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illustration overlays to demonstrate examination techniques in greater depth, and a fifteenth “Putting It All Together” video that shows a head-to-toe examination of an adult along with appropriate life span variations. The series includes three special topics: Effective Communication and Interviewing Skills, Physical Examination of the Hospitalized Patient, and Putting It All Together: Physical Examination of the Child. All 18 videos in this video series are offered in two formats: streaming (online) and networkable (for institutional purchase).

Our Core Values In the ninth edition of Seidel’s Guide to Physical Examination: An Interprofessional Approach, we have made every attempt to consider patients in all of their variety and to preserve the fundamental messages explicit in earlier editions. These include the following: • Respect the patient. • Achieve the complementary forces of competence and

compassion. • The art and skill essential to history taking and physical

examination are the foundation of care; technologic resources complement these processes.

• The history and physical examination are inseparable; they are one.

• The computer and technology compliments you. Your care and skills are what builds a trusting, fruitful relation- ship with the patient.

• That relationship can be indescribably rewarding. We hope that you will find this a useful text and that it will continue to serve as a resource as your career evolves.

Dedication We dedicate the ninth edition of this text to two original authors, Henry M. Seidel, MD, and William Benedict, MD, who served on seven and six editions, respectively. Both physicians had academic appointments at The Johns Hopkins University School of Medicine for decades and made important contributions to patient care and medical student education in their specialties of pediatrics and endocrinology/internal medicine, respectively.

As original authors they contributed greatly to the initial text design as well as to its ongoing development. Both Dr. Seidel and Dr. Benedict understood the importance of communication, sensitivity, compassion, and connection with patients. This text was one of the earliest collabora- tions of a physician and nurse author team, in this case to develop a text targeted to students of medicine, nursing, and other allied health professions. The ability of these physicians to mesh their visions with that of the nurse authors and to collaborate as an effective team allowed the authors to shape this text and share important values with students.

This text was renamed in Henry Seidel’s honor for the eighth edition as Seidel’s Guide to Physical Examination.

Acknowledgments The ninth edition of our textbook is possible only because of the professionalism and skills of so many others who really know how to fashion a book and its ancillaries so that it is maximally useful to you. First, there are those instructors and students who have so thoughtfully and constructively offered comment over the years. Improvements in content and style are often the results of their suggestions.

While the authors have provided the content, it must be accessible to the reader. A textbook needs a style that ensures readability, and our partners at Elsevier have made that happen. Lee Henderson, our Executive Content Strate- gist, provided oversight and guidance with the eye of an experienced editor along with strategies to meet the changing environment of print and electronic publishing. The whole textbook revision is a demanding project requiring effective teamwork. Courtney Sprehe, Jennifer Hermes, and Saman- tha Dalton, our Content Development Specialists, maintained professional skill and calm while obtaining chapter reviews, editing chapters, and moving the project forward. Heather Bays did a spectacular job of keeping everything moving with her qualitative eye for detail and design throughout. Brian Salisbury’s design is visually appealing and showcases the content.

We also want to recognize the indispensable efforts of the entire marketing team led by Becky Ramsaroop, as well as the sales representatives, who make certain that our message is honestly portrayed and that comments and suggestions from the field are candidly reported. Indeed, there are so very many men and women who are essential to the creation and potential success of our ninth edition, and we are indebted to each of them.

The remarkable teaching tools we call the ancillaries need special attention. These are the laboratory manual, handbook, TEACH, test banks, Health Assessment Online, and video series, all demanding an expertise—if they are to be useful—that goes beyond that of the authors. Frances Donovan Monahan offers hers for the laboratory manual. Joanna Cain offers hers for the Power Point slides, nursing test bank NCLEX review questions, student checklists, and key points; Jennifer Hermes offers hers for TEACH; and Frank Bregar offers his for the advanced practice test bank. The careful attention to all asset development is overseen by Jason Gonulsen. The development of Health Assessment Online is led by Frances Donovan Monahan; Chris Lay; Nancy Priff, Glenn Harman, and Paul Trumbore’s efforts are essential to the success of the video series.

And finally—our families! They are patient with our necessary absences, support what we do, and are unstinting in their love. They have our love and our quite special thanks.

Jane W. Ball, DrPH, RN, CPNP Joyce E. Dains, DrPH, JD, RN, FNP-BC, FNAP, FAANP

John A. Flynn, MD, MBA, MEd Barry S. Solomon, MD, MPH

Rosalyn W. Stewart, MD, MS, MBA

1

The History and Interviewing Process

CHAPTER

1  This chapter discusses the development of relationships with patients and the building of the histories or health- care narratives. We write of it as “building” a history rather than “taking” one because you and your patient are involved in a joint effort, a partnership, which should have, among other outcomes, a history that truly reflects the patient’s perspectives and unique status (Haidet, 2010; Haidet and Paterniti, 2003). The chapter discusses the context of the relationship in emotional, physical, and ethical terms and offers suggestions in verbal and nonverbal behavior that you may adapt to your individual comfort and style. Finally, we offer widely accepted, time-tested approaches to the structure of a history with adaptations suggested for age, children, adolescents, pregnant patients, older adults, and patients with disabilities. The history is vital to the appropriate interpretation of the physical examination.

