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 SEVENTH EDITION

Textbook of
Physical Diagnosis:
HISTORY AND EXAMINATION
Mark H. Swartz, MD, FACP
Professor of Medicine
State University of New York (SUNY)
Downstate College of Medicine
Brooklyn, New York

Adjunct Professor of Medicine

New York Medical College
Valhalla, New York

Professor of Medical Sciences

New York College of Podiatric Medicine
New York, New York

Director
C3NY—Clinical Competence Center of New York
New York, New York
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899

TEXTBOOK OF PHYSICAL DIAGNOSIS, SEVENTH EDITION ISBN: 978-0-323-22148-1

Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1989 by Saunders, an imprint of
Elsevier Inc.

No part of this publication may be reproduced or transmitted in any form or by any means,
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This book and the individual contributions contained in it are protected under copyright by
the Publisher (other than as may be noted herein).

Notices

Knowledge and best practice in this field are constantly changing. As new research and
experience broaden our understanding, changes in research methods, professional
practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds, or experiments described
herein. In using such information or methods they should be mindful of their own safety
and the safety of others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to
check the most current information provided (i) on procedures featured or (ii) by the
manufacturer of each product to be administered, to verify the recommended dose or
formula, the method and duration of administration, and contraindications. It is the
responsibility of practitioners, relying on their own experience and knowledge of their
patients, to make diagnoses, to determine dosages and the best treatment for each
individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or
editors, assume any liability for any injury and/or damage to persons or property as a
matter of products liability, negligence or otherwise, or from any use or operation of any
methods, products, instructions, or ideas contained in the material herein.

Library of Congress Cataloging-in-Publication Data

Swartz, Mark H., author.

Textbook of physical diagnosis : history and examination / Mark H. Swartz.—Seventh edition.
   p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-323-22148-1 (hardcover : alk. paper)
I. Title.
[DNLM: 1. Diagnosis. 2. Medical History Taking. 3. Physical Examination. WB 200]
RC76
616.07′54–dc23
   2013032066

Acquisitions Editor: James Merritt

Developmental Editor: Julia Rose Roberts
Publishing Services Manager: Patricia Tannian
Project Manager: Kate Mannix
Design Direction: Louis Forgione

Printed in China

Last digit is the print number: 9 8 7 6 5 4 3 2 1

One of the essential qualities of the clinician is interest in humanity,
for the secret in the care of the patient is in caring for the patient.

Francis Weld Peabody (1881–1927)

 To Vivian Hirshaut, MD,
my wife, my life’s companion, and my best friend, for her love, patience,
support, and understanding;

To Talia H. Swartz, MD, PhD,

my loving and brilliant daughter, for her encouragement
and sustained devotion;

To Ofer Nagar,
my wonderful son-in-law, who helped produce two of the most delightful
granddaughters anyone could wish for;

To Yael Julia and Karen Eve,

my granddaughters, for providing so much joy in my life;

To the memory of my parents, Hilda and Philip;

and

To my students, from whom I am always learning.

