1. PREPARATION FOR THE INTERVIEW
• Introduce yourself and explain your role
• If a third party is present, explain his/her role in the interview (e.g.
evaluator, tutor, colleague)
• Explain to the patient that the contents of the interview will be kept
confidential. Recognize, however, that certain cases (e.g. child abuse,
gunshot wounds, certain infectious diseases) may require mandatory
reporting depending on government policies
• Posture and Positioning: sit at the same or at a lower level than the
patient, in a position that permits but does not force eye contact. It is
preferable to be on the patient's right side, at a comfortable distance
that facilitates conversation but does not invade the patient's personal
space
• Maintain eye contact and show interest
• Ask the patient how he/she would like to be addressed
• If the patient is accompanied by someone, suggest that he/she wait
outside while you conduct the interview and physical exam
EBM: Perspective on Greetings In Medle~~l Encounters ~
Physicians are encouraged to shake hands with patients but should · ·
remain sensitive to nonverbal cues that might Indicate whether
patients are open to this behavior or not. As a general rule for the
lnltlallntervlew, physicians should use both first and last names when Introducing
themselves and addressing patients.
Makoul G, Lick A, Green M. 2007. Arch tntem Mtd 167{11}:1172-1176.
2. GENERAL HISTORY
The general history is organized into the following sections:
• Identifying data (ID)
• Chief complaint (CC)
• History of the present illness (HPI)
• Past medical history (PMHx)
• Family history (FHx)
• Medications (MEDS) and Allergies (ALL)
• Social history (SHx)
• Review of systems or functional inquiry (ROS/FI)
Identifying Data
• Record date of interview
• Patient's name, age, gender, relationship status, dependents,
occupation, ethnicity, and living status
• If applicable, document translators and family members present during the
interview
Chief Complaint
• Brief statement of why the patient is seeking medical attention using the
descriptors and words that the patient provides
• Include duration of symptoms
History of Present Illness
• A comprehensive and chronological account of the presenting chief
complaint
• Symptom characterization:
o 0 =Onset and duration
o P = Provoking and alleviating factors
o Q = Quality of pain (e.g. sharp, dull, throbbing)
o R = Does the pain radiate?
o S = Severity of pain ("on a scale from 1 to 1 0, 10 being the most
severe")
o T =Timing and progression ("Is the pain constant or intermittent?
Worse in the morning or at nighttime?")
o U = "How does it affect 'U' in your daily life?"
o v = Deja vu ("Has this happened before?")
o W ='What do you think it is?"
• Explore relevant risk factors, relevant past medical and family history,
and associated symptoms
• Include pertinent positive and negative symptoms in the HPI
• Explore the patient's thoughts/feelings of presenting problem
Past Medical History
• Inquire about childhood illnesses, past medical illnesses, injuries,
operations, gynecological and obstetrical history for women,
immunizations, and screening procedures (e.g. Pap smear,
mammogram, colonoscopy)
• Record dates
Family History
• Inquire about all serious illnesses within immediate family (first-degree
relatives); if relevant, include grandparents, aunts, and uncles
• Pay attention to illnesses/disorders that are familial or genetically
transmitted
• Construct a genogram (also called a family tree or pedigree); record
ages of family members, illnesses, and causes of death if applicable
o e.g. Mrs. Jill Hill, the consultant, and Mr. Jack Hill are consanguineous
in that their mothers are sisters. They have a healthy son and a
healthy daughter who is 16 weeks pregnant. Jack has a healthy older
sister and an older brother who died of an autosomal recessive (AR)
disease. Jill has a healthy younger brother. Jill's uncle (mother's
youngest brother) had a son who passed away of the same AR
disease and two other healthy boys
Medication
Record prescription drugs (name, dosage, frequency, and route
of administration), over-the-counter medications, all nutritional
supplements and herbal remedies
Allergies
• Record all environmental, ingestible, and drug-related allergies
• Include the response (rash, anaphylaxis) and timing (immediate or
delayed)
Social History
• Living arrangements
o Type of home (e.g. apartment, basement, house), location,
occupants, privacy
• Education (highest level obtained)
• Occupation (current and past)
o WHACS1: What do you do? How do you do it? Are you concerned
about any of your exposures or experiences? Coworkers or others
exposed? Satisfied with your job?