Developing a Relationship With the Patient Our purpose is to offer instruction in learning about the well and the sick as they seek care. History and physical examination are at the heart of this effort. It is not easy to get the sense of another person or to fully appreciate someone else’s orientation in the world. You and the patient may seem to have a similar experience but may in all likelihood interpret it differently (see Clinical Pearl, “Unique,” Originally Derived From Latin “Unus,” Meaning “One”). On the other hand, you and your patient may come from very different backgrounds without any shared experi- ences. If you are to prevent misinterpretations and misper- ceptions, you must make every effort to sense the world of the individual patient as that patient senses it. (See Chapter 2 for additional discussion.)

The first meeting with the patient sets the tone for a successful partnership as you inform the patient that you really want to know all that is needed and that you will be open, flexible, and eager to deal with questions and explana- tions. You can also explain the boundaries of your practice and the degree of your availability in any situation. Trust evolves from honesty and candor.

A primary objective is to discover the details about a patient’s concern, explore expectations for the encounter, and display genuine interest, curiosity, and partnership. Identifying underlying worries, believing them, and trying to address them optimizes your ability to be of help. You need to understand what is expected of you. If successful, the unique and intimate nature of the interview and physical examination will be reinforced. You will savor frequent tender moments with patients when you recognize that your efforts are going well and that trust is there. We want to help ensure those moments occur.

CLINICAL PEARL

“Unique,” Originally Derived From Latin “Unus,” Meaning “One” We use “unique” in that sense of being the only one. Each of us is unique, incomparably different from anyone in the past, present, or future. No relationship, then, has an exact counterpart. Each moment is unique, different from the time before with the same patient.

From Merriam-Webster’s Learner’s Dictionary, 2016.

CLINICAL PEARL

The Patient Relationship You will, in the course of your career, have numerous relationships with patients. Never forget that each time they are having an experience with you, it is important to them.

Much has been written about technology replacing the history and physical examination in some part, but personal- ized care of patients goes far beyond the merely technical. Appropriate care satisfies a need that can be fully met only by a human touch, intimate conversation, and the “laying on of hands.” Personal interactions and physical examination play an integral role in developing a meaningful and therapeutic relationships with patients (Kugler and Verghese, 2010).

This actual realization of relationships with patients, particularly when illness compounds vulnerability, cannot be replaced (see Clinical Pearl, “The Patient Relationship”).

Because cost containment is also essential, the well- performed history and physical examination can justify the appropriate and cost-effective use of technological resources. This underscores the need for judgment and the use of resources in a balance appropriate for the individual patient.

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ss them. You have to be aware of your cultural beliefs, faith, and conscience so that they do not inappropriately intrude as you discuss with patients a variety of issues. That means knowing yourself (Curlin et al, 2007; Gold, 2010; see also Chapter 2).

You react differently to different people. Why? How? Do you want to be liked too much? Does thinking about how you are doing get in the way of your effort? Why does a patient make you angry? Is there some frustration in your life? Which of your prejudices may influence your response to a patient? Discuss and reflect on such questions with others you trust rather than make this a lonely, introspective effort. You will better control possible barriers to a successful outcome.

Effective Communication Establishing a positive patient relationship depends on communication built on courtesy, comfort, connection, and confirmation (Box 1.2).

Be courteous; ensure comfort, both physical and emo- tional; be sure that you have connected with the patient with trust and candor; and confirm that all that has happened during the interaction is clearly understood and your patient is able to articulate the agreed-on plan. That is communication.

Seeking Connection. Examine your habits and modify them when necessary so that you are not a barrier to effective communication. Stiff formality may inhibit the patient; a too-casual attitude may fail to instill confidence. Do not be careless with words—what you think is innocuous may seem vitally important to a patient who may be anxious and searching for meaning in everything you say. Consider intellectual and emotional constraints related to how you ask questions and offer information, how fast you talk, and how often you punctuate speech with “uh-huh” and “you know.” The interaction requires the active encouragement of patient participation with questions and responses addressed to social and emotional issues as much as the physical nature of health problems.

At the start, greet the patient. Welcome others and ask how they are connected to the patient. Begin by asking open-ended questions (“How have you been feeling since we last met?” “What are your expectations in coming here today?” “What would you like to discuss?” “What do you want to make sure we cover in today’s visit?”). Resist the urge to interrupt in the beginning. You will be amazed how many times a complete history is provided without prompting. Later, as information accumulates, you will need to be more specific. However, early on, it is entirely appropriate to check the patient’s agenda and concerns and let the information flow. It is important not to interrupt the patient at the start of the interview and to ask whether there is “anything else” a few times to be sure the patient’s primary concerns are identified early in the visit. Thus, you and the patient can collaboratively set the current visit’s agenda.