 PREFACE

This is the seventh edition of the Textbook of Physical Diagnosis: History and Examination, which,
like its predecessors, has been written for students of health care who are learning to com-
municate effectively with patients, examine patients, and assess patients’ medical problems.
Although 25 years have passed since the publication of the first edition, this text still offers a
unique, comprehensive (but concise) approach to physical diagnosis. By discussing pathophysi-
ology of disease and emphasizing the humanistic element of health care, I attempt to show
the importance of the old-fashioned doctor’s approach to the patient. “The primary aim of this
textbook,” as stated in the preface to the first edition, “is to provide a framework for the clini-
cal assessment of the patient in a humanistic manner.” The book, then and now, focuses on
the patient: his or her needs, problems, and concerns.
The history and physical examination must not be seen as procedures performed by a robot
but rather as a process that requires interpersonal awareness and technical skill. In this era of
extraordinary advances in diagnostic modalities, procedures and tests have been emphasized,
whereas the importance of the history and physical examination has been minimized. It is
well known, however, that among the most valuable and least costly medical evaluations are
the history and physical examination. This book focuses on how to offer the best medical care
through the art of effective interviewing and physical examination.
The seventh edition represents a major revision based on a complete review of the field
of physical diagnosis. The chapters have been reviewed and modified where appropriate.
Extensive changes have been made to many chapters. As times change, so do standards of
physical diagnosis. Several of the tests indicated in the previous editions have been either
modified or eliminated.
Included with this print text is an accompanying website on Student Consult
(studentconsult.com*), which is an online interactive learning platform that presents a vast
collection of popular Elsevier textbook titles with a wide variety of ancillary materials. The
website features fully searchable text; integration links that will seamlessly connect the user to
additional and related content in other Student Consult titles; an image library, with figures
that can be easily downloaded into PowerPoint; and supplementary material such as audio or
video clips. Users can gain access to the online version of this book by going to http://
www.studentconsult.com and entering the unique PIN code provided on the inside front cover
of this book.
In trying to keep up with the needs of the readership and recognizing that many readers
place a premium on portability and accessibility in textbooks, this edition introduces several
changes. The print book has been made much smaller than the previous edition by moving
select material to the online version of the text, available on Student Consult. All of the chap-
ters on history-taking and the physical examination remain in this printed edition, but the
chapters on the focused history and physical examination (Chapter 26), cultural diversity
(Chapter 27), alternative and complementary medicine (Chapter 28), nutrition (Chapter 29),
the epilogue (Chapter 30), and all the appendices are found exclusively on Student Consult.
The DVD-ROM that previously accompanied this book has also been eliminated, and the
content can now be streamed directly from Student Consult. These high-quality
videos contain step-by-step demonstrations of the complete physical examination of the man
and of the breast and pelvic examinations of the woman. They also illustrate the pediatric

*See the inside front cover for a full description of this site and instructions for activation.

ix
x n Preface

examinations of the newborn and the toddler and the neurologic evaluation of the toddler.
Using standardized patients, the video presentation shows history-taking with an adolescent
and her mother and interviewing techniques regarding sensitive topics with a geriatric patient.
These sensitive topics include a discussion of advance directives (i.e., health care proxy deter-
mination and living wills), a mental status examination of a patient with a cognitive impair-
ment, and a scenario showing how to give bad news. Finally, scenarios demonstrating the
focused history and physical examination of a young man with abdominal pain, counseling
a woman about health-related issues, and a pediatric telephone consultation are presented.
These are very useful scenarios for preparing for the USMLE Step 2CS Examination. This online
resource, coupled with the printed textbook, provides a comprehensive clinical reference for
the understanding of the organization and fluidity of the complete assessment of the patient.
Another new and unique feature of this edition is the use of QR codes throughout the
book. QR codes, short for quick response codes, are optical machine-readable labels attached to
items that record information related to the item.* Users with a camera phone equipped with
the correct reader application can scan the image of the QR code in this textbook to open a
web page with a selected video or another URL. For example, when reading about a certain
physical examination technique, the reader can scan the QR code associated with
that maneuver and actually watch how that specific examination is performed
while reading the text.
QR codes can be used on iOS† devices and Google’s Android operating system, with Google
Goggles‡ and third-party barcode scanners. At the time of publication, Apple’s iOS did not
natively include a QR code reader, but more than 50 free and paid apps were available with
the ability both to scan the codes and to link to an external URL.§
The references at the end of each chapter have all been completely updated and provide
information for further study. To reduce the size of the textbook, all of the references have
been removed from the printed textbook and now can be accessed via Student Consult. Thus,
the reader will be able immediately to access up-to-date information on a smart-
phone, iPod, or iPad!
Illustrations are an integral part of a physical diagnosis textbook. They help the reader better
understand the pathologic processes. As in the previous editions, the book is richly illustrated,
with more than 950 photographs and line art. More than 80% of the photographs of pathologic
conditions are original; they have not been reprinted from other textbooks. In this new edition,
most of the original black-and-white images demonstrating the techniques of the examina-
tion have been replaced with 4-color images.
Any health care provider today must be able to synthesize basic pathophysiology with
humanistic medical care. As the medical profession continues to be under great scrutiny, we
must emphasize an empathetic approach to patient care, recognizing the role of culture in
illness and using modern technology to enhance our clinical assessment, not to replace it. We
must always remember that a patient is a person suffering from disease, not a vehicle for a
disease!
I hope that you will find this seventh edition of Textbook of Physical Diagnosis: History and
Examination to be reader friendly, comprehensive, and an exciting addition to your library.
Mark H. Swartz, MD, FACP

