The Clinical Encounter, Interviewing Process, Health History & Physical Examination

Patient vs Clinician-Centered Encounter

patient-centered: follow pt lead
recognize importance of personal context of illness

clinician-centered:
acquire:
symptoms
details
data

combination is optimal→disease/illness distinction model

Disease/Illness Distinction Model

disease: focuses on clinician’s organization of symptoms and developing clinical diagnosis

illness: focuses on how the patient perceives his/her illness and its effects on relationships/function/overall well-being

Clinical Encounter Steps

1. initiation

2. information gathering

3. physical examination

4. explanation and planning

5. closing the session

Initiate The Encounter

set the stage and adjust the environment:

• check your appearance

• make interview setting private and comfortable

• adjust the room temperature

• arrange the room so you can sit at pt’s eye level (or below)

• move physical barriers (move computer so it doesn’t obstruct your view of the pt/hide your face)

• consider lighting

review the clinical board

set your agenda:
greet the patient+establish rapport

• introduce yourself to everyone in the room+shake hands

• explain role+how you are involved in their care

confirm pt. name+birthday+how they want to be identified (gender)

Establishing Rapport With Specific Populations: Newborns+Infants

• focus on parents

• encourage parents to hold baby however they’re most comfortable

• affirm they can feed child during encounter if needed

• ask parents how they’re doing

Establishing Rapport With Specific Populations: Young+School-Aged Children

• introduce yourself to child THEN family/caregiver

• recommended→beginning w. play→distracts child+controls mood

• ask age-appropriate questions

Establishing Rapport With Specific Populations: Teenagers+Adolescents

• direct questions to pt but ensure caregiver’s concerns are heard

• spend time with pt alone (acknowledge confidentiality+trust during this time)

Establishing Rapport With Specific Populations: Older Adults

• provide enough space for them to maneuver (assistive devices)

• decrease background noise

• keep room at comfortable (warm) temperature

• allow time for open-ended questions+reminiscing (delayed cognition)

Establishing Rapport With Specific Populations: Pts With Physical+Sensory Disabilities (General)

• “people first” language

• speak directly to pt (not caregivers)

• avoid assuming they need help→ask how you can help

Establishing Rapport With Specific Populations: Wheelchairs

• ensure path of access to the room+clear any obstacles

• respect personal space

• don’t separate pt from wheelchair

• provide accessible equipment when necessary

Establishing Rapport With Specific Populations: Deaf/Low Hearing

• consider sign language interpretation/writing

• do not use family members for interpretation

• ensure mouth is not covered

• look directly at pt when speaking

• minimize background noise

Establishing Rapport With Specific Populations: LGBTQIA+ Adults

• often have significant anxiety

• may still be fluctuating in their sexual identity

• unlikely to reveal their sexual identity/health concerns if they experience any perceived bias/discrimination

• higher rates of depression/suicide/anxiety/drug use/sexual vicitimization/risk of infection with HIV/STIs

LGBTQIA+ Adults Barriers to Healthcare

“lack of providers who are knowledgeable about LGBT health needs as well as fear of discrimination in health care settings” (Institute of Medicine)

transgender study→33%/1 in 3 reported negative experience in the last year related to identity
-refusal of tx
-harassment
-physical/sexual assault
-having to teach providers about transgender pronouns

Information Gathering

initiate information gathering+establish agenda for encounter

• develop a chief complaint/presenting problems

• ask open ended questions

• determine what’s most important to pt and start there

Invite the pt’s story

• ask about most important issue

• let pt talk

• once pt finished→ask specific questions for additional info

gather information about pt’s perspective of illness

FIFE:
-Feelings
-Ideas
-effect on Function
-Expectations

identify+respond to emotional cues

• address specific feelings

NURSE:
-Name
-Understand/legitimize
-Respect
-Support
-Explore

gather info by exploring biomedical perspective

specific questions:
-health hx
-past medical hx
-family hx
-social hx
-review of systems (ROS)

