INTERVIEWING TECHNIQUES

PDR 2
AUGUST 11,2021
DR. WILFREDA G. SABANAL
 EFFECTIVE COMMUNICATION

Promotes trust, rapport and confidence on the part of

the patient..
COMMUNICATION SKILLS are needed in:

1. Ascertaining patients concerns and worries in the

process of diagnosis.
2. Explaining treatment options.
3. Informing them of the nature of their illness, the
therapeutic intervention and its side effects
4. Addressing psychosocial problems
5. Counseling
COMMUNICATION PROCESS

Involves the following elements :

1. Stimulus
2. Perception
3. Interpretation
4. Decision
5. Encoding
6. Message
7. Response
8. channel
FORMS OF COMMUNICATION

1. Verbal communication
2. Non verbal communication
several forms:
a. eye contact
b. mannerisms
c. touch
d. gestures
e. tone of voice
f. posture
[Link] communication

The four commonly adapted communication skills are

1. listening
2. speaking
[Link]
4. writing
 ACTIVE LISTENING SKILLS

1. Listening skill cluster

- active process
- total kind of perceptiveness
a. attending
b. paraphrasing
c. perceptive checking
2. Leading Skills Cluster
a. indirect leading- helps the patient get started
b. direct leading- focus on specific topic and
encourage patient to elaborate
c. focusing
d. questioning
* direct questions
* yes-no questions
* confrontation questions
* probing questions
[Link] Skill Cluster

[Link] feelings
[Link] content
[Link] experience
COMMUNICATING IN SPECIAL SITUATIONS

1. Terminal illness and bereavement disclosure

- Doctors are afraid of breaking the bad news
results to errors
*simply not do it and wait for other colleague
to do it
*deliberately not picking up the patient’s cue
*falsely putting on an aura of deepening gloom
*lying outright
Since patient –doctor relationship is based on TRUST:

• The doctor must ascertain how much the patient wants to

know and make his disclosure appropriately.

• The attending physician must be the sole and primary

agent responsible for the disclosure.

• He should be emotionally stable,

capable of giving empathy and encouragement,
show emotional sensitiveness
technically knowledgeable and capable of imparting
information in a simple way
• Disclosure should be done in a private place, face to
face

• Relatives and other medical staff may join if the

patient permits

• The disclosure should be done when there are

conclusive tests already and when the patient is
physically and emotionally ready.

• The truth regarding diagnosis, prognosis and

treatment should be told in a gradual and reassuring
manner.

• Technical terms should be avoided

 Steps on disclosure
1. The doctor should ask the patient directly how much he
knows about his condition.

2. The doctor must disclose the bad news using emotive words with care.

2. The doctor should discuss the treatment options and involve the patient
in decision-making and plans.

4. The doctor should summarize and check the patient’s understanding

of the illness as well as his plans.

5. The patient should be given information regarding support services.

VARIOUS PATIENT’S
CHARACTERISTICS

[Link] patient
[Link] patient
[Link] patient
4. Emotional patient
[Link] patient

Noncompliant patient
THE MEDICAL INTERVIEW
PDR 2
THE MEDICAL INTERVIEW

-interchange of ideas ( doctor and patient)

-result in an accurate and comprehensive

story of patient’s situation

- should be well planned and organized

As soon as you encounter your patient,
you will face the common questions

How much should I do?

Should my assessments be comprehensive or

focused?
 Comprehensive Assessment

- Is usually done with patients you are seeing

for the 1st time in the office or hospital.

- It includes all the elements of health history

and the complete physical examination.
Focused Assessment

-Is also known as Problem-Oriented Assessment

-Is more flexible and used in many situations

-is appropriate particularly with patients you know

well , returning for routine care or those with
specific” urgent care” concerns like
sore throat or knee pain
PHASES OF MEDICAL INTERVIEW

[Link] the Interview

[Link] the patient’s narrative
3. Focusing upon a topic
4. Obtaining specific information
5. Closing the interview
 THE SEQUENCE AND CONTEXT OF THE INTERVIEW

PREPARATION,SEQUENCE , AND CULTURAL CONTEXT

1. PREPARATION ( before seeing the patient)

a. Review the Clinical Records

- this gives you a background information and
suggests areas to explore
- like the general data, past medications
and diagnosis.
b. Setting Goals for Interview
- clarify your purpose for the interview
- as a student, you need to make a comprehensive
history to comply with requirements
- for practicing clinicians, goals maybe to assess
regarding new concerns, to treatment follow up,
to completing forms
- consider to align your goals with the patient’s
agenda
c. Reviewing Your Clinical Behavior
and Appearance
-just as you observe the patient, he is also
observing your words and behavior
posture, gestures, eye contact,
- tone of your voice convey the extent
of your acceptance, interest, attention
and understanding
-patients find cleanliness, neatness,
conservative dress and a name tag reassuring
- patient’s perspective about you builds trust
d. Adjusting Environment
make the interview setting as private and
comfortable as possible
- These efforts are always worth the time
The sequence of the Interview
[Link] the patient and establishing rapport
[Link] the agenda
3. Inviting the patients’ story
4. Exploring the patients’ perspective

Refer to Bates’ for details on Cultural Context

p.75
1. Opening the Interview

-important in establishing
rapport with the patient

-use the 1st 20 seconds

of contact wisely
2. Assisting the patient’s
narrative

-a process of data gathering

by asking questions allowing
the patients to elaborate their
story without suggestion and
interruption
3. Focusing upon a topic
- Analyze the information given to
determine the main problem
- problems maybe both medical and
psychosocial
4. Obtaining specific information
-extract important information from
the past medical, social, work and
family histories of the patient
5. Closing the interview

- Try to summarize the history by highlighting

the key points

- Make suggestions and alternatives with the

probable outcomes, cost and adverse
effects.
 Classification of Medical History

1. Primary History
-centers on HPI,
-based on chief complaint

2. Secondary History
-centers on ROS
- Elaborates the HPI with certain amount of interpretation

3. Tertiary History
- Centers on the PMH related to HPI
Overview : Components of the Adult Health History
Chief Complaint /s
- The one or more symptoms or concerns causing the patient to
seek care.

History of Present Illness

-amplifies the CC

-describe how each symptom is developed

-includes the patient’s thoughts and feelings about the illness

- Includes the pertinent positives and negatives

- May include medications, allergies, tobacco and alcohol use

which are frequently pertinent to the present illness
PAST HISTORY
- Includes a list of childhood and adult
illnesses with dates of events in at least 4
categories ( medical, surgical, obstetrics /
gynecologic and psychiatric)

- Includes health maintenance practices like

immunization, screening test, lifestyle issues,
and home safety
FAMILY HISTORY

- Outlines or diagrams age and health

or age and cause of death , of
siblings , parents, and grandparents

- Documents the absence or presence

of specific illnesses in family such as
hypertension, diabetes or any type of
cancer
PERSONAL AND SOCIAL HISTORY
-Describesthe educational level, family of origin,
current household, personal interest and lifestyle
REVIEW OF SYSTEMS

-documents presence or absence of symptoms

Related to each of the major body systems
This is all
for today!
Thank you
for
listening!
The Cultural Context
of the Interview

WILFREDA [Link],MD.,LPT,MAED-EM
PDR2
AUGUST 25,2021
Demonstrating Cultural Humility—
A Changing Paradigm.