*These codes consist of black modules (square dots) arranged in a square grid on a white background. QR
codes storing Uniform Resource Locators (URLs) appear in magazines or on signs, buses, business cards, or
almost any object about which users might need information. They are used to take a piece of information
from a source and put it into your cell phone, iPad, or other electronic device.
†
iOS is a mobile operating system developed by Apple, supporting their popular devices such as the iPhone,
iPod, and iPad.
‡
Visual search technology used to identify various labels or barcodes such as a QR code.
§
ShopSavvy, Inc. and TapMedia, Ltd., among other companies, have free QR code readers for iPhone, iPod,
and iPad. Google Goggles is an example of one of many applications that can scan and link URLs for iOS.
With BlackBerry devices, the App World application can natively scan QR codes and load any recognized
URLs on the device’s browser. Windows Phone 7.5 is able to scan QR codes through the Bing search app.
It takes around 1 minute for someone with an iPhone or Android phone to find and install a QR code
reader.
 ACKNOWLEDGMENTS

I wish to acknowledge all of my professional colleagues and friends who have supported and
guided me in writing this seventh edition. I express my heartfelt thanks to the following
people, without whose assistance I could not have brought this book to a reality:
To all my teachers, students, and patients who have taught me so much about
medicine.
Special thanks to the following people who have helped in reviewing chapters for this
edition:

Jerry A. Colliver, PhD Mark A. Kosinski, DPM

Former Director of Statistics and Research Professor, Division of Medical Sciences
Consulting and Professor of Medical New York College of Podiatric Medicine
Education (1981–2007) New York, New York
Southern Illinois University School of Instructor of Surgery
Medicine New York Medical College
Springfield, Illinois Valhalla, New York

Siobhan M. Dolan, MD, MPH Robert Kushner, MD

Associate Professor of Obstetrics & Professor of Medicine
Gynecology and Women’s Health Department of Internal Medicine
Department of Obstetrics & Gynecology Northwestern University Feinberg School
and Women’s Health of Medicine
Albert Einstein College of Medicine & Chicago, Illinois
Montefiore Medical Center
Bronx, New York Ellen Landsberger, MD
Associate Professor of Obstetrics &
Margaret Clark Golden, MD Gynecology and Women’s Health
Clinical Associate Professor of Pediatrics Department of Obstetrics & Gynecology
Department of Pediatrics and Women’s Health
State University of New York (SUNY) Albert Einstein College of Medicine &
Downstate College of Medicine Montefiore Medical Center
Brooklyn, New York Bronx, New York

Vivian Hirshaut, MD Robert W. Marion, MD

Attending Physician of Ophthalmology Professor of Pediatrics and Obstetrics and
Department of Ophthalmology Gynecology
Mount Sinai Medical Center Ruth L. Gottesman Professor of Child
New York, New York Development
Department of Ophthalmology Director of the Children’s Evaluation and
Albert Einstein College of Medicine Rehabilitation Center
Bronx, New York Co-Director, Medical Student Education
Department of Pediatrics
Albert Einstein College of Medicine
Co-Chief, Section of Genetics
Director, Center for Congenital Disorders
Children’s Hospital at Montefiore
Bronx, New York
xi
xii n Acknowledgments