At a first meeting, you are in a position of strength and your patients are vulnerable. You may not have similar per- spectives but you need to understand the patient’s if you are to establish a meaningful partnership. This partnership has been conceptualized as patient-centered care, identified by the Institute of Medicine (IOM) as an important element of high-quality care. The IOM report defined patient-centered care as “respecting and responding to patients’ wants, needs and preferences, so that they can make choices in their care that best fit their individual circumstances” (IOM, 2001). Box 1.1 identifies questions that represent a patient-centered approach in building a history. Your own beliefs, attitudes, and values cannot be discarded, but you do have to discipline

BoX 1.1 Patient-Centered Questions

The following questions represent a patient-centered approach in building a history. • How would you like to be addressed? • How are you feeling today? • What would you like for us to do today? • What do you think is causing your symptoms? • What is your understanding of your diagnosis? Its importance? Its

need for management? • How do you feel about your illness? Frightened? Threatened?

Angry? As a wage earner? As a family member? (Be sure, however, to allow a response without putting words in the patient’s mouth.)

• Do you believe treatment will help? • How are you coping with your illness? Crying? Drinking more?

Tranquilizers? Talking more? Less? Changing lifestyles? • Do you want to know all the details about your diagnosis and its

effect on your future? • How important to you is “doing everything possible”? • How important to you is “quality of life”? • Have you prepared advance directives? • Do you have people you can talk with about your illness? Where

do you get your strength? • Is there anyone else we should contact about your illness or

hospitalization? Family members? Friends? Employer? Religious advisor? Attorney?

• Do you want or expect emotional support from the healthcare team?

• Are you troubled by financial questions about your medical care? Insurance coverage? Tests or treatment you may not be able to afford? Timing of payments required from you?

• If you have had previous hospitalizations, does it bother you to be seen by teams of physicians, nurses, and students on rounds?

• How private a person are you? • Are you concerned about the confidentiality of your medical records? • Would you prefer to talk to an older/younger, male/female healthcare

provider? • Are there medical matters you do not wish to have disclosed to

others? We suggest that use of these questions should be determined by

the particular situation. For example, talking about a living will might alarm a patient seeking a routine checkup but may relieve a patient hospitalized with a life-threatening disease. Cognitive impairment, anxiety, depression, fear, or related feelings as well as racial, gender, ethnic, or other differences should modify your approach.

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Confidentiality, which is important in all aspects of care, is another essential element. The patient should provide the information. It is important to identify everyone in the room to be sure the patient is comfortable and wants others to participate in the visit. You may want to ask the parent, spouse, or other person to step out of the room so you can have a confidential discussion with the patient. If language

Having clear and agreed-upon goals for each interaction leads to successful communication. You must be a skilled listener and observer with a polished sense of timing and a kind of repose that is at once alert and reassuring. Your nonverbal behavior complements your listening. Your face need not be a mask. You can be expressive and nod in agreement, but it is better to avoid the extremes of reaction (e.g., startle, surprise, or grimacing). Eye contact should be assured and comfortable, and your body language should show that you are really in the room, open to and engaged with the patient. You should be comfortably seated close to the patient and, if using an electronic medical record, so you and the patient can both visualize the screen. Do not stand and do not reach for the doorknob (see Clinical Pearl, “Professional Dress and Grooming”).

Remember that patients also communicate nonverbally, and understanding this is advantageous to both you and the patient (Henry et al, 2012).

BoX 1.2 Communication

Courtesy, Comfort, Connection, Confirmation Courtesy • Knock before entering a room. • Address, first, the patient formally (e.g., Miss, Ms., Mrs., Mr.) It is

all right to shake hands. • Meet and acknowledge others in the room and establish their roles

and degree of participation. • Learn their names. • Ensure confidentiality. • Be in the room, sitting, with no effort to reach too soon for the

doorknob. • If taking notes, take notes sparingly; note key words as reminders

but do not let note-taking distract from your observing and listening.

• If typing in the electronic medical record, type briefly and maintain eye contact with patient, if possible.

• Respect the need for modesty. • Allow the patient time to be dressed and comfortably settled after

the examination. Follow-up discussion with the patient still “on the table” is often discomfiting.

Comfort • Ensure physical comfort for all, including yourself. • Try to have a minimum of furniture separating you and the

patient. • Maintain privacy, using available curtains and shades. • Ensure a comfortable room temperature or provide a blanket—a

cold room will make a patient want to cover up. • Ensure good lighting. • Ensure necessary quiet. Turn off the television set. • Try not to overtire the patient. It is not always necessary to do it all

at one visit.

Connection • Look at the patient; maintain good eye contact if cultural practices

allow.

• Watch your language. Avoid professional jargon. Do not patronize with what you say.

• Do not dominate the discussion. Listen alertly. Let the patient order priorities if several issues are raised.

• Do not accept a previous diagnosis as a chief concern. Do not too readily follow a predetermined path.

• Find out whether the patient has turned from other healthcare providers to come to you.

• Take the history and conduct the physical examination before you look at previous studies or tests. Consider first what the patient has to say.

• Avoid leading or direct questions at first. Open-ended questions are better for starters. Let specifics evolve from these.

• Avoid being judgmental. • Respect silence. Pauses can be productive. • Be flexible. Rigidity limits the potential of an interview. • Assess the patient’s potential as a partner. • Seek clues to problems from the patient’s verbal behaviors and body

language (e.g., talking too fast or too little). • Look for the hidden concerns underlying chief concerns. • Never trivialize any finding or clue. • Problems can have multiple causes. Do not leap to one cause too

quickly. • Define any concern completely: Where? How severe? How long? In

what context? What soothes or aggravates the problem?