•Communicating effectively with patients

from every background has always
been an important professional skill.
It has been documented that there exist a gap in
the risk of disease,
 mortality and morbidity among different
population groups which reflects the:
 biases or imbalance in care access
 income and educational level
 language proficiency
 type of insurance and
 provider decision making
To moderate these disparities,
clinicians are increasingly urged to
engage in self-reflection, critical
thinking, and cultural humility as
they experience diversity in their
clinical practices
Taking Time for Self-Reflection.
Clinical Empathy or Mindfulness

• Mindfulness refers to the state of being “purposefully

and nonjudgmentally attentive to [one’s] own
experience, thoughts, and feelings.

• As you encounter people of diverse ages, gender

identities, social class, race, and ethnicity, being
consistently respectful and open to individual
differences is an ongoing challenge of clinical care.
Cultural competence
- is commonly viewed as “a set of attitudes,
skills, behaviors, and policies that enable
organizations and staff to work effectively in
cross-cultural situations.
Cultural Competence
- It reflects the ability to acquire and use knowledge
of the health-related beliefs, attitudes, practices, and
communication patterns of clients and their families to
improve :
1. services
2. strengthen programs
3. increase community participation and
[Link] the gaps in health status among diverse population
groups
Culturally competent care requires
“understanding of and respect for the
cultures, traditions, and practices of a
community
Cultural humility
- Is defined as a “process that requires
humility as individuals continually engage
in self-reflection and self-critique as
lifelong learners and reflective
practitioners.”
It has been documented that there exist a
gap in the risk of disease, mortality and
morbidity among different population groups
which reflects the biases or imbalance in care
access, income and educational level,
language proficiency , type of insurance and
provider decision making
It calls for clinicians to “bring into check the power imbalances
that exist in the dynamics of (clinician)–patient communication”
and maintain mutually respectful and dynamic partnerships
with patients and communities.

To attain these attributes, seek out the more effective training

models that continue to emerge
Cultural Humility:
Scenario
A 16-year-old high school student
came to the local teen health center
because of painful menstrual cramps
that interfered with her concentration
at school.
She was dressed in a tight top and short skirt and had multiple
piercings. The 30-year-old male clinician asked the following
questions:
“Are you passing all of your classes?
What kind of job do you want after high school?
What kind of birth control do you want?
What do you think of this situation?
The teen felt pressured into accepting birth control pills,
even though she had clearly stated that she had never had
intercourse and planned to postpone it until she got married.

She was an honor student planning to go to college, but the

clinician did not elicit these goals. The clinician glossed over
her cramps by saying, “Oh, you can just take some ibuprofen.
Cramps usually get better as you get older.” The patient will
not take the birth control pills that were prescribed, nor will
she seek health care soon again.
• She experienced the encounter as an interrogation, so
failed to gain trust in her clinician.

• In addition, the clinician’s questions made assumptions

about her life and did not show respect for her health
concerns.
• Even though the provider pursued important psychosocial
domains, she received ineffective health care because of
conflicting cultural values and clinician bias.
In this case, the clinician allowed stereotypes to
dictate the agenda instead of listening to the
patient and respecting her as an individual.
Each of us has our own cultural background and
our own biases. These do not simply fade away
as we become clinicians
• Avoid letting personal impressions about
cultural groups turn into professional
stereotyping.
• Evaluate each patient as an individual, not
decreasing the dose of analgesics, but staying
attuned to your reactions to the patient’s style.
• Work on an informed clinical approach to each
patient by consciously acknowledging your own
values and biases, developing communication skills
that transcend cultural differences, and building
therapeutic partnerships based on respect for each
patient’s life experience.

This type of framework, described in the next section,

will allow you to approach each patient as a unique
individual.
The Three Dimensions of Cultural Humility
1. Self-awareness. Learn about your own biases; we all have
them.

2. Respectful communication. Work to eliminate assumptions

about what is “normal.” Learn directly from your patients; they
are the experts on their culture and illness.

3. Collaborative partnerships. Build your patient relationships on

respect and mutually acceptable plans.
• Because we bring our own values, assumptions, and biases
to every encounter, we must look inward to see how our own
expectations and reactions affect what we hear and how we
behave.
• Self-reflection is a continual part of professional development
in clinical work. It brings a deepening personal awareness to
our work with patients. This personal awareness is one of the
most rewarding aspects
of patient care.
Culture is the system of shared ideas, rules,
and meanings that influences how we view
the world, experience it emotionally, and
behave in relation to other people. It can be
understood as the “lens” through which we
perceive and make sense out of the world we
inhabit.
The meaning of culture is much broader than
the term “ethnicity.” Cultural systems are not
limited to minority groups; they emerge in many
social groupings, including clinical
professionals
 Interviewing
the
Challenging Patient
As you spend time inviting patient stories, you will
find that some patients are more difficult to
interview than others.

For some clinicians, a quiet patient might seem

difficult, for others, a patient who is more
assertive.
Being aware of your reactions helps develop your
clinical skills.

Your success in eliciting the history from different

types of patients grows with experience, but take into
account your own stressors, such as fatigue, mood,
and overwork. Self-care is also important in caring for
others.

Even if a patient is challenging, always remember the

importance of listening to the patient and clarifying his
or her concerns.
The Silent Patient
Silence has many meanings.

Patients fall silent to:

1. collect their thoughts
2. remember details
3. decide if they can trust you with certain information
• Periods of silence usually
seem longer to the clinician
than the patient.

• Be attentive and respectful,

and encourage the patient
to continue when ready.
• Watch the patient closely for nonverbal
cues, such as difficulty controlling
emotions
• . Being comfortable with periods of
silence may be therapeutic, prompting
the patient to reveal deeper feelings.
• At times, silence may be the patient’s response to how you are
asking questions.
 Are you asking too many short-answer questions in rapid
succession?
 Have you offended the patient by showing disapproval or
criticism?
 Have you failed to recognize an overwhelming symptom such
as pain, nausea, or shortness of breath?

If so, you may need to ask the patient directly,

“You seem very quiet. Have I done something to upset you?”
 The Confusing Patient
o Some patients present a confusing array of multiple symptoms.
They seem to have every symptom that you ask about, or “a
positive review of systems.”

o With these patients, focus on the context of the symptom,

emphasizing the patient’s perspective (see pp. 77–78), and
guide the interview into a psychosocial assessment
 At other times, you may feel baffled and
frustrated because the history is vague,
and ideas are poorly connected and
hard to follow.

 Even with careful wording, you cannot

prompt clear answers to your questions.
The patient may seem peculiar, distant,
aloof, or inappropriate.
 Perhaps there is a mental status change
like psychosis or delirium, a mental
illness such as schizophrenia, or a
neurologic disorder.

