PCM: The Medical Interview

=The Medical Interview=

Describe the characteristics of positive regard for patients (respect, genuineness, empathy) and how this leads to willingness to join patients as partners.
Set the stage – context of visit, introduction, purpose for visit, outline agenda, establish rapport and build trust. Elicit information (LOCATES, OPQRST) Give information Understand patient’s perspective – interpersonal relationships, work/school, sexual relationships, emotional stability End the encounter – have and review plan, diagnostics, therapeutics, (education, negotiation, motivation), concludes with an implied contract
 * SEGUE

Describe the purpose of each of the three basic functions of the interview:
a.	Gathering data b.	Building rapport and responding to patient’s emotions c.	Education, negotiation and motivation

List the topics of an initial interview and written history:

 * identifying data: name, sex, age, ethnicity or race & ID of person giving history
 * CC: symptoms that caused the patient to seek medical care. Use the patient’s own words.  Use open ended questions.
 * HPI: OPQRST (onset, provocative/palliative factors, quality, region/radiation, severity, timing) or LOCATES (location, other associated symptoms, character/quality, alleviating/aggravating, timing, environment/setting, severity)
 * PMH:  any significant past health events
 * Use elements from OPQRST mnemonic
 * Onset of symptom – when did it start?
 * Palliative factors –what makes it better?
 * Quality – what is the symptom like – achy, sharp, repetitive?
 * Region – where is it, does it radiate?
 * Severity – where is it on a scale of 1-10?
 * Timing – when does it occur, e.g., after meals, in the morning?
 * Include Other Relevant elements
 * Past medical history – e.g. history of a previous heart attack when the patient complains of shortness of breath
 * Past surgical history – e.g., previous cardiac bypass surgery
 * Family history – e.g., mother died of a heart attack at age 45
 * Social history – e.g., smoked 2 packs per day for 10 years


 * Allergies and Intolerances:
 * Medicines
 * Food/Environmental – e.g., peanuts, eggs, grass
 * Allergy = hives, angioedema, rash
 * Current Medications
 * Prescription Drugs, transdermal patches etc.
 * Supplements – vitamins, herbal products
 * OTC drugs
 * Recreational drugs, EtOH, Tobacco (may be a more natural place to ask than social history
 * Always ask if the patient recently stopped taking any drugs


 * ROS: any aspect of patient’s physical or emotional health not previously discussed
 * General: Weight loss or gain, fever, chills, fatigue, night sweats, malaise
 * Skin: Rashes, bruises, changes in moles, dryness
 * Head, Eyes, Ears, Nose, Throat (HEENT)
 * Head: headache, lumps or bumps, syncope
 * Eyes: blurred vision, pain, floaters, double vision, visual field cuts, visual acuity
 * Ears: hearing loss, tinnitus, infections, dizziness, vertigo, pain
 * Nose: nosebleed, discharge, allergies
 * Throat/Mouth: dental disease, hoarseness, dryness, throat pain
 * Respiratory: cough, shortness of breath (dyspnea), wheezing, pneumonia, recurrent bronchitis, asbestos exposure, TB
 * Cardiovascular: chest pain, murmurs, cyanosis, peripheral edema, orthopnea, exercise intolerance, paroxysmal nocturnal dyspnea, dypsnea on exertion
 * Gastrointestinal: dysphagia, abdominal pain, nausea, vomiting, hematemesis, diarrhea, constipation, melena, borborygmi, change in bowel habits, jaundice, red blood in stool, gastric reflux, fecal incontinence, food intolerance
 * Genitourinary: frequency, urgency, dysuria, hematuria, infections, discharges, venereal disease
 * Males – testicular masses or tenderness, impotence, penile discharge, dribbling, hernias
 * Females – age at menarche, age at menopause (vasomotor symptoms), menstrual flow, dysmenorrhea, pregnancies, abortions, miscarriages, contraception, breast lumps or tenderness, inter-menstrual bleeding
 * Endocrine: Temperature intolerance, skin or hair changes (hair loss or silkiness), polyuria, polydipsia, hormonal therapy
 * Musculoskeletal: Bone or muscle pain, history of fractures, joint pain or swelling, arthritis, muscle weakness, joint deformities
 * Lymphatics: edema, lymph node swelling
 * Neurological: weakness, paralysis, paresthesias, memory changes, vertigo, seizures, tremors, syncope
 * Psychiatric: emotional disturbances, hallucinations, sleep disturbances, depression, mania, anxiety, general mood, irritability

