The History and Interviewing Process: Seidel's Guide to Physical Examination

Learning Objectives of History and Interviewing

  • Recognize Ethical Considerations: Understand the ethical dimensions inherent in the patient-examiner relationship.
  • Classify Communication Aspects: Identify the various elements of communication that influence and affect the interview process.
  • Obtain Comprehensive Health History: Learn the methods required to gather a full and detailed health history from a patient.
  • Apply Clinical Presentation Elements: Integrate the specific elements of a clinical presentation into the documentation of a health history.
  • Organize Data: Utilize a structured clinical history outline to organize the collected information efficiently.
  • Compare History Taking Across the Lifespan: Adapt history-taking techniques for adults as well as persons of various ages and specific conditions.

The Philosophy of History Building

  • "Build" vs. "Take": History should be "built" rather than merely "taken." This distinction emphasizes that the process is a joint effort between the examiner and the patient.
  • Relationship Context: The patient-examiner relationship is expressed through emotional, physical, and ethical terms.
  • Structural Adaptations: History structure must be modified for specific groups, including:
    • Children and adolescents.
    • Gender-specific considerations.
    • Pregnant patients.
    • Older adults.
    • Patients with disabilities.
  • Vitality of the History: The history is essential for the correct interpretation of physical examination findings.

Developing a Relationship and Effective Communication

  • Sensing the Patient’s World: To avoid misperceptions or misinterpretations, the examiner must attempt to see the world from the patient's perspective.
  • The Five Pillars of a Positive Relationship: Establishing a strong connection relies on communication built upon:
    • Courtesy
    • Comfort
    • Connection
    • Confirmation
    • Confidentiality

Techniques for Enhancing Patient Responses

  • Question Types:
    • Open-ended question: Grants the patient discretion regarding the extent and detail of their answer.
    • Direct question: Used to seek specific, targeted information.
    • Leading question: Potentially limits the response as it may suggest the patient should provide the information they think the examiner wants to hear (often discouraged).
  • Communication Techniques for Understanding:
    • Facilitate: Encourage the patient to provide more information (e.g., "Go on").
    • Reflect: Repeat the information heard back to the patient.
    • Clarify: Ask specifically, "What do you mean?"
    • Empathize: Demonstrate understanding and acceptance of the patient's feelings.
    • Confront: Address and discuss disturbing or difficult patient behaviors.
    • Interpret: Repeat what has been heard to confirm the patient’s intended meaning.

Potential Barriers to Communication

  • Interpersonal Dynamics: Curiosity about the examiner, anxiety, silence, and depression.
  • Emotional Responses: Crying or compassionate moments, anger, and avoidance.
  • Intimacy Concerns: Physical and emotional intimacy, as well as seduction.
  • Practical Concerns: Financial considerations.

Setting for the Interview

  • Perspective: The history is built on the patient’s perspective, not the examiner’s.
  • Environmental Requirements:
    • Comfort: The space must be comfortable for all parties involved.
    • Removal of Barriers: Eliminate physical barriers between the patient and examiner.
    • Clock Access: The examiner should have unobtrusive access to a clock to manage time without disrupting the flow.
    • Engagement: Maintain consistent eye contact and use a conversational tone.

Procedural Steps for Building the History

  • Introduction: Introduce yourself and address the patient properly.
  • Engagement: Make eye contact and listen actively.
  • Pacing: Proceed at a reasonable pace and do not interrupt the patient.
  • Clarification: Use "where, when, what, how, and why" questions to clarify responses.
  • Review: Summarize and review what has been heard with the patient to ensure accuracy.

Approaching Sensitive Issues

  • General Guidelines:
    • Ensure strict privacy.
    • Communicate directly; do not "waffle."
    • Do not apologize for asking necessary questions.
    • Avoid preaching or being judgmental.
    • Avoid the use of medical jargon.
    • Do not push the patient too hard if they are resistant.
  • Alcohol and Drug Use: Utilize screening tools to identify problems:
    • CAGE
    • CRAFT
    • TACE
  • Intimate Partner Violence (IPV):
    • If IPV is detected, the examiner should also consider the possibility of child abuse.
    • Screening tool: HITS
  • Spirituality: Screen using the FICA acronym.
  • Sexuality and Gender Identity: Use gender-neutral language and respect the patient's identity.

Structure and Outline of the Clinical History

  • Identifiers: Name, date, time, age, gender identity, race, source of information, and referral source.
  • Chief Concern (CC): The primary reason the patient is seeking care.
  • History of Present Illness/Problem (HPI): Detailed chronological account of the current issue.
  • Past Medical History (PMH): Previous illnesses, surgeries, and treatments.
  • Family History (FH): Health status and relevant illnesses of blood relatives.
  • Personal and Social History (PSH): Lifestyle, work, and social support.
  • Review of Systems (ROS): A systematic quest for symptoms in all body systems.