 Consider delirium in acutely ill or

intoxicated patients and dementia in the
elderly. Their histories are inconsistent
and dates are hard to follow. Some may
even fabricate imaginary experience to fill
in the gaps in their memories
If you suspect a psychiatric or neurologic disorder, shift to the mental
status examination,
focusing on level of consciousness, orientation, memory, and
capacity to understand. You can ease this transition by asking
questions like

“When was your last appointment at the clinic?

Let’s see . . . that was about how long ago?”
“Your address now is . . . ? . . . and your phone number?”

You can confirm these responses in the chart or ask permission to

speak with family members or friends
to obtain their perspectives.
The Patient with Altered Cognition.

Some patients cannot provide their own histories because of

delirium, dementia, or mental health conditions. seizure. Under
these circumstances, you will need to obtain historical
information from other sources such as family members or
caregivers.
Always seek the best-informed source. Apply the basic
principles of interviewing to your conversations with
relatives or friends.
Find a private place to talk.
Introduce yourself, state your purpose, inquire how they
are feeling under the circumstances, and recognize and
acknowledge their concerns.

As you listen to their accounts, assess their credibility in

light of the quality of their relationship with the patient.
Establish how they know the patient
Some patients can provide a history, but lack the ability to make informed health
care decisions. You then need to determine whether a patient has “decisionmaking
capacity,” which is the ability to understand information related to health,
weigh choices and their consequences, reason through the options, and communicate
a choice. Capacity is a clinical designation and can be assessed by clinicians,
whereas competence is a legal designation and can only be decided by a court. If a
patient lacks capacity to make a health care decision, then identify the health care
proxy or the agent with power of attorney for health care. If the patient had not
identified a surrogate decision-maker, then that role may shift to a spouse or
family member. It is critical to remember that decision-making capacity is both
“temporal and situational”:62 It can fluctuate depending on the condition of the
patient and the complexity of the decision involved. A patient who is quite ill
may be unable to make decisions about care, but can regain capacity with clinical
improvement. A patient may be unable to make a complex decision, but still
able to make simple decisions. Even if patients lack capacity for certain decisions,
it is still important to seek their input, as they may have definite opinions
about their care
Read [ng assignment:
O1. talkative patient
[Link] patient
[Link] or disruptive patient
[Link] with a Language Barrier
5. Patient with Low Literacy or Low Health Literacy
[Link] Hearing Loss and Impaired Vision
7Patient with Limited Intelligence
8. Patient with Personal Problem
[Link] Patient
Sensitive Topics
These discussions can be awkward when you are inexperienced or assessing
patients you do not know [Link] seasoned clinicians are inhibited by societal
constraints when discussing certain subjects:
1. abuse of alcohol or drugs,
2. sexual practices
3. death and dying,
4. financial concerns,
5. racial and ethnic bias
6. domestic violence
7. psychiatric illness,
8. physical deformity
9. bowel function, and others

Many of these topics trigger strong personal responses related to family, cultural, and
societal values. Mental
illness, drug use during pregnancy, and same-sex practices are examples of issues
that may evoke biases that affect your interaction with the patient
Several basic principles can help guide your response
to sensitive topics:
Guidelines for Broaching Sensitive Topics
1. The single most important rule is to be
nonjudgmental.
Your role is to learn from the patient and help the patient achieve better health.
Acceptance is the best way to reach this goal.

2. Explain why you need to know certain information. This makes patients less
apprehensive

[Link] opening questions for sensitive topics and learn the specific kinds of
information needed for your shared assessment and plan.

4. Consciously acknowledge whatever discomfort you are feeling. Denying your

discomfort may lead you to avoid the topic altogether.
 The Sexual History

 Exploring the sexual history can be life-saving.

 Sexual behaviors determine risks for pregnancy, STIs,
and human immunodeficiency virus (HIV); good
interviewing helps prevent or reduce these risks.

 Many patients express their concerns more freely when

you ask about sexual health

 In addition, sexual dysfunction may result from

medications or clinical issues that can be readily corrected.
You can elicit the sexual history at multiple points in the interview
If the chief complaint involves genitourinary symptoms, include questions about
sexual health as part of “expanding and clarifying” the patient’s story.

For women, you can ask these questions during the Obstetric/Gynecologic section
of the Past Medical History.

You can include the sexual history in discussions about Health Maintenance, or in
the Personal and Social History as you explore lifestyle issues and important
relationships.
In a comprehensive history, you can also ask about sexual practices during the
Review of Systems.
Do not forget to cover the sexual history in older patients and patients with
disability or chronic illness.
 The Mental Health History
Cultural constructs of mental and physical illness vary widely, leading to
differences in social acceptance and attitudes. Think how easy it is for
patients to talk about diabetes and taking insulin compared with
discussing schizophrenia and using psychotropic medications.

Ask open-ended questions initially. “Have you ever had any problem
with emotional or mental illnesses?”
 Then move to more specific questions such as
“Have you ever seen a counselor or psychotherapist?”
“Have you ever taken medication for a mental health condition?
“Have you ever been hospitalized for an emotional or mental health
problem?”
“What about members of your family?”
Watch for mood changes or symptoms such as fatigue, unusual
tearfulness, appetite or weight changes,
insomnia, and vague somatic complaints.

Two validated screening questions for depression are:

“Over the past 2 weeks, have you felt down, depressed, or hopeless?”
and
“Over the past 2 weeks, have you felt little interest or pleasure in doing things?”

If the patient seems depressed, always ask about suicide:

“Have you ever thought about hurting yourself or ending your life?
 Alcohol and Prescription and Illicit Drugs
The high prevalence of substance abuse makes it is essential to routinely assess current and past
use of alcohol and drugs, patterns of use, and family history. Be familiar with current definitions of
addiction, dependence, and tolerance.
Addiction, Physical Dependence, and Tolerance

Tolerance: A state of adaptation in which exposure to a drug induces

changes that result in a diminution of one or more of the drug’s effects
over time.
Physical Dependence: A state of adaptation that is manifested by a drug
classspecific withdrawal syndrome that can be produced by abrupt
cessation, rapid dose reduction, decreasing blood level of the drug,
and/or administration
of an antagonist.
Addiction:
 A primary, chronic, neurobiologic disease, with genetic,
psychosocial, and environmental factors influencing its
development and manifestations.
 It is characterized by behaviors that include one or more of the
following: impaired control over drug use, compulsive use,
continued use despite harm, and craving.
Source: American Pain Society. Definitions Related to the Use of Opioids for the Treatment of
Pain. A consensus statement from the American Academy of Pain Medicine, the American Pain
Society, and the American Society of Addiction Medicine, 2001. Available at [Link]
org/docs/public-policy-statements/1opioid-definitions-consensus-2–[Link]?sfvrsn=0. Accessed
January 13, 2015.
 Alcohol
Questions about alcohol and other drugs follow naturally after
questions about caffeine and cigarettes. “Tell me about your use of
alcohol” is an opening query that avoids the easy yes-no response.
Remember that some
patients do not consider wine or beer as “alcohol.” Positive answers to
two additional
questions are highly suspicious for problem-drinking:

“Have you ever had a drinking problem?” and “When was your last
drink?”, especially if the night
before.
The most widely used screening questions are the CAGE questions about Cutting
down, Annoyance when criticized, Guilty feelings, and Eyeopeners.