Confirmation • Ask the patient to summarize the discussion. There should be clear

understanding and uncertainty should be eased. • Allow the possibility of more discussion with another open-ended

question: “Anything else you want to bring up?” • If there is a question that you cannot immediately answer, say so.

Be sure to follow up later if at all possible. • If you seem to have made a mistake, make every effort to repair it.

Candor is important for development of a trusting partnership. Most patients respect it.

CLINICAL PEARL

Professional Dress and Grooming Appropriate dress and grooming go a long way toward establishing a first good impression with the patient. Although clean fingernails, modest clothing, and neat hair are imperative, you need not be formal to be neat. You can easily avoid extremes so that appearance does not become an obstacle in the patient’s response to care.

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ss When asking how often something happened, allow the patient to define “often,” rather than asking, “It didn’t happen too often, did it?” Sometimes the patient does not quite understand what

you are asking and says so. Recognize the need when it is appropriate to: • Facilitate—encourage your patient to say more, either

with your words or with a silence that the patient may break when given the opportunity for reflection.

• Reflect—repeat what you have heard to encourage more detail.

• Clarify—ask, “What do you mean?” • Empathize—show your understanding and acceptance.

Do not hesitate to say “I understand,” or “I’m sorry” if the moment calls for it.

• Confront—do not hesitate to discuss a patient’s disturbing behavior.

• Interpret—repeat what you have heard to confirm the patient’s meaning. What you ask is complemented by how you ask it. Take

the following actions, if necessary, to clarify the patient’s point of view: • Ask what the patient thinks and feels about an issue. • Make sure you know what the chief concern is. • Ask about the patient’s life situation, so that nothing

seemingly extraneous to the chief concern and present illness has gone unnoticed.

• Suggest at appropriate times that you have the “feeling” that the patient could say more or that things may not be as well as they are reported.

• Suggest at appropriate times that it is all right to be angry, sad, or nervous, and it is all right to talk about it.

• Make sure that the patient’s expectations in the visit are met and that there are no further questions. Make sure your questions are clearly understood. Define

words when necessary and choose them carefully. Avoid technical terms if possible. Adapt your language when necessary to the patient’s education level. Ask the patient to stop you if he or she does not understand what you are talking about. Similarly, do the same if you do not grasp the patient’s meaning. For example, a patient may report that he had “low blood” (anemia), “high blood” (hyperten- sion), “bad blood” (syphilis), and “thin blood” (he was taking anticoagulants). It can take a bit of exploring to sort it all out. Do not assume every question needs a complex and technical answer. Avoid medical jargon with all patients, even those who are in the healthcare field.

Moments of Tension: Potential Barriers to Communication

Curiosity About You. Patients will sometimes ask about you. Although you are not the point, you may be comfortable revealing some relevant aspects of your experience (“I have trouble remembering to take medicines too” or “I remember when my children had tantrums”). A direct answer will usually do. Often, simply informing your patients that you have experienced similar life events (e.g., illness, pregnancy,

is a barrier, a professional interpreter, rather than a family member, should be used (Fig. 1.1).

Gentle guidance and polite redirection are sometimes necessary to keep the visit focused and moving forward (e.g., “Now let’s also talk about …” or “I’m sorry to interrupt, but let me make sure I understand …”). Be prepared with questions you think are important to address based on the patient’s history and main concerns. If the patient touches on something that does not seem immediately relevant to your purposes (e.g., introducing a possible problem not previously mentioned), be flexible enough to clarify at least the nature of the concern. Some apparent irrelevancies may contain clues to the care-seeking behaviors or concerns that may be hidden beneath the primary concern and may greatly help in understanding the patient’s illness perspec- tive. The patient’s body language will also suggest the intensity of an underlying feeling. Although too many digressions can lead to misspent time, paying attention may save a lot of time later, and information learned may be important to the future plan of care.

Enhancing Patient Responses. Carefully phrased questions can lead to more accurate responses. Ask one question at a time, avoiding a barrage that discourages the patient from being complete or that limits answers to a simple yes or no: • The open-ended question gives the patient discretion

about the extent of an answer: “Tell me about …” “And then what happened?” “What are your feelings about this?” “What else do you need to talk about?”

• The direct question seeks specific information: “How long ago did that happen?” “Where does it hurt?” “Please put a finger where it hurts.” “How many pills did you take each time?” and “How many times a day did you take them?”

• The leading question is the most risky because it may limit the information provided to what the patient thinks you want to know: “It seems to me that this bothered you a lot. Is that true?” “That wasn’t very difficult to do, was it?” “That’s a horrible-tasting medicine, isn’t it?”

FIg. 1.1 Interviewing a patient with the help of an interpreter. Someone other than a family member should act as interpreter to bridge the language difference between the healthcare provider and the patient.