Mimi McEvoy, RN, CPNP Tracie L. DeMack

Assistant Professor of Pediatrics University of Chicago School of Medicine
Department of Pediatrics Chicago, Illinois
Albert Einstein College of Medicine
Bronx, New York Ethan D. Fried, MD
Columbia University College of Physicians
Talia H. Swartz, MD, PhD and Surgeons
Instructor in Internal Medicine New York, New York
Department of Internal Medicine
Mount Sinai Medical Center Sheldon Jacobson, MD
New York, New York Mount Sinai School of Medicine
New York, New York
And to the following people who helped in
previous editions: Peter B. Liebert, MD
Mount Sinai School of Medicine
James R. Bonner, MD New York, New York
University of Alabama School of Medicine
Birmingham, Alabama Meryl H. Mendelson, MD
Mount Sinai School of Medicine
Dennis W. Boulware, MD New York, New York
University of Alabama School of Medicine
Birmingham, Alabama Joanna F. Schulman, MD
Mount Sinai School of Medicine
Gabriele Chryssanthou, CO New York, New York
New York, New York

And finally, special thanks:

To Wendy Beth Jackelow, who has artistically illustrated all editions of this book.
To Frederick S. Bobrow for his tireless efforts to expertly produce the video presentations
for the book.
To Margaret Clark Golden, MD, for all of her time and help in preparing the pediatric
and adolescent portions of the video presentation and for her help in writing the pediatric
chapter. Dr. Golden wishes to acknowledge with thanks Dr. Robert Louis Gatson, who taught
her what it means to be a pediatrician.
To Ella-Jean L. Richards-François, MD, for preparing the adolescent history portion of
the video presentation.
To Joan Kendall, Meg Anderson, Lily Burd, Tom Pennacchini, Sandra Parris, and
Lane Binkley, who were the remarkable actors portraying the patients in the video
presentation.
To the many employees at Elsevier for their expert assistance and cooperation. In par-
ticular, I would like to acknowledge the help of James Merritt, my editor, and the production
team of Julia Rose Roberts, Kate Mannix, Louis Forgione, Michael Carcel, and
Abigail Swartz, whose efforts have been critical in the planning, production, design, media,
and marketing of this edition.
And finally to my wife, Vivian Hirshaut, MD, for her love, personal support, endless
patience, and understanding. Without her boundless affection, indefatigable help, sustained
devotion, and encouragement, none of the editions of this book could have come to
fruition.
Mark H. Swartz, MD
 PHOTOGRAPH
CREDITS

A photograph makes a concept or disease entity more understandable and easier to recognize.
As the well-known proverb says, “A picture is worth a thousand words.” I wish to acknowledge
with deep gratitude the following colleagues who have graciously allowed me to use photo-
graphs from their own teaching collections to help illustrate this seventh edition. My thanks
go to:

Christina Ryu, MD Christina Ryu, MD

Alexis Cullen, CRA Jim Thomas, CRA
Henry Ford Health System Henry Ford Health System
Detroit, Michigan Detroit, Michigan
7-22A 7-84B
7-22B
7-84C Beth Snodgrass, CRA
Byers Eye Institute at Stanford
Christina Ryu, MD Palo Alto, California
Steve Oglivy, CRA 7-116B
Henry Ford Health System 7-118B
Detroit, Michigan
7-24 Tracey Troszak, CRA
7-129A Henry Ford Health System
7-129B Detroit, Michigan

Christina Ryu, MD
Bradley Stern, CRA
Henry Ford Health System
Detroit, Michigan
7-30A
7-30B
7-130

The following individuals were kind enough to contribute their slides to previous editions:

