2. Marc Imhotep Cray, M.D.
Format of Comprehensive Health History
Source and Reliability of History
History of Present Illness
o Medications, Allergies, Tobacco, Alcohol and Drugs
o Childhood Illness
o Adult Illness: Medical, Surgical, Ob/Gyn, Psychiatric, Health
Personal and Social History
Review of Systems
3. Marc Imhotep Cray, M.D.
Sequence of the Interview
Greeting the patient and establishing rapport
Inviting the patient’s story
Establishing the agenda for the interview
Expanding and clarifying the patient’s story; generating and testing
Creating a shared understanding of the problem(s)
Negotiating a plan (includes further evaluation, treatment, and
Planning for follow-up and closing the interview
4. Marc Imhotep Cray, M.D.
The Seven Attributes of A Symptom
1. Location. Where is it? Does it radiate?
2. Quality. What is it like?
3. Quantity or severity. How bad is it? (For pain, ask for a
rating on a scale of 1 to 10.)
4. Timing. When did (does) it start? How long did (does) it
last? How often did (does) it come?
5. Setting in which it occurs. Include environmental factors,
personal activities, emotional reactions, or other
circumstances that may have contributed to the illness.
6. Remitting or exacerbating factors. Does anything make it
better or worse?
7. Associated manifestations. Have you noticed anything else
that accompanies it?
5. Marc Imhotep Cray, M.D.
Exploring the Patient’s Perspective
The patient’s thoughts about the nature and the cause of the problem
The patient’s feelings, especially fears, about the problem
The patient’s expectations of the clinician and health care
The effect of the problem on the patient’s life
Prior personal or family experiences that are similar
Therapeutic responses the patient has already tried
6. Marc Imhotep Cray, M.D.
Techniques of Skilled Interviewing
See Bates, pgs. 68-74
7. Marc Imhotep Cray, M.D.
Options for Clarifying Patient’s Story
See Bates, pgs. 68-74
Directed questioning-from general to specific
Questioning to elicit a graded response
Asking a series of questions, one at a time
Offering multiple choices for answers
Clarifying what the patient means
8. Marc Imhotep Cray, M.D.
Guidelines for Working with an Interpreter
Choose a professional interpreter in preference to a
hospital worker, volunteer, or family member. Use
interpreter as a resource for cultural information.
Orient interpreter to components you plan to cover
in interview; include reminders to translate
everything patient says.
Arrange room so that you and patient have eye
contact and can read each other’s nonverbal cues.
9. Marc Imhotep Cray, M.D.
Working with an Interpreter cont.
Seat interpreter next to you and allow interpreter
and patient to establish rapport.
Address patient directly. Reinforce your questions
with nonverbal behaviors.
Keep sentences short and simple. Focus on most
important concepts to communicate.
Verify mutual understanding by asking patient to
repeat back what he or she has heard.
Be patient. The interview will take more time and
may provide less information.
10. Marc Imhotep Cray, M.D.
Guidelines For Broaching Sensitive Topics
(Sexual Hx, Mental Health Hx, AOD Hx & Family Violence)
Single most important rule is to be nonjudgmental
o Clinician’s role is to learn about patient and help patient achieve better health
• Disapproval of behaviors or elements in health history will interfere with this goal
Explain why you need to know certain information This makes patients less
o For example, say to patients, “Because sexual practices put people at risk for certain
diseases, I ask all of my patients the following questions.”
Find opening questions for sensitive topics and learn specific kinds of information needed
for your assessments
Finally, consciously acknowledge whatever discomfort you are feeling
o Denying your discomfort may lead you to avoid topic altogether
11. Marc Imhotep Cray, M.D.
The Cage Questionnaire
THE CAGE QUESTIONNAIRE
Have you ever felt the need to Cut down on drinking?
Have you ever felt Annoyed by criticism of your drinking?
Have you ever felt Guilty about drinking?
Have you ever taken a drink first thing in the morning (Eye-opener) to
steady your nerves or get rid of a hangover?
(Mayfield D, McCleod G, Hall P. The CAGE questionnaire: validation of a new alcoholism screening instrument.
Am J Psychiatry 131:1121–1123, 1974.)
The CAGE questionnaire, a new brief alcoholism screening test, was administered to all patients (N = 366; 39
percent alcoholic) admitted to a psychiatric service over a one-year period. The authors indicate that the CAGE
questionnaire is not a sensitive alcoholism detector if a four-item positive response is the criterion; however, if a
two- or three-item criterion is used, it becomes a viable rapid alcoholism screening technique for large groups.
12. Marc Imhotep Cray, M.D.
Physical abuse--often not mentioned by either victim or perpetrator--
should be considered in following settings:
Clues To Possible Physical Abuse
If injuries are unexplained, seem inconsistent with the patient’s story,
are concealed by the patient, or cause embarrassment
If the patient has delayed getting treatment for trauma
If there is a past history of repeated injuries or “accidents”
If the patient or person close to the patient has a history of alcohol or
If the partner tries to dominate the interview, will not leave the room,
or seems unusually anxious or solicitous
13. Marc Imhotep Cray, M.D.
Death and the Dying Patient
Many clinicians avoid subject of death b/c of their own discomforts
You will need to work through your own feelings with help of reading and discussion
Kubler-Ross model has described five stages in a person’s response to loss or the
anticipatory grief of impending death:
o Denial and isolation
o Depression or sadness
These stages may occur sequentially or overlap in different combinations
At each stage, follow the same approach…See Bates Chapter 20, The Older Adult, p. 909.
14. Marc Imhotep Cray, M.D.
Societal Aspects of Interviewing
Demonstrating Cultural Humility—A Changing Paradigm
Communicating effectively with patients from every background/ culture is a highly
important professional skill Nonetheless, disparities in risks of disease, morbidity,
and mortality are marked and well documented across different population groups
reflecting inequities in
health care access
type of insurance
language proficiency, and
provider decision making
To level these disparities, clinicians are urged to focus on their own attributes and
responsiveness as they experience diversity in their clinical practices
15. Marc Imhotep Cray, M.D.
Students and clinicians are now increasingly being trained
to move toward the precepts of cultural humility
Cultural humility is defined as a “process that requires humility as individuals
continually engage in self-reflection and self-critique as lifelong learners and
Tervalon M, Murray-Garcia J. Cultural humility versus cultural competence: a critical distinction in defining
physician training outcomes in multicultural education. J Health Care Poor Underserved 9(2):117–125, 1998.
It is a process that includes “the difficult work of examining cultural
beliefs and cultural systems of both patients and providers to locate the
points of cultural dissonance or synergy that contribute to patients’ health
Tervalon M. Components of culture in health for medical students’ education. Acad Med 78(6):570–576, 2003.
16. Marc Imhotep Cray, M.D.
Clinician Goals for Cultural Competence
Self-awareness. Learn about your own biases . . . we all have them.
Enhanced communication. Work to eliminate assumptions about what
is “normal.” Learn directly from your patients—they are the experts on
their culture and illness.
Collaborative partnerships. Build your relationships with patients on
respect and mutually acceptable plans.
18. Marc Imhotep Cray, M.D.
Recommended textbook reading:
Bickley LS & Szilagyi PG. Interviewing and the Health History,
Ch. 3 (Pgs. 55-96). In: Bates’ Guide to Physical Examination and
History Taking. 10th ed. Wolters Kluwer-Lippincott Williams &