• Hobbies and leisure activities (e.g. sports, reading, traveling)
• Marital/relationship status, social support, finances, and living
conditions; primary caregiver if applicable
• Sexual history ("Do you have sex with men, women, or both?") (see
Review of Systems/Functional Inquiry and Difficult Interviews)
• Spirituality c·oo you have any religious beliefs conceming your health or
medical treatment?")
• Smoking ("Have you ever smoked?" to determine pack years)
o 1 pack year = (1 pack or 20 cigarettes a day) x (1 year)
• Alcohol (type, how much, how often)
o Use CAGE2 to assess alcoholism: Have you ever felt the need to Cut
down on your drinking? Have people Annoyed you by criticizing your
drinking? Have you ever felt bad or Guilty about your drinking? Have
you ever had a drink first thing in the morning to steady your nerves
or to get rid of a hangover- an Eye opener?
• Recreational drugs (type, how much, how often)
• Diet and stress
Review of Systems/Functional Inquiry
• A head-to-toe review of the patient's current state of health (•at this time
is there anything new?" or "has anything changed recently?u)
• Primarily yes/no questions: positive answers should be explored in
greater detail and be moved to HPIIPMHx if appropriate
• General: weight gain/loss, loss of appetite, fever, chills, fatigue, night
sweats
• Dermatological (DERM): rashes, lumps, sores, skin discoloration,
pruritus, changes to nails or hair
• Head: headaches, dizziness, light-headedness
• Eyes: visual changes, visual field deficits, dry eyes, excessive tearing,
red eyes, pain
• Ears: tinnitus, vertigo, hearing loss, earaches, discharges
• Nose: epistaxis, nasal stuffiness, sinus pain
• Mouth and Throat: dental disease, dry mouth, hoarseness, throat pain,
difficulty swallowing
• Neck: swollen glands, lumps, goiter
• Breasts: lumps, pain, nipple discharge, skin changes
• Respiratory (RESP): cough, dyspnea, sputum (color, quantity),
hemoptysis, wheezing, chest pain
• Cardiovascular (CV): chest pain, murmurs, dyspnea, orthopnea,
paroxysmal noctumal dyspnea, edema, palpitations, syncope,
intermittent claudication, leg cramps, change in color of fingers and toes
with cold exposure, varicose veins
• Gastrointestinal (GI): dysphagia, heartburn, abdominal pain, nausea,
vomiting and/or hematemesis, diarrhea, constipation, hemorrhoids, food
intolerance, hyperflatulence, changes in frequency of bowel movements
or stool appearance (e.g. color, size, melena, hematochezia)
• Urinary (GU): dysuria, frequency, urgency, polyuria, nocturia, hematuria,
and in males: hesitancy, dribbling or decrease in caliber of urinary stream
• Sexual: sexual orientation, interest and function, number of partners,
birth control methods, history of sexually transmitted diseases
o Female: age of menarche, regularity, frequency and duration of
periods, amount of bleeding, bleeding between periods or after
intercourse, last period, dysmenorrhea, age of menopause, vaginal
discharge, sores or lesions, pregnancies (number, type of delivery,
complications), abortions
o Male: penile discharge, genital sores, testicular pain or masses
• Endocrine: polydipsia, polyuria, skin or hair changes, heat or cold
intolerance, change in glove/shoe size
• Musculoskeletal (MSK}: joint pain, swelling, redness, arthritis,
myalgias, stiffness (note onset and timing)
• Neuropsychiatric (PSYCH): weakness, seizures, problems with gait,
paresthesia, memory loss, depression
• Hematologic: anemia, easy bruising or bleeding, blood transfusions
EBM: Accuracy of the History and PhysicaiiE:um ~
One study that surveyed hospitalists and senior residents found . · ·
that in correctly diagnosed cases, history alone was identified as the .
most useful tool20% of the time, whereas the physical examination ·
alone was most useful less than 1% of the time. A combination of both history and
physical examination was identified as most useful in 39% of correctly diagnosed
cases. Togethet these account for 60% of all correct diagnoses.
Paley L. et al. 2011 • .Arch Intern Med 171(15):1394-1396.