J. Daniel Arbour, MD Gregory C. Hoffmeyer

Marc Blouin, DEC, OA Anthony Iorio, DPM, MPH
Andrew H. Eichenfield, MD Brian M. Kabcenell, D.M.D.
Stephen A. Estes, MD Michael P. Kelly
Neil A. Fenske, MD Karen Ann Klima, BA, CRA, COMT
Raul Fleischmajer, MD Mark A. Kosinski, DPM
Peter T. Fontaine, CRA, EMT William Lawson, MD
Howard Fox, DPM Alan B. Levine, DC
Alan Friedman, MD Thomas P. Link, CRA
Bechara Y. Ghorayeb, MD Harry Lumerman, DDS
Alejandra Gurtman, MD Bryan C. Markinson, DPM
Michael Hawke, MD Michael A. Rothschild, MD
Donald E. Hazelrigg, MD Donald Rudikoff, MD

xiii
xiv n Photograph Credits

Ben Serar, M.A., CRA Phillip A. Wackym, MD

Deborah L. Shapiro, MD Joseph B. Walsh, MD
Michael Stanley Katherine Ward, DPM
Arthur Steinhart, DPM

I wish to acknowledge with thanks the authors and publishers of the following books for per-
mission to reprint figures from their texts:

E28-7: Redrawn from Wensel LO (ed): Acu- 5-135: Photo courtesy of Public Health Image
puncture in Medical Practice. Reston, Virginia, Library (PHIL) ID #284. Source: CDC/James.
Reston Publishing Co., Appleton & Lange,
1980. 6-14: From Wallace C, Siminoski K: The Pem-
berton sign. Ann Intern Med 125:568, 1996.
E29-2, E29-5, E29-7, E29-8A, E29-10AB, E29-
11AB, E29-12AB: From Morgan SL, Weinsier 7-19, 7-20, 7-28, 7-34, 7-35, 7-46, 7-51, 7-58,
RL: Fundamentals of Clinical Nutrition, 2nd ed. 7-63, 7-69B, 7-96, 7-98, 7-106, 7-126, 7-128,
St. Louis, Mosby, 1998. 7-142: From Kanski JJ, Nischal KK: Ophthal-
mology: Clinical Signs and Differential Diagnosis.
E29-8B, E29-9, 5-6B, 5-8, 5-16AB, 5-26B, 5-29, St. Louis, Mosby, 2000.
5-45, 5-50, 5-60, 5-61, 5-63, 5-70B, 5-71, 5-76,
5-77, 5-79, 5-81, 5-84, 5-87, 5-88, 5-93, 5-94, 7-32, 7-47A, 7-52, 7-53, 7-60, 7-67, 7-72B,
5-96, 5-111, 5-114, 5-116, 5-118, 5-120B, 10-7, 10-8, 14-14: From Mir MA: Atlas of Clini-
5-123, 9-13, 9-50, 11-15, 12-3, 15-8, 15-9, cal Diagnosis. London, WB Saunders, 1995.
15-10, 15-14A, 15-15, 15-17, 15-34, 16-15,
7-36, 7-37, 7-59: From Kanski JJ, Nischal KK:
16-34, 5-129A, 5-126, 21-27, 21-48, 21-49,
Ophthalmology: Clinical Signs and Differential
21-50, 21-53, 21-55: From Callen JP, Paller AS,
Diagnosis. London, Mosby, 2002.
Greer KE, et al: Color Atlas of Dermatology,
2nd ed. Philadelphia, WB Saunders, 2000. 9-3, 9-4, 9-18, 9-34, 9-37A, 9-43, 9-47, 9-48,
9-49, 9-57, 21-40: From Eisen D, Lynch
5-6A, 5-28, 5-33, 5-36, 5-46, 5-53, 5-62, 5-78,
DP: The Mouth: Diagnosis and Treatment.
5-80, 5-97, 5-110, 5-113, 5-115, 5-117, 5-120A,
St. Louis, Mosby, 1998.
8-20, 9-25, 11-13, 12-19, 13-5, 13-13, 15-16,
15-36, 15-37, 21-52: From Callen JP, Greer KE, 9-12, 21-7, 21-11, 21-25, 21-29, 21-51: From
Hood AF, et al: Color Atlas of Dermatology. Cohen BA: Atlas of Pediatric Dermatology.
Philadelphia, WB Saunders, 1993. London, Wolfe Publishing, 1993.
5-9, 5-10, 5-40, 5-41, 5-65, 5-66, 5-67, 16-6, 9-27, 9-58: From Silverman S: Color Atlas of
16-7, 16-8: From Hordinsky MK, Sawaya ME, Oral Manifestations of AIDS, 2nd ed. St. Louis,
Scher RK: Atlas of Hair and Nails. Philadelphia, Mosby-Year Book, 1996.
Churchill Livingstone, 2000.
15-7, 16-32, 16-33: From Korting GW: Practi-
5-73, 5-99, 5-100B to E, 5-101AB, 5-112, 7-31: cal Dermatology of the Genital Region. Philadel-
From Friedman-Kien AE, Cockerell CJ (eds): phia, WB Saunders, 1980.
Color Atlas of AIDS, 2nd ed. Philadelphia, WB
Saunders, 1996. 15-11, 15-12, 15-41, 16-9, 16-10, 16-11, 16-13,
21-9: From Leibowitch M, Staughton R, Neill
5-92, 5-122, 11-14, 14-5, 17-61: From Lebwohl S, et al: An Atlas of Vulval Disease: A Combined
MG (ed): Atlas of the Skin and Systemic Disease. Dermatological, Gynecological and Venereological
New York, Churchill Livingstone, 1995. Approach, 2nd ed. London, Mosby, 1997.
5-119: From Jordon RE: Atlas of Bullous Disease. 15-40: From Bolognia JK, Jorizzo JL, Rapini RP:
Philadelphia, Churchill Livingstone, 2000. Dermatology. London, Mosby, 2003.
5-132, 5-133: Photographs courtesy of the 17-23: From Baran R, Dawber RPR, Tosti A,
Centers for Disease Control (CDC). Haneke E: A Text Atlas of Nail Disorders: Diag-
nosis and Treatment. St. Louis, Mosby, 1996.
5-134: Photo courtesy of Public Health Image
Library (PHIL) ID #3. Source: CDC/Cheryl 5-129B: From Nzuzi SM: Common nail disor-
Tyron. ders. Clin Podiatr Med Surg 6:273, 1989.
 Photograph Credits n xv

