¹ Inquiring about the chief complaint by using an open-ended question.

² This is an example of reflection.

³ The patient is now telling the history of the current illness.

⁴ Possibly false reassurance from the physician, or the patient heard what he wanted to hear.

⁵ Interviewer continues obtaining information with another open-ended question about the current illness.

⁶ An example of verbal facilitation.

⁷ An example of nonverbal facilitation.

⁸ An example of confrontation.

⁹ Inquiring about the patient’s understanding of the test.

¹⁰ The interviewer does not want to give false reassurances. Therefore she chooses not to answer the question directly. Notice how the interviewer gets the narrative back on course.

¹¹ This example of body language has been termed Levine’s sign. It is discussed in Chapter 11, The Heart.

¹² The interviewer is now starting to ascertain whether the patient has any risk factors for coronary artery disease.

¹³ Notice that the interviewer has just now decided to ask the patient’s age.

¹⁴ Notice that the interviewer ignores the statement that the patient didn’t take his medications. Questioning the patient “Why not?” would only put the patient on the defensive.

¹⁵ Notice that the patient was beginning to ramble. The interviewer politely interrupted and redirected the interview. She is now inquiring about the family history.

¹⁶ Notice that the interviewer does not assume anything about the mother’s well-being or health. Because the patient approached the family’s health history, the interviewer is now directing her questions to that history.

¹⁷ Notice that the patient did not mention his brother when first asked about other family members with heart attacks or when asked about other brothers or sisters. The patient did not even acknowledge his brother’s cardiac problem. This is an example of denial of a family history of coronary artery disease.

¹⁸ Notice that the interviewer does not assume that Mr. Doe is married now, even though he referred to his wife at the beginning of the interview and has acknowledged “Emily.” “Emily” may not be his wife.

¹⁹ In this case, “Emily” is the patient’s wife. It is extremely important for the patient to identify family members. The interviewer must never make an assumption that another person with the patient or described in the history is related to the patient.

²⁰ Had the patient answered in the affirmative, the interviewer would have asked when, and the patient’s record would have been reviewed later.

²¹ The interviewer is specifically asking about nonmedical hospitalizations (e.g., for psychiatric reasons). This type of question is not offensive. If the patient has had such admissions to hospitals, he can usually describe them at this time. If not, as in this case, watch how the interview progresses. Notice how the interviewer continues directly with the next question.

²² This question can follow nicely after the history of sore throats.

²³ The interviewer slowly asks about each illness, after which she pauses for the patient to respond.

²⁴ Because this patient has demonstrated so much denial, the interviewer wishes to ask specifically about diseases of the major organs. Each question is asked slowly, and the interviewer pauses after each question, waiting for a response.

²⁵ The interviewer is not satisfied with qualitative statements. She pursues each question to quantify as best as possible.

²⁶ Despite the fact that he knows that shrimp is not as healthy as fish, he still eats it. This is further denial of his illness.

²⁷ The interviewer has now picked up some other somatic element of depression and will now pursue it.

²⁸ An example of an interpretation.

²⁹ The interviewer could have elected to ask the patient his reactions if surgery cannot be performed. How will he face life? Is there a possibility of suicide? The interviewer chose not to create further anxiety at this time.

³⁰ An example of empathetic support. The interviewer cannot answer the patient’s questions, but she allows the patient to express his emotions. She is, in essence, saying, “I’m with you.”

³¹ Interviewer is inquiring about the patient’s lifestyle and psychosocial history.

³² The interviewer now begins asking the review of systems. She asks about each symptom. If the patient answers in the affirmative, further questioning is appropriate.

³³ The interviewer continues through the entire review of systems, asking further questions when necessary.

³⁴ By indicating to the patient that the interviewer and her preceptor will be back, the patient is less likely to press the interviewer for her opinion at this time. The interviewer should never provide an answer at this point. False reassurances can be dangerous.

³⁵ The abbreviation qid means “four times a day.” It is often better to write this abbreviation out since it may be misinterpreted as “qd,” meaning every day.

³⁶ Notice that the history of the current illness summarizes all the information related to the current illness chronologically, regardless of when the information was obtained during the interview.

³⁷ The review of systems would then indicate any of the other symptoms that may be present.

³⁸ Notice that the positive symptoms are indicated first. The important, or pertinent, negative symptoms are then listed. A pertinent negative symptom in this patient is the lack of claudication. Coronary artery disease is often associated with peripheral vascular disease. The absence of a major symptom of peripheral vascular disease, claudication, makes claudication in this patient a pertinent negative symptom. Chapter 12, The Peripheral Vascular System, provides a further discussion of pertinent positives and negatives.

³⁹ This statement indicates that none of the other symptoms is either present or contributes to the patient’s current illness.