The CAGE Questionnaire is readily available online.

Two or more affirmative answers to the CAGE Questionnaire suggest alcohol

misuse and have a sensitivity that ranges from 43% to 94% and specificity
ranging from 70% to 96%.90,91 Several well-validated short screening tests,
such as the MAST (Michigan Alcohol Screening Test) and the AUDIT (Alcohol
Use Disorders
Identification Test), are also helpful.

If you detect misuse, ask about blackouts (loss of memory about events during
drinking), seizures, accidents or injuries while drinking, job problems, and conflict
in personal relationships.
 .
Illicit Drugs.
The National Institute on Drug Abuse recommends first asking a highly
sensitive and specific single question:
“How many times in the past year have you used an illegal drug or used a
prescription medication for nonclinical
reasons?
If there is a positive response, ask specifically about nonclinical use of illicit
and prescription drugs
: “In your lifetime have you ever used: marijuana; cocaine; prescription
stimulants; methamphetamines; sedatives or
sleeping pills; hallucinogens like lysergic acid diethylamide (LSD),
ecstasy,mushrooms…; street opioids like heroin or opium; prescription
opioids like fentanyl, oxycodone, hydrocodone…; or other substances.”
For those answering yes, a series of further questions is
recommended.
Another approach is to modify the CAGE questions by adding
“or drugs” to each
question. Once you identify substance abuse, probe further with
questions like

“Are you always able to control your use of drugs?” “Have you
had any bad reactions?”
“What happened . . . Any drug-related accidents, injuries, or
arrests?
Job or family problems?” . .
. “Have you ever tried to quit? Tell me about it.”
Intimate partner Violence and Domestic Violence

Violence is the leading cause of serious injury and the second leading cause of death
among U.S.
 women and men experience rape, physical violence, or stalking by an intimate
partner; these are groups that experience high rates of mental health disorders
And substance abuse.

 Elders are also highly vulnerable to neglect and abuse.

 Sensitive interviewing is essential, since even with skilled inquiry, only 25%
of patients disclose their abuse experience.
Disclosure is more likely when probing questions lead and then in depth
direct questions follow.
“Are you in a relationship where you have been hit or threatened?”
with a pause to encourage the patient to respond.

If the patient says no, continue with

“Has anyone ever treated you badly or made you do things you don’t
want to?”
or “Is there anyone you are afraid of?”
or “Have you ever been hit, kicked, punched, or hurt by someone you
know?”

Following disclosure, empathic validating and nonjudgmental responses

are critical, but currently occur less than half the time.
 Clues to Physical and Sexual Abuse
 . Bealert to the unspoken clues to abuse, often present in the
growing numbers of victims of human sex trafficking.

 When you suspect abuse, it is important to spend part of the visit

alone with the patient. You can use the transition to the physical
examination as a reason to ask others to leave the room.
 If the patient is also resistant, do not force the situation,
potentially placing the victim in jeopardy.
 Be attuned to diagnoses that have a higher association with
abuse, such as pregnancy and somatic symptom disorder.
To begin screening for child abuse, ask parents about their
approach to discipline.
Ask how they cope with a baby who will not stop crying or a child
who misbehaves:
“Most parents get very upset when their baby cries (or their child
has been naughty).

How do you feel when your baby cries?”

“What do you do when your baby won’t stop crying?”
“Do you have any fears that you might hurt your child?”
Clues to Physical and Sexual Abuse
● Injuries that are unexplained, seem inconsistent with the patient’s story, are
concealed by the patient, or cause embarrassment
● Delay in getting treatment for trauma
● History of repeated injuries or “accidents”
● Presence of alcohol or drug abuse in patient or partner
● Partner tries to dominate the visit, will not leave the room, or seems unusually
anxious or solicitous
● Pregnancy at a young age; multiple partners
● Repeated vaginal infections and STIs
● Difficulty walking or sitting due to genital/anal pain
● Vaginal lacerations or bruises
● Fear of the pelvic examination or physical contact
● Fear of leaving the examination roo
Thank You
 INTERVIEWING TECHNIQUES

FORMS OF COMMUNICATION
ACTIVE LISTENING SKILLS
COMMUNICATING IN SPECIAL SITUATIONS

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FoRMs oF CoMMUNICA.T!oN

Communication is a dynamic process. Ir involves~ a desired

response through verbal symbolization. The ~ i t s e l ~ 1) stimu-
lus 2) perception 3) interpretation 4) decision 5) encoding 6) mes-
~ e 7) response and 8) channel. These elements are always prese~
whatever form of communicalion 1s used, whether it be verbal, non-
verbal or symbolic.

VERBAL COMMUNICATION
Much of the time m the clinical interview 1s spent on verbal