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Crying and Compassionate Moments. People will cry. Let the emotion proceed at the patient’s pace. Resume your questioning only when the patient is ready. If you suspect a patient is holding back, give permission. Offer a tissue or simply say, “It seems like you’re feeling sad. It’s OK to cry.” Name the emotion. Be direct about such a tender circumstance, but gently, not too aggressively or insistently. Do not hesitate to say that you feel for the patient, that you are sorry for something that happened, and that you know it was painful. At times, the touch of a hand or even a hug is in order. Sometimes, a concern—a difficult family relation- ship, for example—must be confronted. You may have to check an assumption and hope that you have guessed correctly in bringing the patient’s feelings to the surface. If uncertain, ask without presupposing what the response might be.

Physical and Emotional Intimacy. It is not easy to be intimate with the emotions and the bodies of others. Cultural norms and behaviors are at once protective of and barriers to trusting relationships. The patient is in a dependent status as well. You can acknowledge this while explaining clearly and without apology what you must do for the patient’s benefit. Of course, respect modesty, using covers appropriately without hampering a complete examination. Be careful about the ways in which you use words or frame questions. You cannot be sure of the degree to which a given patient has been “desensitized” to the issues of intimacy. However, respect for modesty carried too far, such as skipping examination of the genitals, can be a trap delaying or barring access to much needed information. You can keep the necessary from becoming too big an issue by being calm and asking questions with professional poise.

Seduction. Some patients can be excessively flattering and manipulative and even seductive. Their illness and insecurity beg for extra-special attention. Do not be taken in by this. There are limits to warmth and cordiality. Certainly not all touch is sexually motivated; a heartfelt hug is sometimes just right. Nevertheless, beware of that trap. Avert it courteously and firmly, delivering the immedi- ate message that the relationship is and will remain profes- sional. It takes skill to do this while maintaining the patient’s dignity, but there is no room for sexual misconduct in the relationship, and there can be no tolerance for exploitation of the patient in this regard.

Anger. Sometimes the angriest patients (or persons with them) are the ones who may need you the most. Of course, it can be intimidating. Confront it. It is all right to say, “It seems like you’re angry. Please tell me why. I want to hear.” Speak softly and try not to argue the point. You may not know if or why you made someone angry. Most often, you have done nothing wrong, and the patient’s emotion is unrelated to you or the visit. Still, the stress of time, heavy workload, and the tension of caring for the acutely—even terminally—ill can generate your own impatience and potential for anger. Avoid being defensive, but acknowledge the problem. Only when appropriate, apologize and ask

and childbirth) can help alleviate fears and, with further exploration, can help in the identification of the patient’s concerns. The message that you are a “real” person can lead to a trust-enhancing or even therapeutic exchange. At the same time, it is wise to exercise caution and remain professional in what and how much you disclose (Lussier and Richard, 2007).

Anxiety. Anxiety has multiple sources, such as an impending procedure or anticipated diagnosis. Some disorders will be more likely to cause an intense response, such as those associated with crushing chest pain or dif- ficulty in breathing; with other disorders, just seeing a healthcare professional can cause anxiety. You can help by avoiding an overload of information, pacing the conversation, and presenting a calm demeanor.

Silence. Sometimes intimidated by silence, many health- care providers feel the urge to break it. Be patient. Do not force the conversation. You may have to move the moment along with an open-ended question (“What seems to worry you?”) or a mild nudge (“And after that?”). Remember, though, that silence allows the patient a moment of reflection or time to summon courage. Some issues can be so painful and sensitive that silence becomes necessary and should be allowed. Most people will talk when they are ready. The patient’s demeanor, use of hands, possible teary eyes, and facial expressions will help you interpret the moment. Silence may also be cultural: for example, some cultural groups take their time, ponder their responses to questions, and answer when they feel ready. Do not push too hard. Be comfortable with silence but give it reasonable bounds.

Depression. Being sick or thinking that you are sick can be enough to provoke situational depression. Indeed, serious or chronic, unrelenting illness or taking certain prescription medications (e.g., steroids) is often accompanied by depression. A sense of sluggishness in the daily experi- ence; disturbances in sleeping, eating, and social contact; and feelings of loss of self-worth can be clues. In addition to screening for depression at ambulatory visits, pay atten- tion. First ask, “When did you start feeling this way?” Then ask, “How do you feel about it?” “Have you stopped enjoying the things you like to do?” “Do you have trouble sleeping?” “Have you had thoughts about hurting yourself?” “Are you depressed?” A patient in this circumstance cannot be hurried and certainly cannot be relieved by superficial assurance. You need not worry about introducing the idea of suicide (see Clinical Pearl, “Adolescent Suicide”). It has most often been considered, if only briefly (see Chapter 7, Risk Factors box, “Suicide”).

CLINICAL PEARL

Adolescent Suicide Suicide is a major cause of mortality in the preteen and teen years, more often in boys. If the thought of it occurs to you, you can be pretty sure that it has to the patient too. You can mention it and thus give permission to talk about it. You will not be suggesting anything new. You may actually help prevent it.

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one of your prime concerns. You can do this only by concentrating on the matter at hand, giving it for that moment primacy in your life and putting aside both personal and professional distractions.