Physical Examination

perform in head-to-toe format

maintain pt comfort throughout

avoid embarrassment

physical findings→show presence/absence of disease/illness

Explanation+Planning

provide useful information+verify pt understanding

• elaborate pt chief concerns+how it relates to disease/illness

• avoid medical jargon

• after explaining→”teach-back” or “show-me” method

negotiate plan using shared decision making

1. introduce choices+describe options

2. explore pt preferences

3. move toward pt’s chosen decision

Closing the Encounter

let pt know time is running out+ask if they have any final questions

pt mentions new concern: assure them of your interest
make plans for follow-up

summarize plan from visit+plan for future evaluations/txs/follow-ups

self-reflect

Self Reflection

mindfullness: being purposefully and non-judgmentally attentive to one’s own experience, thoughts, and feelings

people bring own biases/values/assumptions to every encounter and must reflect on how we behave

continual part of professional development to create deeper personal awareness

Fundamentals of Skilled Interviewing

active/attentive listening:
-paying attention to verbal+non-verbal clues from pt

empathetic responses:
-empathy: the capacity to identify with the pt and feel the pt’s pain as your own→respond in a supportive matter
-don’t assume understanding of how pt feels→ask for elaboration

summarization:
-review what pt said→allow them to correct you/fill any additional details

transitions

partnering

validation:
-allows pt to feel as though their response is legitimate+understandable

empowering pt:
-ask questions
-express concerns
-question/probe recommendations→more likely for pt to follow plan

reassurance:
-identify+acknowledge pt feelings

guided questioning:
-open-ended to focused questions
-questioning that elicits graded response
-ask a series of questions one at a time
-offer multiple choices for answers
-clarify what the pt means
-encourage with continuers
-use echoing/repetition

appropriate verbal communication:
-use simple/recognizable words
-avoid medical jargon (use jargon→explain meaning)
-use non-stigmatizing language

appropriate non-verbal communication
-postures/gestures/facial expressions (ex: nodding)
-eye contact
-tone of voice/use. ofsilence
-mirroring pt position→increases pt rapport

Subjective vs Objective Information

subjective information: what the pt tells you
ex:
CC of “sore throat x 3 days”
“crushing chest pain”

objective information: PE findings+DX
ex:
chest wall tenderness to palpation
vitals temperature: 102.1°F
hemoglobin: 11.5 g/dL

Comprehensive History Outline

initial information+identifying details

chief complaint (CC)

history of present illness (HPI)

past medical history (PMH)

family history

personal+social history

review of systems (ROS)

Patient Identifiers (Initial Information+Identifying Details)

date+time of evaluation

pt identifiers:

• name/initials

• age

• gender

source of information:

• patient

• parent

• spouse

• caregiver

• EMS

• pt unreliable/unable to contribute to hx→document reason+who is reliable historian

Chief Complaint (CC)

primary symptom/concern causing pt to seek care

dx→”chief complaint” x duration
ex: “I have crushing chest pain” x 3 hours

multiple complaints: primary sx listed as CC+additional complaints addressed in HPI

History of Present Illness (HPI)

OP5QRS2T

O: onset (when did this start)

P: precipitating (what caused the sx/what did you do before the sx happened)

P: palliative (what makes it better)

P: provocative (what makes it worse)

P: progression (how has the sx changed since its start)

P: prior episodes (has it happened before)

Q: quality (description of the sx)

R: radiation (does the sx move/travel anywhere else)

S: site (point with finger where sx happens)

S: severity (scale of 1 to 10)

T: timing (does it get better/worse during a specific time)

Onset

when sx began (if pt vague→ask clarifying questions)

open-ended questions: “when did the sx start?”

focused questions: “what does a long time mean to you?”

multiple choices: “does a long time mean a few days/months/years?”

Precipitating Events/Factors

what caused/precipitated the sx

open-ended questions:
“what were you doing when the sx began"?”
“was anything unusual going on in your life when this started?”

focused questions:
specific risk factors/RF for dx on your differential
relevant past medical hx/social hx
ex: angina/SOB→ask about recent travel

Palliative+Provocative Factors

factors that make the sx better/worse

open-ended questions: “does anything make it better/worse?”

focused questions:
“did you take anything for your pain?”
“did it help?”

closed questions:
specific palliative/provocative questions→narrows differential
“does chest pain get worse with exercise/deep breathing/walking up a flight of stairs?”

Progression

how the sx has changed since onset

focused questions:
“has the sx changed since it began?”
“how has the sx changed since it started?”

closed questions:”
have the episodes lasted longer/become more frequent/more severe”

Prior Episodes

has it happened before

focused questions: “have you ever experienced this before?”

closed questions: follow up if question above→”yes”→“what was the cause at that time?”

Quality

open-ended questions: “can you describe the sx for us”

focused questions: “what dose dizziness mean for you?”

closed questions: “is it aching/burning/sharp/pressure/squeezing?”