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·
r
n_, t 1c conrn.: o i-he 1nt l' rv 1c w . rhc 1, h , "ci:rn
sI10uld use J voc-1bul -, . I ·11 b spc.1ki 11 g , rcad i111~ .111d w11u11L~- ,luL1 <1 r
..: c;1s 1·1y understood hv 1hL p:1t1
, t:1 H. 111 .1 p .111c 11 1 ;,·\.111 , 111 .li'I"· 1h c.:•,L
• -'') 1 1::ir .v1
The use of techn ic:il r,<:rms. an J mcL-11·ecu _1 • I · skill ~ .in: ll CC LSS;1r y 111 III\ It' r:1 uk 111 i-; , rn .11n 1.1 111 i 11t' 11c,: 1, ., I c·u1 1, ! ··.
prgo n s 1ould be .11·o ided 111 prcscriptiLrn wri11 ng ,111cl hc;1Irh cduca 1ion .
order
_
to make the pati ,
_
+ I d
<:nt L c:1 r y un ersr:m
d wlur
. . . 1s
the phys1c1:1.n
saying. In threshing o ut sc nsirive issues, the patiem 's education , he1lch
Ac nvE L 1sTENtNc SKtLL.5
beliefs and culcura.l backITT - 1 be ta1<en ·into cons1der:1tion
::, oun cl !>·h ou Id [Link] ·
when interviewing. Intcrpreting a. nd reacting to the patient's narrative Listening requires a complex of physi ological. neurological , and psy-
statemenr should be avo ided . chological factors in order to understand and reta in ve rbal mace r_i als
presented in spoken form . Ir plays an important part in co mmunJCa-
NONVERBAL COMMUN ICAT ION cion. le can be improved through practice, identificat io n with the
- - - - -- -----The-nmwerbaHorm of comm unicacion-is-often-neglecced-in rnedi- - \ ___ speaker,-watch ing-the-speaker,-and-organ izing-what is-heard .--- ·
cal interviews because the concenaarion is mainly on the verbal form. A doctor-patient encounter should be an act ive one and not pas-
However, this aspect is very important since it helps physicians ex- sive. This requires the use of the d ifferent forms of com mun ica tio n as
plore psychosocial problems [Link] analyze the impact of illness on pa- well as skills. The skills are divided into three clusters: listeni ng, lead -
tients and their family. ing and reflecting.
Nonverbal communication rakes several forms: 1. LISTENING SKIW CLUSTER
Eye contact indicates sincerity, bur it does not mean that physi- Superficially, listening implies a pass ive act, bur actually it involves
cians has to have a frxed scare in order to be effective. Scaring might a very active process of responding to total messages . It is not simply
threaten your paciems. listen ing with your ears to the patient's words and with your eyes rn
Mannerisms. These should be avoided because they distract the his body language but a total kind of perceptiveness. It includes at-
patient while he cells the hiscory of illness. tending, paraphrasing _a nd perception checking.
• Touch. This connotes char the phys ician wanes to establish a sense Attending includes greetings, eye contact, posture, gesture, and verbal
of personal relacionship with the patient. statements that relate without interruption to the patient's statement.
Gesture. This should be done with ease so char it appears sponta-
Paraphrasing is a method of restating yo ur patient's basic message
neous and avoids disuacr1ons .
Tone of voice. One's voice should be modulated in order co avoid
in similar but fewer words. The main purpose is co test under-
standing of what the patient has said. It also conveys crying co
threatening the pacienc.
understand the message. An example:
• Posture. The interested physician le:ins forward coward the pa-
tiencin a relaxed manner. leaning backward or crossing one's :urns Patient (voice trembling) : My chest pain started last month.
may communicate that che physician is not interested in what his I j ust took paracetamol and it was relieved. But it recurred last
paciem is saying. week and I consulted at the health center. Nfy ECG showed nor-
mal results. Now it keeps coming back.
SYMBOLIC COMMUNICATION
Desaipcive of the external manifestations of both che paciencs and Doctor: This is the third time that you had chest pain and
you can't understand what is the cause.
the physician , symbolic communicat ion includes che manner of
dressing, hairstyle, lifesryle , and social distance. As a physician , one Perception checking helps clarify what you ~eard from yo ur pa-
muse dress professionally when going w rhe clinic and maintain a com- tient , usually over several statements . It is si milar co paraphrasing
f~rrable distance wic:h the patient when interviewing. in content; the difference lies in the interrogative phrasing. An
example:
The four commonly adapted [Link] skills are listen ing,

28 29
 l'he Filipino Physician Today ,..._

communic u ion · D unn · g r hc courst: o l·- t /1e 111c

· crv 1·cw, 1I1c: p I1ys 1cun
·· · spce1k in g , readi ng .111 d wrn in g . 111 .1 du c1nr-p.111c111 rc la r1 onsl11p . Lh cSe
sh o uld use a voc:ib ub ry rh::u will bL· ..:;.1s ily unJcrs t,lL>J hy the p:1 ci t: 11 1. :; kills arc n cc..:ss:ir y in lrnrory cak in g , rn.11111 :1in i11 g ncdi , .d rccoi d s,
The use of rechn ic3.l terms and rncdicaJ jargo n should be :1 vni J ..:d in prescriptio n wri1 ing an d hc:1ltl1 edu cat io n.
order to make the pa tient cle:i rly understand wh at the physician is
saying. In threshing o ur sensitive issues, the patient 's education , health A CT IVE LI ST EN ING SKILLS
beliefs and cultural backgro und should also be taJcen into consideration
Listening requires a complex of physiological , neurological. :ind psy-
when interviewing. lnrcrprcting and reacting ro the pa tient's narrative
chological factors in order to understand and re tain ve rbal mate rials
statemenr should be :ivoided.
presented in spoken form . Ir plays an important part in co mmun ica-
NONVERBAL COMMUNICATION tion. It can be improved through practice, identification with the
The-n011verbaHorm of comm unication-is-ofren-neglected-in medi- - - - ... speaker,-warching-the-spealrnr,-and-organizing-whar-is-heard-. --- - -
cal interviews because the concentration is mainly on the verbal form . A doctor-patient encounter should be an active one and not pas-
However, this aspect is very important since it helps phys icians ex- sive. This requires the use of the d ifferent forms of commun ication as
plore psychosocial problems and analyze the impact of illness on pa- well as skills. The skills are divided into three clusters: listen ing, lead-
tients and their [Link]. ing and reflecting.

Nonverbal communication takes several forms: 1. LISTENING SKiw CwsTER

Eye contact indicates sinceriry, but it does not mean that physi- Superficially, listen ing impl ies a passive ace, but actually it involves
cians has to have a fixed srare in order robe effective. Staring might a very active process of responding ro total messages. Ir is nor simply
thre:iten your patients. listen ing with your ears to the patienc's words and with your eyes to
• Mannerisms. These should be avoide_d because they disuact the his body language but a total kind of perceptiveness. Ir includes at-
patient while he tells the history of illness. tending, paraphrasing _and perception checking.
• Touch. This connotes that the physician wants to establish a sense Attending includes greetings, eye contact, posrure, gesrure, and verbal
of personal relationship with the patient.
statements chat relate without interruption to the patient's statement.
• Gesnue. This should be done with ease so rhar it appears sponta-
neous and avoids d iscracrtons. . Paraphrasing is a method of restating your patient's bas ic message
• Tone of voice. One's voice should be modulated in order ro avoid in similar bur fewer words. The main purpose is to rest under-
chrearening the patient. standing of what the patient has said. Ir also conveys trying ro
• Posture. The interested physician leans forward toward the pa- understand che messag~ . .An example:
tiencin a relaxed manner. Leaning backward or crossing one's :[Link] Patient (vo ice trembling) : My chest pain starred last month.
may communicate chat the physician is not interested in what his !_ju.st took paracetamol and it was relieved But it recurred last
patient is saying. week and I consulted at the health center. lvfy ECG showed nor-
5YMBOLlC COMMUNICATION med results. Now it keeps coming back.
Descriptive of the external manifestations of both the patients and Doctor: This is the third time that you had chest pain and
the physician , symbolic communication includes the manner of you can't understand what is the cause.
dressing, hairstyle, lifestyle, and social distance. As a physician , one Perception checking helps clarify what you 9-eard from your pa-
must dress professionally when going co the clinic and maintain a com- tien r, usually over several statements. Ir is similar co paraphrasing
fortable distance wich the patient when interviewing. in content; che difference lies in rhe interrogative phrasing. An
The four commonly adapted communica_tion skills are listen ing, example:

28 29
 _, _; - - ..:J

The Filipino Physici~

■: ■:
1

Today
•.:
Patient: lvfy blood pressu re is on the rise because J ,tm both-
story. [r c m usu:illy bt: :rnswc rt:<l with ::i wo rd ,) r :.1 b rief scn rence,
ered? ,l lot ofthings at home. The kids are very noisy tlnd keep
runmng around My husband is alway s shouting even at lit:tle which is usu;illy an cx::ict d :ira [Link] gives rhe pJ. cient littl e roo m for
things_ My mother-in-law has a poker fa ce. expl;ination. Examples are: '' W h;it is you r name ;" '' Where J o yo u
live?" "What is your job?"
Doctor: You mean you have a lot ofproblems right now. Am
I right? -2. Yes-no questions are those answerable by ei ther "yes" or "no"
and are used for obtain ing the fa mily history or fo r the review o f
2. LEADING SKILLS CLUSTER . systems.
- - - - -- ---- - ~his_cluster includ~[Link]:_e_c5 leading.!._~rec~ ~~~-i~~• focusing, and 3. Confrontation questions are based on an observation by the
quest1orung. - ---- - - - -------- ,:·- - - - - - --- physician that po1nrs- i:o- a pacienr's striking behavior or pr~~~- - -- --
- l d" h l
l n d zrrct , statement. Examples are chose which start with the word why. They
/ ea mg e ps the patient get started and gives him a. cue to ,
are not recommended for use since they connote a threatening im-
. keep the interview go ing. An example of indirect leading would
pact on the patient. Bue they could be modified so char the word why
be your nonverbal. communicarion such a.s nodding or hand ges- i, •.
- will be in the middle of the question. You can therefore ask, "Is there
[Link]. A verbal statement such as "What can I do for you?" is { any reason why you ;_.ere not able to take your meditations?"
another example. ,
4 . .Probing questions explore the previous statement of the pa-
Direct leadinu focuses the topic more specifically. It encourages
o ciem. An example:
the patiem to elaborate on what he is saying. This can only be
used if indirect leading has been done. An example: Parienr: I have had this headache since last week. It has be-
come intolerable today. It's as ifsomething is pressing on my right
Patient: Dr. Sison, I've been having this chest pain for th e head. I self medicated with paracetamol but there was no relief
last nvo weeks. ft usually occurs when I am studying my lessons.
Dr. Sison: Kindly explain to me the circumstances that Led Doctor: Aside from studying, is there any other incident that
to yuur chest pain. could have provoked your headache?

Focusing is used when there is confusion on the part of the physi- 3. REFLECTlN G S1<1u.s CLUSTER
cian because the patient tries to mix confounding data.. An ex- Reflecting is one way of expressing to the patient that the phys i-
ample is as follows: cian is in his frame of reference and shares his deep concern. There are
Patient: Three days ago, I had this headache. I also lost ap- three areas of reflecting: feelings , content and experience.
petite and my hands seem to be trembling. I experience it any Re;1ecting feelings determ ines what feel in g the patient is express-
time ofthe day . . ing_ Observing his reactions and asking for feedback regarding
Doctor: It seems that you have a lot ofproblems. Let us go the reaction will help. Probing can lead into reflection also. An
over them one at a time. So let's talk about your headache first. example:

QUt:Stionint may be conducted in the form of o~en-ended or_closed- ·Patient: I cannot understand why I am having this head-
. . b d propnarely The different ache far three weeks now. lvly grandmother also had the same
ended questions , but it must e use ap . . d
. b I·no yes -no quesr10ns, a n thing fast year and she died ofit.
forms are direct quesr10ns , pro o•
Doctor: So you're afraid that the same thing might happen
confi-onracion quemons -
.fy d dd detail co the to you_
I. Direct questions serve ro clan areas an a
31

30
 Reflecting cont 1 ·
h k'
- • .. . . ... v

I I
,· uy1>1cun ·today

en invo ves t 1e use of par:iphr:is ino :i n<l perception

c ec mg. I~ helps the patient express h imself cle:i;ly by giving him
words t_o picture .our what he s:iid. Examples of paraphr:ise and
• •
Fir5r,
■ ••, •
'T he n1y sicia;, a" ~eal ~1 '-...ue fwv,der ·

the doctor should 1~k patient directly how much he knows

Jbo ur the, "ba cl news. " ·r n CJse the pa ne
:,
••
· nr see ms rductanc m know t he
truth regar d.111g h.1s ·I 11 ness, ·11 sl1ou l<l be ·impressed 11pon him
. chat his
·
'

percepnon check are given above.

condition is serious and is life-threatening. The docto r has to explore
Reflectin~ expen·ence is a descriptive feedback rhar relates broad psychosocial issues and facilitate a change in awareness. Through reas-
observations of the patient. An example is: surance, the physician should encourage the patient to ask questions
Doctor: I notice that your hands are tremblin . What does or ventilate his issues, then confirm his opin ion if ir is correcr, or re-
this imply? i fure it and explain why, if ir is nor.
- --- - - - - ---- --
Second, the doctor should disclose rhe bad news by using emotive
- words-with-cue.-Active listenings [Link] should be used. After giving the
information, the physician should allow rime for the patient to absorb
TERMINAL [Link] AND BEREAVEMENT: DISCLOSURE ir. By doing so, he addresses the patient's feelings,
Muth of the difficulty in communication in cases of terminal ill- Third, the physician should discuss the treatment options and
ness. cente~ around the diagnosis and prognosis. Some physicians are involve the patient in decision-making and plans,
afoud ~o dis~lose the "bad news" because of its consequences. This
Fourth, the doctor should summarize and check the patient's un-
results m vanous errors: simply not doing it and hoping another col~
derstanding of the illness as well as his plans.
league would do it, deliberately not picking up the patient's cues, falsely
adapting or putting on an aura of deepening gloom, or lying outright. Finally, the patient should be given information regarding sup-
pore services.
Since trust is an essential component in the doctor-patient rela-
tionship, the decision- making abouc· the flow of information has co be
VARJOUS PATIENT'S CHARACTERISTICS
carried out as a delicate negotiation between the doctor and the pa-
Every patient mwifests different characteristics, and physicians
tient. The doctor must ascertain how much the patient wants to know
should know how to respond to a particular type, whether he be the
and make his disclosure appropriately. The attending physician should
demanding, detached, emotional, unhygienic, or harassing type of pa-
be the sole and primary agent responsible for breaking the bad news. tienr.
As such, he should be emotionally mature and stable, capable of giving
empathy and encouragement, show emotional sensitiveness, technically. The demanding patient usually resorts to hostile behavior or anger
knowledgeable and capable of imparting information in a simple way. when his excessive demands for attenrion are not mer. The physi-
cian should nor respond in an angry manner or high-pitched voice;
The disclosure must be done in a private place [Link]
instead, he should expiore the issue by saying, "Can you tell me
can see each other face to face. Relatives may be with the patient dur- what happened why you're so angry?"
ing that rime. If the patient permits, other members of the medical
st:iff may also be present. Generally, however, the patient will opt to The detached patient does not q re for any interpersonal contact
have it confidential. Wharever che preferred circumstances, the disclo- and is usually shy and resentful of having his privacy intruded.
sure should be done when there are conclusive rests already and when The physician needs to establish rapport first in order to gain his
the parienc is physically and emotionally re~dy. Otherwise, there is a co nfidence.
need co explore certain iss ues through counseling. The unhygienic patient, however irritating his appearance may be,
The truth regarding diagnosis, prognosis and treatment should be should not elicit in the physician event he faintest dislike. Instead,
rold in a gradual, reassuring manner. Technical terms should be avoided. the physician should carry on with the interview, then lacer inform

32 33
 ·-: ··!
; '.

