

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; responded with empathy, 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 Fig. 5-1. To illustrate each step, we will continue to follow Ms. Jones.

FIGURE 5-1

The integrated medical interview.

COMPLETE A CHRONOLOGICAL DESCRIPTION OF THE PATIENT'S CHIEF CONCERN AND OTHER ACTIVE PROBLEMS—STEP 6

Step 6 (Table 5-1) is the most important and most challenging part of the middle of the interview. 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 your physical examination and the subsequent laboratory evaluation, if any. The companion video titled “Clinician-Centered Interviewing: An Evidence-Based Approach,” available on the McGraw-Hill website (www.accessmedicine.com/SmithsPCI) demonstrates what we will now describe. Module 8 in DocCom provides additional information about developing and clarifying the patient's HPI.1

TABLE 5-1

Continuing the HPI/OAP

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