Chapter 3
Putting the History Together
The doctor may also learn more about the illness from the way the patient tells the story than from the story itself.
James B. Herrick (1861–1954)
In the first two chapters, the interviewer’s questions and the patient’s responses were discussed. In this chapter, these materials are put together to create a mock interview. In the following interview, note the way in which the interviewer allows the patient to speak and the way various techniques are incorporated. The footnotes refer to the type of technique used and other important aspects of the interview.
In writing up the history, be precise and well organized. The patient relates the history in his or her order; you need to reorganize the facts into the standard form discussed in Chapter 1 (i.e., chief complaint, history of present illness, etc.). Your skill in writing up the history will evolve with time as you gather more experience. Make sure that you organize the history in chronological order. Always record all the relevant data obtained. If data aren’t recorded, that data will be lost permanently. Be careful about using abbreviations; they may mean something different to others. As an example, PND often stands for paroxysmal nocturnal dyspnea; however, it is often used to mean postnasal drip (or discharge). Finally, be objective; the patient record is no place for editorial or judgmental comments. Your opinion should not be in evidence; just state the facts. For example, state, “alcohol on breath,” not “patient drunk.”
Interview of Mr. John Doe
Mr. John Doe, the patient, is lying comfortably in a two-bed room in St. Catherine’s Hospital. He is a white man, slightly obese, and in his mid-40s. Mr. Doe is watching television. The interviewer, wearing a white coat, enters the room.
(Interviewer smiles and extends hand for a firm handshake.)
Interviewer: Good morning, I’m Susan Smith, a second-year medical student. Are you Mr. John Doe?
(Pause; interviewer watches for response.)
(Extends hand to shake hand of Mr. Doe.)
Interviewer: Nice to meet you, Mr. Doe. I’ve been asked to interview and examine you today.
(Patient smiles, appearing friendly.)
Patient: Dr. James, my resident, told me you’d be coming to see me.
Interviewer: Would you mind if we turn off the TV?
(Patient turns off television.)
Interviewer: How are you today?
Patient: OK. No pain for the past 2 days.
Interviewer: Tell me about the problem that brought you to the hospital, Mr. Doe?1
Patient: I’ve been having terrible chest pain for the past 6 months. . . .
Patient: Yeah. I had my first heart attack.3
Interviewer: How did you feel when you left the hospital?
Patient: I really felt fine. No more chest pain. My doctor there had given me some pills and said I would be fine.4
Interviewer: Then what happened?5
Patient: I went back to work after about 3 weeks. I really felt great!
Interviewer: What type of work do you do?
Interviewer: You mentioned that this was your first heart attack. Have you had others?
Interviewer: Tell me about it.6
Patient: Six months later, I had my second attack.
Interviewer: What were you doing?
Interviewer: Did you have any tests while you were in the hospital?
The doctor just gave me some pills to strengthen my heart and for the irregularity.
Interviewer: Your silence makes me think that you want to tell me something.8
Patient: I should have listened to him.
I’ve really not been able to do anything for the past 6 months.
I had to give up my work at the office. Sure, they still call me for advice, but it’s not the same.
The commuting by car just got to me.
My son and his friends yelling around the house.
Interviewer: What did your doctor tell you about the test?9
Interviewer: After the study, your doctor will be in the best position to answer that question.10
Tell me about the pain you’ve been having.
Interviewer: What’s the pain like now?
Patient: It’s an awful tightness, like a vise. . . .
Interviewer: When you get the pain, do you feel it anywhere else?
Patient: Yeah. It goes straight to my back and my left arm. The arm feels so heavy.
Interviewer: Are there any other times when you get the pain?
Patient: It seems I get it with the slightest effort or emotion.
Interviewer: Do you get the pain during sexual intercourse?
Interviewer: Have you had any difficulty breathing?
Patient: When I get the pain, I get short of breath.
Interviewer: Do you ever get short of breath without the pain?
Patient: I find I just can’t walk far any more without getting winded.
Interviewer: How many level blocks can you walk now without getting short of breath?
Interviewer: How much could you walk 6 months ago?
Patient: I guess about two to three blocks.
Interviewer: Since your heart attack, have you had any skipped beats or fluttering of your heart?
Interviewer: Has anyone ever told you that your cholesterol or fats in your blood were high?12
Interviewer: Have you ever smoked?
Patient: I stopped after my first heart attack.
Interviewer: That’s great that you stopped smoking. How much did you smoke?
Patient: About two packs a day.
Patient: Oh . . . since I was about 18.
Interviewer: May I ask your age?13
Interviewer: Have you ever had high blood pressure?
Interviewer: Do you know how high your pressure was?14
Interviewer: Do you have diabetes?
Interviewer:(interrupting) I’m glad his hip is well healed. Is there anyone else in your family who has diabetes?15
Interviewer: Anyone else in your family who’s had a heart attack?
Patient: I think my mother’s father died of a heart attack.
Interviewer: What about your mother?16