3.1NTERVIEW SKILLS
• Progress from open-ended questions (•can you describe the pain?") to
directed questions (•Is the pain sharp, dull, or burning?", *Does the pain
radiate to your left arm?")
• Encourage the patient to continue (•uh-huh", "yes"} and do not interrupt
the patient
• Redirect the patient when necessary (•It seems this Is Important to you and
maybe we can discuss it further, but right now I would like to focus on ... ")
• Ask the patient to define vague terms (suddenly, a little, tired, dizzy,
hurts, sick, weak)
• Summarize to refocus the interview or to transition into a new topic
• Ask one question at a time
• Avoid leading questions ("You don't smoke, right?")
• Avoid jargon
At the end of the interview, summarize and ask the patient if there is
anything else they wish to add to ensure all has been covered
EBM: Verbal and NonveriNIIBehiiViors Assodated with Positive
Health Outcomes
Verbal behaviors associated with positive health outcomes include
empathy; support/encouragement for patient's questions; high
proportion of objective statements In the concluding part ofthe visit; positive
reinforcement; addressing problems of daily IMng, social relations, feelings and
emotions; increased time on health education, sharing medical data with the
patient; discussion of treatment effects; friendliness; courtesy; summarization,
talking at the patient's level, and clarifying statements; humor, and increased
encounter length.
Nonverbal behaviors associated with positive health outcome include forward
leaning, head nodding, uncrossed arms and legs, arm symmetry, and less mutual
eye contact.
Beck RS, Daughtridge R, Sloane PD. 2002.JABFP 15(1):25-38.
Emotion Handling Skills: NURSE3
• N: Name the emotion
• U: Show Understanding
• R: Handle the issue with Respect
• S: Show Support
• E: Ask the patient to Elaborate on the emotion
Understanding the Patient's Perspective: FIFE1
• F: Feelings and Fears ("'What concerns you the most?")
• 1: Ideas (-what do you think is going on?")
• F: Function ("How has your illness affected you day-to-day?")
• E: Expectations (•How do you expect this treatment to help?" "What do
you think will happen with your illness?")
Breaking Bad News: SPIKES4
• S: Setting up the interview
o Deliver the news while sitting
o Ensure privacy
o Involve significant others (if appropriate)
o Inform the patient about time constraints or interruptions
• P: Perception of the patient
o Use open-ended questions to assess the patient's understanding of
hislher situation
• 1: Invitation to disclose information
o Ask the patient what he/she would like to know
• K: Knowledge Giving
o Warn the patient (•Unfortunately I have some bad news ... ")
o Deliver information in small chunks using non-technical words
o Avoid being too blunt; be careful and considerate in your choice of
words and phrasing
• E: Empathizing with the Patient's Emotions
o Allow the patient to express his/her emotions, identify the reason
behind his/her emotions, and validate his/her emotions
• S: Strategize and Summarize
o Ask the patient to summarize his/her understanding of what was
discussed
o Elicit treatment goals and discuss suitable treatment plans
4. DIFFICULT INTERVIEWS
Sexual History
• It is especially important to take a sexual history if the patient presents
with:
o Urethral and/or vaginal discharge
o Painful urination
o Genital rash and/or ulcers
o Abdominal pain
o Pain during or after intercourse
o Anorectal symptoms
o Suspected sexually transmitted infection(s)
• Preface the interview by explaining why the sexual history is necessary,
and ask the patient for permission
• Ask about the last date of intercourse, number of partners (in the last
6 months and lifetime partners), pregnancy risk, condom use, whether
they have sex with men, women, or both, contact with sex workers, and
sexual practices
• Sexual abuse history may be relevant
Cross-Cultural History Taking
• To improve communication it is important to be familiar with diverse
cultures and beliefs
• Avoid using stereotypes
• If language is a barrier, use an interpreter who is not a relative of the
patient
• Introduce the interpreter to the patient and ask the interpreter to
translate in the patient's own words
• Maintain eye contact with and direct questions toward the patient
• Keep your sentences short and simple
• Ensure the patient's understanding of the content of the interview
Spousal/Partner Abuse
• Types of Abuse
o Physical: pushing, choking
o Sexual: forced sexual contact, pregnancy, abortion
o Emotional: name-calling
o Psychological: social isolation, controlling behavior
o Financial control
• Common Signs of Spousal Abuse5
6
o Unexplained traumatic injuries inconsistent with history taken
o Head or neck injuries: facial lacerations, fractures, bums, perforated
eardrums, fractured teeth, retinal detachment, orbital blow-out
fracture, retinal hemorrhages, skull fractures, subdural and epidural
hematomas, multiple bruises at different stages of healing
o Chest, abdominal, pelvic or back pain
o Multiple visits for nonspecific and often stress-related complaints
o Headaches, insomnia, anxiety, depression
o Suicidal ideation, suicide attempts
o Chronic pain syndromes
o Substance abuse
o Eating disorders
o Pregnancy complications (miscarriage, stillbirth, abruptio placentae,
premature labor) or injuries during pregnancy
o Recovery from illness/injury inappropriately delayed
o Nonadherence with medications, treatment or follow-up
appointments
o Partner appears overly supportive
o Cancelled appointments, especially if cancellation call was made by
partner
• Approach to History and Physical Exam
o Interview the patient alone (document if this is impossible)
o Ensure confidentiality
o Ask direct and specific questions:
» "What happens when your partner loses his/her temper?"