Radiation

is the sx anywhere else

predominately when sx is pain→if not radiating do not ask

open-ended questions: “does the pain move/travel anywhere else?”

closed questions:
specific questions to help with differential
angina: “does it travel to your neck/jaw/arm?”
abdominal pain: “does it travel to your back?”→”yes”→”does it wrap around or go straight through?”

Site

location of the sx

open-ended questions: “where is the sx occurring?”

focused questions:
“can you point with one finger to the are you feel the pain?”
“where is the weakness you are feeling?”

closed questions: “is the weakness the same in both legs or worse on one side?”

Severity

how bad is the sx

sx→pain:
“on a scale from 1 to 10 (10→worst) how severe is your pain?”
palliative/provocative factors present→ask how pain grading changes

sx→no pain:
“how is the sx affecting your ability to complete your normal activities?”
ask for general categorization (mild/moderate/severe)

Timing

time of day: “is there a time of day your sx are worse”

frequency: “how often do you experience the sx?”

duration: “how long do the episodes last?”

pattern: “is it intermittent/constant/waxing and waning?”

Associated Symptoms

other sx present besides chief complaint

OP5QRS2T→positive associated sx
-things on ROS that pt says “yes” to

then list all negative associated sx
-things on ROS that pt says “no” to

Past Medical History (PMH) List

adult illnesses (+dates/years since dx)
-medical
-surgical
-OBGYN
-psychiatric

childhood illnesses

health maintenance

mx

allergies

Adult Illnesses

Medical:
hx of specific diagnosis
include date/# of years since dx

surgical:
type of surgery
date/year of surgery
surgeon’s name

OBGYN:
obstetric hx
menstrual hx
methods of contraception
sexual function

psychiatric:
depression/anxiety/suicidal ideation/suicidal attempts/homicidal ideation
yes→prior psychiatric hospitalizations (date/duration/tx)

Childhood Illnesses

acute illnesses:
measles/mumps/rubella
chicken pox
whooping cough (pertussis)
rheumatic fever
scarlet fever
polio

chronic illnesses:
asthma
diabetes

Health Maintenance

immunizations:
name+year(s) administered
annual/recurrent vaccines:
influenza
COVID
Tdap

screening tests:
age-appropriate preventive measures+last date performed:
colonoscopy
mammogram
PAP smear
stool test for occult/microscopic blood
cholesterol screening

Medications

name

dose

route:
PO
IM/SQ injection
patch
etc.

frequency

indication (why/what dx is mx for)

ex: lisinopril 20mg oral daily, for hypertension

Allergies

allergen+type of reaction

date/year found allergy

allergies:
food
mx
environmental
insect

ex: penicillin-rash (1996)

Family History (FH)

outlines age+health/age+cause of death of family members

ask 2 generations above+below:
grandparents
parents
siblings
children
grandchildren

ask about age/age of death for each relative

ask about health+medical problems
deceased→cause of death

ask after about chronic diseases+document if negative:
HTN
coronary artery disease
elevated cholesterol levels
stroke
diabetes
thyroid/renal disease
arthritis
tuberculosis
asthma/lung disease
headache
seizure disorders
mental illness
suicide
substance abuse

cancer hx:
breast
ovarian
colon
prostate cancer

Personal+Social History

personality+interests/coping mechanisms/strengths+concerns→clues about dx (be non-judgemental)

can be sensitive→explain why you need to know

influenced by societal/cultural/family constraints

find opening+specific questions to get information

acknowledge own discomfort→failure leads to avoiding topic→missing important info

tobacco use:
yes→cigarettes/vaping chewing+how many per day+how long
no→past use→yes→how much+how long+when quit

pack years:
pack x years=pack years

illicit/recreational drug use:
ask “how many times in past year have you used an illegal drug/Rx mx for nonclinical reasons”
yes→what mx+when last used
currently using mx→how much+how often

alcohol use:
how often drink+how many drinks+when was last drink
“have you ever had a drinking problem?”
misuse:
blackouts
withdrawal seizures
accidents/injuries after drinking
difficulty at work/relationship
CAGE questionnaire
AUDIT-C questionnaire

occupation+highest level of education

marital status

lifestyle habits (diet/exercise/supplements/caffeine intake/etc.)

safety measures

sexual orientation+gender identification:
-do not assume
-use appropriate but direct questioning
-use specific language
-refer to genitalia with explicit words (consider gender-neutral terms/ask pt how they refer to genitalia)

consider with a generalized approach:
-“do you have any specific concerns/questions we can start with regarding your sexual health/practices?”→5Ps+
-genitourinary system problem→ask as part of ROS/HPI

birthplace

personal environmental map:
significant relationships+safety in relationships
home environment
important life experiences
leisure activities
sexuality
spirituality→FICA screening tool
social support systems

baseline level of function (ADLs/iADLs)