Structure of the History You build the history to establish a relationship with the patient, so that you jointly discover the issues and problems that need attention and priority. A widely accepted approach is provided that can and should be modified to fit the individual circumstance: • First, the identifiers: name, date, time, age, gender

identity, race, source of information, and referral source • Chief concern (CC) • History of present illness or problem (HPI) • Past medical history (PMH) • Family history (FH) • Personal and social history (SH) • Review of systems (ROS)

The chief concern is a brief statement about why the patient is seeking care. Direct quotes are helpful. It is important, however, to go beyond the given reason and to probe for underlying concerns that cause the patient to seek care rather than just getting up and going to work. If the patient has a sore throat, why is help sought? Is it the pain and fever, or is it the concern caused by past experience with a relative who developed rheumatic heart disease? Many interviewers include the duration of the problem as part of the chief concern.

Understanding the present illness or problem requires a step-by-step evaluation of the circumstances that surround the primary reason for the patient’s visit. The full history goes beyond this to an exploration of the patient’s overall health before the chief concern, including past medical and surgical experiences. The spiritual, psychosocial, and cultural contexts of the patient’s life are essential to an understanding of these events. The patient’s family also

how to make things better. Explore the feelings. Often, you can continue on a better footing after anger is vented. On occasion, nothing will seem to help. It is then all right to defer to another time or even to suggest a different profes- sional (Thomas, 2003).

Afterward, do not hesitate to talk about the episode with a trusted colleague. It helps. Discussing the incident later may lend insight into behaviors and help prevent the occurrence again. Better ways of responding can be explored.

Avoiding the Full Story. Patients may not always tell the whole story or even the truth, either purposely or uncon- sciously. Dementia, illness, alcoholism, sexual uncertainties, intimate partner violence, and child abuse are among the reasons. Do not push too hard when you think this is happening. Allow the interview to go on and then come back to a topic with gentle questioning. You might say, “I think that you may be more concerned than you are saying” or “I think you’re worried about what we might find out.” Unless there is concern about the safety of the patient or another individual, learning all that is necessary may not come in one sitting. You may have to pursue the topic at a later visit or perhaps with other members of the family or friends or your professional associates.

Financial Considerations. The cost of care and the resulting drain on resources (and the potential impact on employment or insurance coverage) are often sources of stress for the patient. Talk about them with candor and accurate knowledge. Provide resources (social worker or financial counselor). Otherwise, an appropriate care plan acceptable to the patient cannot be devised or implemented. Pressing circumstances and obligations may still present barriers to appropriate care.

The Patient History A first objective in building the history is to identify those matters the patient defines as problems, the subtle as well as the obvious. You need to establish a sense of the patient’s reliability as an interpreter of events. Consider the potential for intentional or unintentional suppression or underreport- ing of certain experiences that may give context to a problem that is at odds with your expectation. Constantly evaluate the patient’s words and behavior. The history is built on the patient’s perspective, not yours. Make modifications as required for the patient’s age and his or her physical and emotional disabilities.

Setting for the Interview Regardless of the setting, make everyone as comfortable as possible. Position yourself so that there are no bulky desks, tables, computer screens, or other electronic equip- ment between you and the patient (Fig. 1.2). If possible, have a clock placed where you can see it without obviously looking at your watch (preferably behind the patient’s chair). Sit comfortably and at ease, maintaining eye contact and a conversational tone of voice. Your manner can assure the patient that you care and that relieving worry or pain is

FIg. 1.2 Interviewing a young adult. Note the absence of an intervening desk or table.

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CHAPTER 1 The History and Interviewing Process 7

walk a fine line between permitting this leisure and meeting the many time constraints you are sure to have. Fix your attention on the patient, avoid interrupting as much as possible, and do not ask the next question before you have heard the complete answer to the prior one.

The patient’s responses may at times be unclear. Seek certainty: • “Of what you’ve told me, what concerns you the most?” • “What do you want to make sure we pay attention to

today?” • “Do you have any ideas about what we ought to do?” • Or a leading question sometimes, “I think _________

worries you the most. Am I right? Shall we talk about that first?” As the interview proceeds, thoroughly explore each

positive response with the following questions: • Where? Where are symptoms located, as precisely as

possible? If they seem to move, what is the range of their movement? Where is the patient when the complaint occurs—at work or play, active or resting?

• When? Everything happens in a chronologic sequence. When did it begin? Does it come and go? If so, how often and for how long? What time of day? What day of the week?

• What? What does it mean to the patient? What is its impact? What does it feel like? What is its quality and intensity? Has it been bad enough to interrupt the flow of the patient’s life, or has it been dealt with rather casually? What else happened during this time that might be related? What makes it feel better? Worse?

• How? The background of the symptom becomes impor- tant in answering the “how” question. How did it come about? Are other things going on at the same time, such as work, play, mealtime, or sleep? Is there illness in the family? Have there been similar episodes in the past? If so, how was it treated or did it resolve without treat- ment? Is there concern about similar symptoms in friends or relatives? Are there spouse complaints or concerns? How is the patient coping? Are there social supports? Nothing ever happens in isolation.