5-108: From Kosinski MA, Stewart D: Nail 24-3: Redrawn from Fagan TJ: Nomogram
changes associated with systemic disease and for Bayes’ theorem. N Engl J Med 293:257,
vascular insufficiency. Clin Podiatr Med Surg 1975. Copyright 1975 Massachusetts Medical
6:295, 1989. Society. All rights reserved.

21-6, 21-12, 21-13, 21-14, 21-17, 21-19, 21-20, 24-5, 24-6: Redrawn from Sackett DL, Haynes
21-21, 21-24, 21-25, 21-27, 21-29, 21-31, RB, Guyatt GH, et al (eds): Clinical Epidemiol-
21-38: From Shah BR, Laude TA: Atlas of Pedi- ogy: A Basic Science for Clinical Medicine,
atric Clinical Diagnosis. Philadelphia, WB 2nd ed. New York, Little, Brown & Co., 1991.
Saunders, 2000.

21-40B: From Zitelli B, Davis H: Atlas of Pedi-

atric Physical Diagnosis, 4th ed. Philadelphia,
Mosby, 2002.
 CHAPTER 1

The Interviewer’s Questions

What is spoken of as a “clinical picture” is not just a photograph of a man sick in bed; it
is an impressionistic painting of the patient surrounded by his home, his work, his
relations, his friends, his joys, sorrows, hopes and fears.
Francis Weld Peabody (1881–1927)