Detailed Review of Systems (ROS)

  • General Constitutional Symptoms: Pain, fever, chills, malaise, fatigue, night sweats, and sleep patterns. Weight assessment includes average, preferred, present, and recent changes.
  • Skin, Hair, and Nails: Rashes, eruptions, itching, changes in pigmentation or texture, excessive sweating, and abnormal nail or hair growth.
  • Head and Neck (General): Headaches, dizziness, syncope, head injuries, concussions, and loss of consciousness.
  • Eyes: Visual acuity, blurring, diplopia (double vision), photophobia, pain, vision changes, glaucoma, eye medications, and trauma.
  • Ears and Nose:
    • Ears: Hearing loss, pain, discharge, tinnitus, vertigo, and infections.
    • Nose: Sense of smell, frequency of colds, obstruction, epistaxis (nosebleeds), postnasal discharge, and sinus pain.
  • Throat and Mouth: Hoarseness, change in voice, frequent sore throats, bleeding/swelling of gums, dental issues (abscesses, extractions), soreness/ulcers of tongue/mucosa, taste changes, and dental care habits.
  • Lymph Nodes: Notable enlargement, tenderness, or suppuration (formation of pus).
  • Chest and Lungs: Pain, dyspnea (shortness of breath), cyanosis, wheezing, cough, sputum production, hemoptysis (coughing up blood), night sweats, tuberculosis exposure, and date of last chest radiograph.
  • Breasts: Development, pain, tenderness, discharge, lumps, galactorrhea, self-awareness, and mammogram history (screening vs. diagnostic).
  • Heart and Blood Vessels: Chest pain, palpitations, dyspnea, orthopnea, edema, hypertension, history of myocardial infarction, exercise tolerance, and dates of cardiac tests (ECG, etc.).
  • Peripheral Vascular and Hematologic:
    • Peripheral Vascular: Claudication (frequency/severity), tendencies to bruise or bleed, thromboses, and thrombophlebitis.
    • Hematologic: Anemia, bruising, and blood cell abnormalities.
  • Gastrointestinal (GI): appetite, digestion, food intolerances, dysphagia, heartburn, nausea/vomiting, hematemesis, history of ulcers/polyps/tumors/gallstones, bowel regularity (constipation, diarrhea, changes in stools), flatulence, hemorrhoids, jaundice, and previous imaging.
  • Diet: Appetite, likes/dislikes, restrictions (dietary/cultural), vitamins/supplements, caffeine intake, and dietary recall.
  • Endocrine:
    • General: Thyroid enlargement/tenderness, heat/cold intolerance, weight change, diabetes, polydipsia, polyuria, changes in facial/body hair, changes in hat/glove size, and skin striae.
    • Female: Menses, discharge, itching, Pap smear history, libido, intercourse, birth control, infertility/pregnancy, and menopause.
    • Male: Puberty onset, erections, emissions, testicular pain, libido, and infertility.
  • Genitourinary: STIs, dysuria, pain, urgency, frequency, nocturia, hematuria, discolored urine, polyuria, hesitancy, dribbling, loss in force of stream, passage of stones, facial edema, stress incontinence, and hernias.
  • Musculoskeletal: Joint stiffness, pain, restriction of motion, swelling, redness, heat, and bony deformity.
  • Neurologic: Syncope, seizures, weakness/paralysis, sensation/coordination abnormalities, tremors, and memory loss.
  • Psychiatric: Depression, mood changes, concentration difficulty, anxiety, agitation, tension, suicidal thoughts, irritability, and sleep disturbances.

Specialized Populations

  • General Rule: Every special population requires a Review of Systems (ROS) tailored to the individual.
  • Children:
    • Use age-appropriate language and utilize play.
    • Inquire about neonatal period, feeding, and developmental milestones.
    • Assess school adjustment, habits, and home conditions.
  • Adolescents:
    • Provide confidentiality to encourage honesty.
    • Assess home, school, work, activities, and friends.
    • Specific screening tools: HEEADSSS, PACES, and CRAFFT.
  • Pregnant/Postpartum Patients:
    • Focus on obstetric, menstrual, and gynecologic history.
    • Conduct risk assessments.
  • Older and Frail Adults:
    • Note cognitive, sensory, and motor changes.
    • Perform risk assessments.
  • Cognitive Impairment: Identify designated healthcare agents and/or advance directives.

Concluding History Questions

  • "Is there anything else that you think would be important for me to know?"
  • "What problem concerns you most?"
  • "What do you think is the matter with you?"
  • "What worries you the most about how you are feeling?"

Types of Clinical Histories

  • Complete History: A comprehensive record usually performed during the initial visit.
  • Inventory History: Touches on major points without providing exhaustive detail.
  • Problem (or Focused) History: Targeted toward acute or specific problems.
  • Interim History: Chronicles events and changes that have occurred since the last visit.
  • Critical Note: Current medications and allergies must be assessed regardless of the history type.

Questions & Discussion

  • Question 1: A health history that is designed to chronicle events that have occurred since the patient’s last visit is called a(n):
    • Answer: Interim history.
  • Question 2: Which tools are beneficial to use when screening adolescents?
    • Answer: PACES, CRAFFT, and HEEADSSS (Note: KATZ was listed as a distractor).
  • Question 3: Which communication technique should the nurse use to confirm the patient’s meaning?
    • Answer: Interpret.