• Why? Of course, the answer to “why” is the solution to the problem. All other questions lead to this one. Once you have understood the patient’s chief concern

and present problem and you have a sense of underlying issues, you may go on to other segments of the history: the family and past medical histories; emotional, spiritual, and cultural concerns; and social and workplace accompani- ments to the present concerns. Remember that nothing in the patient’s experience is isolated. Aspects of the present illness or problem require careful integration with the medical and family history. The life of the patient is not constructed according to your outline, with many factors giving shape to the present illness and with any one chief concern possibly involving more than one illness.

A visit should conclude with a review: • Ask the patient to try to satisfy gaps in your

understanding.

requires attention—their health, past medical history, ill- nesses, deaths, and the genetic, social, and environmental influences. One question should underlie all of your inquiry: Why is this happening to this particular patient at this particular time? In other words, if many people are exposed to a potential problem and only some of them become ill after the exposure, what are the unique factors in this individual that led to that outcome? Careful inquiry about the personal and social experiences of the patient should include work habits and the variety of relationships in the family, school, and workplace. Finally, the ROS includes a detailed inquiry of possible concerns in each of the body’s systems, looking for complementary or seemingly unrelated symptoms that may not have surfaced during the rest of the history. Flexibility, the appreciation of subtlety, and the opportunity for the patient to ask questions and to explore feelings are explicit needs in the process.

Building the History Introduce yourself to the patient and accompanying persons if you have not already met, clearly stating your name and your role. If you are a student, say so. Be certain that you know the patient’s full name and that you pronounce it correctly. Ask if you are not certain.

Address the patient properly (e.g., as Mr., Miss, Mrs., Ms., or the manner of address preferred by the patient) and repeat the patient’s name at appropriate times. Avoid the familiarity of using a first name when you do not expect familiarity in return. Do not use a surrogate term for a person’s name; for example, when the patient is a child, do not address the parent as “Mother” or “Father.” It is respectful and courteous to take the time to learn each name.

It is respectful, too, to look at the patient and not at the electronic device that is usually close at hand. Use it if you must, but position it so that it does not distract from the patient. More and more the electronic device in the examination room is being introduced into the patient- provider dynamic for documentation as well as educational purposes (e.g., demonstrating the findings on an imaging study, showing the trend of a laboratory result over time, or reviewing a website together). Unless you already know the patient and know that there is urgency, proceed at a reasonable pace, asking for the reason for the visit with the intent of learning what their specific expectations of the visit are. Listen, and do not be too directive. You will often be surprised at how much of the story and details you will hear without pushing. Let the patient share his or her full story and reasons for seeking care. If 100 people wake up with a bad headache, and 97 go to work but 3 seek care, what underlying dimension prompted those decisions?

You have by then begun to give structure to the present illness or problem, giving it a chronologic and sequential framework. Unless there is urgency, go slowly, hear the full story, and refrain from striking out too quickly on what seems the obvious course of questioning. The patient will take cues from you on the leisure you will allow. You must

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Alcohol. The CAGE questionnaire is one model for discuss- ing the use of alcohol (Box 1.3). CAGE is an acronym for Cutting down, Annoyance by criticism, Guilty feeling, Eye-openers. Its use does not ensure absolute sensitivity in the detection of a problem. It can be complemented or supplemented by the TACE model (Box 1.4), particularly in the identification of alcoholism in a pregnant patient (because of the potential for damage to the fetus), or by CRAFFT, for identification of an alcohol problem in ado- lescents (Box 1.5). There is similarity in all of these question- naires. You can adapt them to your style and to the particular patient. You can also adapt them to concerns about drugs or substances other than alcohol (see Clinical Pearl, “Screening”).

• Ask for questions. • Interpret and summarize what you have heard. • Ask the patient to summarize for you to ensure complete

understanding. • Repeat instructions and ask to hear them back. • Explain the next steps: needed examinations and/or

studies, appointment times, keeping in touch.

Sensitive Issues Sensitive issues, which may be difficult to discuss (e.g., sex, drug or alcohol use, concerns about death) are important to address. The following guidelines, keys to any successful interview, are essential in an approach to sensitive issues. • Provide privacy. • Do not waffle. Be direct and firm. Avoid asking leading

questions. • Do not apologize for asking a question. • Do not preach. Avoid confrontation. You are not there

to pass judgment. • Use language that is understandable to the patient, yet

not patronizing (see Clinical Pearl, “Watch the Use of Jargon”).

• Do not push too hard. Afterward, document carefully, using the patient’s words (and those of others with the patient) whenever possible. It is all right to take notes, but try to do this sparingly, especially when discussing sensitive issues.

CLINICAL PEARL

Watch the Use of Jargon Unfortunately, many of us may too often lapse into the use of jargon, the language of our profession that is not accessible to the patient. Patient-demeaning words are worse. Stress, frustration, fatigue, and anger are common underlying causes for these lapses. Know yourself. Understand why you might fall into the habit, and do your best to avoid it.

BoX 1.3 CAGE Questionnaire

The CAGE questionnaire was developed in 1984 by Dr. John Ewing, and it includes four interview questions designed to help screen for alcoholism.

The CAGE acronym helps practitioners quickly recall the main concepts of the four questions (Cutting down, Annoyance by criticism, Guilty feeling, Eye-openers).