Alcohol Use+CAGE+AUDIT-C

drink:
8oz malt liquor
12oz beer
5oz wine
1.3oz 80 proof distilled liquor

men: 4+ drinks per day/14+ drinks per week
women: 3+ drinks per day/7+ drinks per week

CAGE questionnaire:
Cutting down: “have you ever felt you should cut down on your drinking?”
Annoyance when criticized: “have people annoyed you by criticizing your drinking?”
Guilty feelings: “have you ever felt bad/guilty about your drinking?”
Eye openers: “have you ever had a drink first thing in the morning to steady you nerves/get rid of a hangover?”

yes→1 point
no→0 points
2+→alcohol abuse

AUDIT-C:
“how often did you have a drink containing alcohol in the past year?”

never→0 points
monthly or less→1 point
2-4 times/month→2 points
2-3 times/week→3 points
4+ times/week→4 points

“how many drinks did you have on a typical day when you were drinking in the past year?”

none→0 points
1-2→0 points
3-4→1 point
5-6→2 points
7-9→3 points
10+→4 points

“how often did you have 6+ drinks on one occasion in the past year?”

never→0 points
less than monthly→1 point
monthly→2 points
weekly→3 points
daily/almost daily→4 points

0→no alcohol use

positive screening:
men→4+
women→3+

5 Ps+

partners:
last time you had intimate contact+did it include sexual intercourse
what gender is sexual partners
how many partners in last 6 months/5 years/lifetime
new partners in last 6 months

practices:
how do you have sex
what kinds (oral/vaginal/anal)
using/sharing toys
what parts of body used

protection (from STIs):
what do you do to protect from HIV/STIs
when do you use condoms:
-no use→ask why
any concerns about HIV infection/AIDS

past hx of STIs:
have you ever had an STI:
-what kind
-when
-tx+what mx
have you ever been tested for STIs:
-for what
-when
-results

pregnancy prevention:
do you have any desires to have (more) children
heterosexual:
-are you concerned about getting pregnant/getting partner pregnant
-are you doing anything to prevent partner from getting pregnant
-do you want information on birth control
-do you have any questions/concerns about pregnancy prevention

plus/+: assessments of trauma/violence/sexual satisfaction/sexual health concerns/problems/support for SOGI

FICA Screening Tool

faith/belief:
“what is your faith?”

importance/influence:
“does your spirituality influence you in your healthcare decision making?”

community:
“are you apart of a spiritual/religious community?”
“Is this a support to you and if so how?”

address:
“how would you like me to address these issues in your healthcare?”

Familial+Social Relationships

abuse→don’t ask questions with anyone else in room
pt resistant to visitor leaving→don’t force situation→places pt at risk

detect potentially threatening relations:
normalizing statement: “because abuse is common in many of my pt’s lives I’ve begun to ask about it routinely”
-are you in a relationship where you have been hit/threatened
-has anyone ever treated you badly/made you do things you’d didn’t want to do
-is there anyone you are afraid of
-have you ever been hit/kicked/punched/hurt by someone you know

Review of Systems (ROS)

shows any problems/sx that were overlooked specifically in areas unrelated to HPI

may reveal sx that lead to different dx

yes/no questions in head-to-toe format

always ask at end of interview when clinical reasoning is gone

uncover any additional major sx related to CC→move to HPI

-general
-skin/hair/nails
-head/eyes/ears/nose/throat (HEENT)
-breasts
-chest/lungs
-heart/blood vessels
-GI
-peripheral vascular
-genitourinary
-musculoskeletal
-psychiatric
-neurologic
-hematologic
-endocrine

Physical Exam (PE)

hand hygiene+contact precautions+PPE

inspection: observation of appearance/behavior/movement

palpation: tactile pressure

percussion: striking finger against digit of other hand to evoke a sound wave

auscultation: using stethoscope to hear hear/lungs/bowels/vasculature

Head to Toe Physical Exam

1. hand hygiene+contact precautions+PPE

2. general survey

3. vitals

4. skin

5. HEENT-N

6. lungs/thorax

7. cardiovascular

8. breasts/axilla

9. abdomen

10. peripheral vascular/lymphatics

11. neurologic

12. musculoskeletal

13. genital/rectal