'
I

The filipino
■!
!
.

Physician loctay
■·
•
,

'

•• • '

the caregiver that [Link] has co be done rega rding the patien r's
hygiene.
• The emotional patient tends to overdramarize to se~k attention .
The physician has co address psychosocial issues raised because
these might have a bearing on the patient's medical problem.

• To the harassing patient, the physician should give positive feed-

back first, so he could ·then focus on che problem at hand. ·

--·--·------ -- -XHE -NONCOMPLIANT-RATlENT-- ----- - --- ---- - - --~- - ------ - -· - --- --------- -
Compliance is often seen as one of the problems encountered in
clinical practice. Among patients who seem to forget their medica-
tions as well as their follow-up with the physician, the physician is in a
firm position to influence compliance. For e~ample, if he wants to
check for compliance, he should ask the patient who might not be
always reliable. It is important that the question should never start
with why; instead, it should be face-saving, nonthreatening, and
nonjudgmental. An example is:" Most p~ople find it difficult to take
their medications. Did you miss any ofyour pills since the last time I
saw you?" If the answer is in the affirmative, the doctor should not get
angry at the patient but instead try to explore issues why he 'missed it.
Then, he should handle the patient's distress.

The guidelines mentioned will help you deal with ·difficult com-
~unication situations. Bear in mind, however, that practice is needed
m order to master these skills?

CASE RESOLUTION
Apnlvino •1Miun lict,,ninfl •lr'll I ·1 · ·
~.JuS
. .. 1"" , .... b - - · "' -'-"'"'-'•Ullt, 'N,1L.e n1terv;cwing ~lan .. : ,h.. ,l.. ~1-. • .... · · ·
ccssfully elicit the impact of illness o _aa.ua.11 , u,e p11y;iiCiai1 IS able to sue-
is then able to ide tif I f n her by probing on her statement "Why me?" He
- n y ier ears and consequently address them.

34
 HISTORY TAKING

THE MEDICAL INTERVIEW

CLASSIFICATION OF THE MEDICAL HISTORY
FORMAT OF THE HISTORY

CASE SCENARIO
Maria, 60, consults because of chesl pain. She is overweight and is fond of eating oily
food.
____________________________ __,,/

THE MEDICAL INTERVIEW

An interview consists of an interchange of ideas through question and

answer in order to. achieve a purpose. The interviewer and the inter-
viewee aimto give and receive information and create good relation-
ships. In a doctor-patient relationship, a good interview should result
in an accurate and comprehensive story of the patient's situation. Thus,
it. should be well-planned and organized.

PHASES OF THE MEDICAL INTERVIEW

I. Opening the interview

This is important in order to establish rapport with the patient.
Use the first 20 secon~c. of contact wisely. Greeting the patient
and using attending skills is warranted. Then verify the main rea-
son for the patient's visit.

2. Assisting the patient's narrative

Develop a worka~le process for data gathering through rhe use of
open-ended questions wherein the patient can elaborate. Then
follow up the answers with facilitation, empathic replies and, if
warranted, silence to learn as much as the patient is able to tell
without suggestion and interference from you.

37
 The Filipino Physician Today 1- ,1:, 10 ,. y T .,,-.H lt:,
\)1--- - ~
Focusing upon a topic Tab le I. l'O ll MAr l) FTI IE \ ll'lllCll . lll'.:Tl 11t'/
-u,d\-/ -~ lh~@oo1
~
Analyze the information given by the pacicm in ordcr to deter- HISTOll'f DATA BASE OUTLIN E
mine the problem. If there arc sever:il pro blems d iciced , focus 0 11
✓\I
Key Content Areas - Check if discussed
it one at a time. Problems may be both medical and psychosocial. ,. ,I
A. GENERAL DATA
- --~- - -- - - - - - - - -- '/JVA,
- i
4. Obtaining specific information B. CHIEF COMPLAINT _ __ _ __ _ _ _ _ _ _ _ __ _
I
Elicit relevant data from the past medical , social, work and family
C. HISTORY. OFTHE PRESENT ILLNESS

II
hiscories of the patient. Us ing the same techniques as the first three ====-o 1. Characteristic of 0 8. Patient's expectations
phases, yes-no questions and direct questions may be used. Symptoms 0 9. Patient's reason for visit
0 Location 010. Preferences for end-of-life
5. Closing the interview 0 Radiation _;_. care (if appropriate)
0 Quality D. PAST MEDICAL HISTORY
Summarize what transpired during the interview by highlighting 0 Severity/Intensity
0 1. Childhood illness
the key points. Present some suggestions and alternatives, along 0 Timing (onset, duration)
0 2. Immunizations
0 Sudden, gradual
with their probable outcomes, cost and adverse effects. Give a 0 3. Adult illness/ hospitali-
0 Acute, chronic zations
follow-up schedule in order to monitor the patient's progress as 0 Frequency/Pattern 0 4. Operations
well as compliance with the management of illness. (intermittent, continuous, 0 5. Injuries/Accidents

CLASSIFICATION OF THE MEDICAL HISTORY

progressive)

0 Aggravating/Exace rbat g
0 6. Obstetric History
0 7. Transfusions \
factors E. CURRENT HEALTH STATUS
The primary history centers on the history of-present illness. Based 0 Alleviating factors O 1. Medications -
0 Associated manifestations 0 2. Allergies and Drug
on the chief complaint, you have to elicit the location, radiation, Reactions
0 2. Associated active medical,
quality, quantity, duration , frequency, aggravating and relieving surgical or psychiatric 0 3. Health Screening (prior
factors, associated symptoms, and effect on· function. problems which may exc!ms, cholesterol, etc.)
impact the Chief 0 4. Diet, Sleep, Exercise
The secondary history centers on the review of systems. It will Complaint O 5. Tobacco, Alcohol, Drugs
0 3. Past experience with F. PSYCHOSOCIAL HISTORY
help expand the history of presem illness. Unlike the primary his- symptom(s) 0 1. Marital status
tory, a cenain amount of interpretation is needed. 0 Prior Treatment? 0 2. Living arrangements/
Response? Data from past Family structure
The tertiary history centers on the past medical history which charts? 0 How are things at
may have a bearing on the patient's illness. O What has patient done home?.
about the symptom(s) O 3. Support/Secondary Gains:
0 4. Significant positives and
are there people you can
FORMAT OF THE MEDICAL HISTORY negatives.
rely on for help? How have
History ralr,.ing is usuilly tl1e first 2 ....r1d most impo!'ta..'1t part of ch,e 0 5. What was the
family or friends
psychosocial context of
health care process. The physician must know what information to get responded to the illness?
the onset of the
0 4. Employment history/job
and liow to gee it while building a relationship as he proceeds. The symptoms?
satisfaction
· 0 6. What is the patient's
format of the history is outlined in Table l. 0 5. Sexual history/function
understanding of the
0 6. Significant life events;
disease? Especially
deaths; divorce, financial
causes/implication/fears
hardships
0 7. impiJct of the disease c! nd/
or its treatment on the G. FAMILY HISTORY
patient's life, work 0 1. Current health of parents,
relation ships siblings, children