social and spiritual histories
 * Family History
 * Draw a tree
 * Clarify blood relatives: Grandparents, parents, siblings, children


 * Past Medical History (PMH) and Surgical History
 * Comprehensive overview of significant past health history
 * Acute illness
 * Chronic diseases such as diabetes (DM), hypertension (HTN), peptic ulcer disease, asthma, chronic pulmonary obstructive disease (COPD), myocardial infarct (MI), Cancer (CA), tuberculosis (TB), etc.
 * Hospitalizations – when and what
 * Prior Surgeries – when and what
 * Social History (SH)
 * Family Status
 * Children
 * Occupation
 * Education
 * Cultural Identity
 * Spiritual values & relation to health care decisions
 * Sexual History

Describe how to greet and put a patient at ease; typical comments to start the interview; typical comments to organize and guide the interview; and typical comments to close the interview
today? *Is there anything else that you think would be important for me to know?
 * What brings you here today? What’s bothering you today? How can I help you
 * How long has this been a problem? Are there any other issues you would like to discuss?
 * Review list of problems, discuss plan, make sure that the patient is on board with the plan

Describe the difference between open-ended and close-ended questions
Close-ended can be answered with a yes/no or specific piece of information, while open-ended leave room for the patient to explain themselves. Both strategies are useful. Open ended questions can allow the patient the opportunity to accurately describe their condition. Close ended questions can guide an interview back towards criteria important for diagnosis.

Demonstrate the ability to effectively elicit the patent’s priorities and concerns at the beginning of an encounter and thereby negotiate an agenda for the medical visit

 * What problem concerns you most?  *What worries you most about how you are feeling?  *We are going to talk about that problem first and if we have time at the end of the appointment we can discuss your other problems or schedule another appointment.

==Demonstrate the ability to engender a therapeutic relationship with a patient through use of communication skills such as expressing empathy, active listening, and eliciting information about the patient’s life, expectations and concerns about medical care==

Additional notes
Don’t forget to use “normalizing language” in difficult situations eg: “people who feel that way sometimes think about hurting themselves. Have you had any such thoughts?”

Body language is key in patient interactions. The physician should try to maintain open body language and, ideally, take the history sitting at the same level as the patient.

Special situations for history-taking include: Children and adolescents: communication issues with younger kids (don’t forget to ask them closed questions, your entire conversation does not have to be with the adult), and confidentiality issues with adolescents (establish ‘rules of confidentiality,’ or what you will or won’t discuss with their parents, age 8 is a good time to establish the practice of giving a child time alone with their physician, without the parent present) Pregnant women: also consider previous obstetric history, occupational & environmental exposures, genetic history for both mother & father, and a social history including the emotional response of the patient and family to the pregnancy as well as risk for domestic violence. Elderly patients: need to be included in the history, do not speak exclusively to their child or forget functional assessments (nutrition, financial independence, depression and alcohol use, sexual history immunization status and preventative screening. Bilingual interviews:  whenever possible use a professional medical translator and address the question as if to the patient and not the translator.  The mentally disabled:  include both patient and caregiver in conversation

Goals of partnering with patients: discovery, sharing, negotiation, union & support

Basic requirements of healthy communication: flexibility, specificity, clarity, subltelty, empathy

Steps of good communication: facilitation, reflection, clarification, empathetic response, confrontation and summary.