Probing questions may be asked as follow-up questions to the CAGE questionnaire.

Many online resources list the complete questionnaire (e.g., http:// addictionsandrecovery.org/addiction-self-test.htm). The exact wording of the CAGE Questionnaire can be found in O’Brien CP. The CAGE Questionnaire for Detection of Alcoholism. JAMA. 300:2054–2056, 2008.

From Sokol et al, 1989.

BoX 1.4 TACE Model

The following questions are included in the TACE model: T How many drinks does it Take to make you feel high? How many

when you first started drinking? When was that? What do you prefer: beer, wine, or liquor? (More than two drinks suggests a tolerance to alcohol that is a red flag.)

A Have people Annoyed you by criticizing your drinking? C Have you felt you ought to Cut down on your drinking? E Have you ever had an Eye-opener drink first thing in the morning

to steady your nerves or get rid of a hangover? An answer to T alone (more than two drinks) or a positive response

to two of A, C, or E may signal a problem with a high degree of probability. Positive answers to all four signal a problem with great certainty.

CLINICAL PEARL

Screening There is a difference between a screening and an assessment interview. The goal of screening is to find out if a problem exists. This is particularly true of CAGE, CRAFFT, and TACE screening tools. They are effective, but they are only the start, and assessment goes on from there. Discover- ing a problem early may lead to a better treatment outcome.

You must always be ready to explain again why you examine sensitive areas. A successful approach will have incorporated four steps: 1. An introduction, the moment when you bring up the

issue, alluding to the need to understand its context in the patient’s life.

2. Open-ended questions that first explore the patient’s feelings about the issue—whether, for example, it is alcohol, drugs, sex, cigarettes, education, or problems at home—and then the direct exploration of what is actually happening.

3. A period in which you thoughtfully attend to what the patient is saying and then repeat the patient’s words or offer other forms of feedback. This permits the patient to agree that your interpretation is appropriate, thus confirming what you have heard.

4. Finally, an opportunity for the patient to ask any questions that might be relevant.

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CHAPTER 1 The History and Interviewing Process 9

These cover two dimensions of partner violence, and a positive response to any one of them constitutes a positive screen. The first question addresses physical violence. The latter two questions evaluate the woman’s perception of safety and estimate her short-term risk of further violence and need for counseling.

Additionally, you may see something suggestive on physical examination and ask the following: “The bruises I see. How did you get them?”

Positive answers require accurate documentation, using words, drawings, and, if possible, photographs and the pres- ervation of any tangible evidence. Positive answers require that the patient’s safety be ensured. Ask the following: • Are you afraid to go home? • Are there guns or knives at home? • Is alcohol (or other drugs) part of the problem? • Has it gotten worse lately? • Are children involved?

A “yes” answer mandates an intervention that requires utilization of other healthcare professionals such as social workers and mental health providers who may be able to provide more in-depth assessment and linkage to resources. Get the patient’s viewpoint. Let her speak; assure her that she is not alone and that you will do your best to help her.

A “no” answer may still leave you uncomfortable. Get permission from the patient to document your concern and your suspicion of injury. Be unafraid to ask direct questions about your suspicion (“Where did that bruise come from?”). Ask her to come back to see you again.

Intimate Partner Violence. We too often underestimate the incidence of intimate partner violence (IPV) in the experience of our patients of any age or gender identity. IPV includes a range of abusive behaviors perpetrated by someone who is or was involved in an intimate relationship with the victim. It affects primarily women, children, and dependent older adults as victims and, in lesser frequency, men. Intimate partners are usually the perpetrators. Same- sex partners probably have the same prevalence, although underreporting may be more of a problem in this population. Alcohol is a common facilitator. Children exposed to IPV are at increased risk for social and emotional problems. There is significant overlap between IPV and child abuse, so when IPV is detected, child abuse should be considered.

Reluctance to screen for fear of offending patients and families is a misplaced concern. This is occasionally compounded by an inappropriate response to an abused woman, such as making too little of her experience or even laying the blame on her. She is, then, twice a victim. The “she” is used advisably. Although IPV affects both men and women as victims and perpetrators, more women experience IPV (Nelson et al, 2012), and transgendered women are at higher risk of physical and psychological IPV than are cisgender adults (Pitts et al, 2006). Likewise, lesbian, gay, bisexual, and transgender (LGBT) youth are at high risk for being victims of IPV (Whitton et al, 2016). Relatively few will discuss IPV willingly with a healthcare provider, and, in that event, the patient is almost always the initiator of the discussion. If a healthcare provider makes the initial inquiry, it is usually asked in an emergency department of a person who may have difficulty getting out of an abusive relationship, a minority woman, or one who is obviously vulnerable. All female patients should be routinely screened in all healthcare settings (Moyer and U.S. Preventive Services Task Force, 2013); however, we recommend all indiviuals be screened. A validated brief Partner Violence Screen (PVS) uses three questions to detect partner violence (MacMillan et al, 2006): 1. Have you been hit, kicked, punched, or otherwise hurt

by someone within the past year? 2. Do you feel safe in your current relationship? 3. Is there a partner from a previous relationship who is

making you feel unsafe now?