Basic Principles

Good communication skills are the foundation of excellent medical care. Even with the excit-
ing new technology that has appeared since 2000, communicative behavior is still paramount
in the care of patients. Studies have shown that good communication improves health out-
comes by resolving symptoms and reducing patients’ psychological distress and anxiety. In the
United States, 85% of all malpractice law suits are based on poor communication skills. It is
not that the doctor didn’t know enough; the doctor did not communicate well enough with
the patient!
Technologic medicine cannot substitute for words and behavior in serving the ill. The
quality of patient care depends greatly on the skills of interviewing, because the relationship
that a patient has with a physician is one of the most extraordinary relationships between two
human beings. Within a matter of minutes, two strangers—the patient and the healer—begin
to discuss intimate details about a person’s life. Once trust is established, the patient feels at
ease discussing the most personal details of the illness. Clearly, a strong bond, a therapeutic
alliance, has to have been established.
The main purpose of an interview is to gather all basic information pertinent to the patient’s
illness and the patient’s adaptation to illness. An assessment of the patient’s condition can
then be made. An experienced interviewer considers all the aspects of the patient’s presentation
and then follows the leads that appear to merit the most attention. The interviewer should
also be aware of the influence of social, economic, and cultural factors in shaping the
nature of the patient’s problems. Other important aspects of the interview are educating
the patient about the diagnosis, negotiating a management plan, and counseling about behav-
ioral changes.
Any patient who seeks consultation from a clinician needs to be evaluated in the broadest
sense. The clinician must be keenly aware of all clues, obvious or subtle. Although body lan-
guage is important, the spoken word remains the central diagnostic tool in medicine. For this
reason, the art of speaking and active listening continues to be central to the doctor-patient
interaction. Active listening takes practice and involves awareness of what is being said in
addition to body language and other nonverbal clues. For the novice interviewer, it is very
3
4 Section 1 n The Art of Interviewing

easy to think only about your next question without observing the entire picture of the patient,
as described masterfully in the quote by Peabody that introduced this chapter. Once all the
clues from the history have been gathered, the assimilation of those clues into an ultimate
diagnosis is relatively easy.
Communication is the key to a successful interview. The interviewer must be able to ask
questions of the patient freely. These questions must always be understood easily and adjusted
to the medical sophistication of the patient. If necessary, slang words describing certain condi-
tions may be used to facilitate communication and avoid misunderstanding.
The success of any interview depends on its being patient-centered and not
doctor-centered. Encourage the patient to tell his or her story and follow the patient’s leads
to better comprehend the problems, concerns, and requests. Do not have your own list of
“standard questions” as would occur in a symptom-focused, doctor-centered interview. Patients
are not standard; don’t treat them as such. Allow the patient to tell his or her story in his or
her own words. In the words of Sir William Osler (1893), “Listen to your patient. He is telling
you the diagnosis. . . . The good physician treats the disease; the great physician treats the
patient who has the disease.” No truer words have been spoken.
Once the patient has told his or her story of the history of the present illness, it is custom-
ary for you to move from open-ended questions to direct, more focused questions. Always start
by casting a wide net and then gradually close the net to develop your differential diagnosis.
Start general and then get more specific to clarify the patient’s story and symptoms.