38 39
 The l'thpino l-'h .
ys1c1an .1 ooay

H 1s rory T uon g
g 2. History of significant illness
3. Death: dates and..ages at death
/
PSYCHOSOCIAL HISTORY
H. REVIEW OF SYSTEMS I T his incl udes info rm:1rio 11 on the.: c.: duc:n io11 . lifr c.:xoeri c.: ncc•;, 1nLI pe r-
son al relationships of chc pa tic.:11 t. •
I. FUNCTIONAL STATUS
Does your health interfere with:
0 1. Taking care of yourself ( . . SEXUAL, REPRODUCTIVE AND GYNECOLOGIC HISTORY
0 2. Your daily activiti ( e.g. to, 1etmg: bathing, dressing)? Th is embraces inform ation on che pati ent's sex ual activity anJ symp-
es working, shopping, housecleaning, cooking)?
toms related to it such as dyspareunia, discharges. Inquiries about sex ual
Sour-cc: Dcputmcnc oflmcm~l Med icine, UST n cuJry f Mccf .
o • io nc i nd Surgery, reprinted wich pam W:ion. relations should be conducted in a nonjudgm en tal manner. D irect
questions regarding oral and anal sex, sexual contacts, and sexual prob-
CHIEF COMPLAINT
lems are important.
The chief complaint is the reason why th . h . For the reproductive and gynecologic history, one must inqu ire
. . e paaent soug_ t medical at-
tenaon . It establishes the agenda for the incervie 5 · about a woman's age of menarche, regularity of mensuual flow, and
h I w. ome paaents may
av~ a or_ of complaints so that the physician needs to focus on a duration of periods. The date of the last menstrual period and then
parncular Jtem by asking, "Which is your most pressing problem?" past menstrual period should be determ ined . In addition , one must
ask about the number of pregnancies, deliveries, abortions, and compli::-
HISTORY OF PRESENT ILLNESS cations of pregnancies. In the reproductive history of a man·, it is impor~-
An elaboration of the information relevant to the chief complaint, the cant to ask about sexual interest, function , satisfaction, and problems.
history of present illness should answer the questions what, when, how,
where, which, who and why. The use of open-ended questions will help. REVIEW OF SYSTEMS
Ir is important to establish the chronology of the events. This includes the list of possible symptoms that m ay have been over-
looked in the History of Present Illness or additional symptoms which
PAST MEDICAL HISTORY may be unrelated to the patient's illness. A best organized review of
This consists of the overall assessment of the patient's health prior to systems contains questions that start from the head and proceed down
the illness. Ir includes past illnesses, hospitalizations, surgery, allergies, to the extremities. The specific symproms to ask about each organ are
immunizations, lifestyle (diet; exercise, smoking, alcohol use and sub- listed in Table 2 below.
stance abuse) , sleep patterns, and current medications. Head Ask about nausea, vomiting, stress in work, headache, seizures, loss of
consciousness, trauma . Understand the time course of the symptoms.
l
t..·
OCCUPATIONAL AND ENVIRONMENTAL HISTORY Eyes Ask about visual changes, loss of vision, blurring or double-vision, presence
Occupational hisrory is mainly concerned with exposure to certain of spot!; or flashing lights.
diseases in me place of work and environment. Ir is imporrant ro in- Ears Ask about hearing loss, ringing in the ears, dizziness, vertigo, ear discharge.
quire on the nature arid duration of the job as well as the use of protec- · Nose Ask about nasal catarrh, bleeding, itchiness and i.f this has a seasonal pattern.
tive devices. For the environmental history, one must inquire on the Throat Ask about sore throat, cough, difficulty in swallowing.
location of the residence as well as possible hazards in the environ- Chest, Heart and Lungs Ask about palpitations, skipped beats. chest
[Link] of breathing, difficulty sleeping flat on bed and whether this has
ment. a relationship to activity.
Abdomen Ask ab~ut nausea, vomiting, loss of appetite, urinary symptoms. change
FAMILY HISlORY
in bowel habits and color of the stools, pain.
Paying attention to possible genetic influences on the disease, the phy-
Extremities Ask about joint pains and signs of inflammation such as redness,
sician should inquire about the diseases acquired by the patient's rela- swelling, heat or loss of function .
tives.
Table 2. REVIEW OF SYSTEMS

41
40
 E~d~dy patienrs pose special problems and issues. They often face
chr~n1c illnesses and diminishing control over their lives. For geriJtric
p~t1ents., certain symptoms listed in Table 3 should be emphasized.
Revie~ of System Elic_i~ if there ~s weight change, nutritional problems, hearing lI
o~v,sual changes, dent1t1on, continence, falls, bowel dysfunction, musculoskeletal
stiffness, sleep problems and alterations in mood. I

Personal and Past _History Ask about medication use, adverse drug reactions,
past and current tobacco use, alcohol abuse, caffeine intake.
Functional Status Ask about activities of daily living. This includes dressing,
toileting, transferring, feeding, bathing, grooming, communication and mobility.
· Social/Financial Status This includes information on family structure, available
support systems, living arrangements, stressful life events and basic financial •
resources.
Environmental history/ home evaluation This includes physical layout of ~
the home and home safety checklists such as assessment of lighting, flooring,
furniture location, heating, air-conditioning and basic home protection devices....
Ease of access to the home is also assessed.

Table 3. SPECIAL CONSIDERATIONS IN THE ELDERLY

Due to the oqvious age-related differences between histories ob-

tained in children and adults, -rhere ·are data specifically pertinent to
the asse~ment of children. These relate to the stage of development.
The pediatric history follows the same outline. as the adult's history,
with certain additions as presented in Table 4 below. .

Past Medical History

Gestational History Ask about the age of the mother during her pregnancy,
her parity, health, nutrition, intake of drugs and exposure to radiation.
Birth HistorJ Ask about the manner of deliver/ and the maturity of the infant.
feeding History For infants, ask about the type of feeding, vitamins given, food
· intolerance and the time solid food is started; for older children, ask about
appetite, type and amount of food eaten, food likes and dislikes and feeding
difficulties.
Growth and development history Appraise past growth and development
based on the developmental milestones. Previous medical records may also be
used.
Childhood Illnesses Take note of the age when the disease was contracted, its
severity and complications.
Immunizations Inquire about the types of ·immunizations given, date given and
untoward reactions, if any.
Table 4. SPECIAL CONSIDERATIONS IN PEDIATRIC PATIENTS-

47
li1story 1aking
~
 History Ta1ang
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. .
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Re~fo~v of Systems:

45