Using an Interpreter

Health care providers are increasingly treating patients across language barriers. In 2006, nearly
49.6 million Americans had a “mother tongue” other than English; an additional 22.3 million
(8.4%) had limited English proficiency. Lack of English proficiency can have deleterious effects.
For any patient who speaks a language other than that of the health care provider, it is impor-
tant to seek the help of a trained medical interpreter. Unless fluent in the patient’s language
and culture, the health care provider should always use an interpreter. The interpreter can be
thought of as a bridge, spanning the ideas, mores, biases, emotions, and problems of the clini-
cian and patient. The communication is very much influenced by the extent to which the
patient, the interpreter, and the provider share the same understanding and beliefs regarding
the patient’s problem. The best interpreters are those who are familiar with the patient’s
culture. The interpreter’s presence, however, adds another variable in the doctor-patient rela-
tionship; for example, a family member who translates for the patient may alter the meaning
of what has been said. When a family member is the interpreter, the patient may be reluctant
to provide information about sensitive issues, such as sexual history or substance abuse. It is
therefore advantageous to have a disinterested observer act as interpreter. On occasion, the
patient may request that a family member be the interpreter. In such a case, clinicians should
respect the patient’s wishes. Friends of the patient, although helpful in times of emergency,
should not be relied on as translators because their skills are unknown and confidentiality is
a concern. The clinician should also master a number of key words and phrases in several
common languages to gain the respect and confidence of patients. When using an interpreter,
clinicians should remember the following guidelines:
1. Choose an individual trained in medical terminology.
2. Choose a person of the same sex as the patient and of comparable age.
3. Talk with the interpreter beforehand to establish an approach.
4. When speaking to the patient, watch the patient, not the interpreter.
5. Do not expect a word-for-word translation.
6. Ask the interpreter about the patient’s fears and expectations.
7. Use clear, short, and simple questions.
8. Use simple language.
9. Keep your explanations brief.
10. Avoid questions using if, would, and could, because these require nuances of
language.
11. Avoid idiomatic expressions.
The U.S. Department of Health and Human Services has put together a useful mnemonic
(INTERPRET) for working with interpreters in a cultural setting:
 Chapter 1 n The Interviewer’s Questions 5

I—Introductions
Make sure to introduce all the individuals in the room. During introductions, include 1
information as to the roles individuals will play.
N—Note Goals
Note the goals of the interview: What is the diagnosis? What will the treatment entail?
Will there be any follow-up?
T—Transparency
Let the patient know that everything said will be interpreted throughout the
session.
E—Ethics
Use qualified interpreters (not family members or children) when conducting an inter-
view. Qualified interpreters allow the patient to maintain autonomy and make informed
decisions about his or her care.
R—Respect Beliefs
Limited English–proficient patients may have cultural beliefs that need to be taken into
account as well. The interpreter may be able to serve as a cultural broker and help
explain any cultural beliefs that may exist.
P—Patient Focus
The patient should remain the focus of the encounter. Providers should interact with
the patient and not the interpreter. Make sure to ask and address any questions the
patient may have before ending the encounter. If you don’t have trained interpreters
on staff, the patient may not be able to call in with questions.
R—Retain Control
It is important as the provider that you remain in control of the interaction and not
allow the patient or interpreter to take over the conversation.
E—Explain
Use simple language and short sentences when working with an interpreter. This will
ensure that comparable words can be found in the second language and that all the
information can be conveyed clearly.
T—Thanks
Thank the interpreter and the patient for their time. On the chart, note that the patient
needs an interpreter and who served as an interpreter this time.
Even with a trained translator, health care workers are ultimately responsible for ensuring
safe and effective communication with their patients. A recent article (Schenker et al., 2008)
describes a conceptual framework of when to call for an interpreter and what to do when one
is not available.
When speaking with the patient, the interviewer must determine not only the main medical
problems but also the patient’s reaction to the illness. This is of great importance. How has
the illness affected the patient? How has he or she reacted to it? What influence has it had on
the family? On work? On social life?
The best interview is conducted by an interviewer who is cheerful, friendly, and
genuinely concerned about the patient. This type of approach is clearly better than that of the
interviewer who acts like an interrogator shooting questions from a standard list at the poor,
defenseless patient. Bombarding patients with rapid-fire questions is a technique that should
not be used.

Important Interviewing Concepts

In the beginning, the patient brings up the subjects that are easiest to discuss. More painful
experiences can be elicited by tactful questioning. The novice interviewer needs to gain experi-
ence to feel comfortable asking questions about subjects that are more painful, delicate, or
unpleasant. Timing of such questions is critical.
A cardinal principle of interviewing is to permit patients to express their stories in their
own words. The manner in which patients tell their stories reveals much about the nature of