» "Do you feel safe at home?"
» "Does your partner ever hit or abuse your children?" (inform the
patient that suspected child abuse must be reported to Children's
Aid Society)
o Remind the patient he/she is not to blame
o Assess his/her risk
» Has the severity/frequency of assaults increased?
» Have threats of homicide or suicide been made? Have these
threats increased?
» Have threats to any children been made?
» Does your partner have access to a firearm?
» Do you know where to call for help in an emergency?
o If the patient is not in immediate risk, do not tell him/her what to do;
help the patient explore each option and be supportive
o If the patient is in immediate risk, help him/her develop a safety
plan that includes emergency numbers, key documents, a packed
suitcase and money
» Encourage the patient to stay with family, friends or at a shelter
o Provide information on available community resources
o Document the patienfs history, physical exam, and medical
treatment in detail as well as your suspicions
o If patient consents, take measurements or photographs of physical
injuries
o Arrange to follow-up
o Do not be frustrated if abuse is denied or help is declined; remain
empathic and nonjudgmental
EBM: Prevalence of Intimate Partner Violence ~
A group family practice clinic In Inner city Toronto surveyed their ·
female patients and found the overall prevalence of intimate partner -
violence in current or recent relationships to be 14.6%. Emotional
abuse was reported by 1 0.4%, threat of violence by 8.3%, and physical or sexual
violence by 7.6% of respondents.
Ahmad F, et al. 2007. Con Fam Physician 53(3):460-468.
S. PREPARATION FOR THE PHYSICAL EXAM
• Prepare the patient by explaining what you are about to do before
proceeding
• Ensure patient comfort, and proper draping, positioning and lighting
• By convention, examine patients from the right side
• Avoid showing extreme reactions during the examination
Principles of Infection Control
• Hand Hygiene
o If hands are not heavily soiled, use alcohol-based hand cleanser
before and after seeing each patient; if hands are soiled (i.e. with
dirt, blood, etc.) use soap and warm water for 15 s
• Barriers
o Body substances include blood, oral secretions, sputum, emesis,
urine, feces, wound drainage, and any additional moist body
substances (excluding tears or sweat)
o Assume that all patients are potentially infected with pathogens and
all body substances are potential sources of transmission
o Use barriers (gloves, gown, mask, eyewear) when appropriate (e.g.
gloves when in contact with any bodily substances, masks when
dealing with respiratory infections)
• Minimize Needlestick Injury
o Never recap needles; immediately dispose of any sharps in
designated containers
Note: additional precautions may apply when working with specific
airborne pathogens and antibiotic-resistant organisms
6. GENERAL INSPECTION
General Appearance
• Apparent state of health: any signs of distress (cardiac, respiratory,
pain, anxiety, depression)? Any lines or tubes present (e.g. Foley
catheter, IV line)? Quickly scan the room (e.g. bedside items, number of
pillows for orthopnea, etc.)
• Physical appearance: dress, grooming, personal hygiene, level of
consciousness, skin (color and obvious lesions), diagnostic facies,
appears stated age (see Table 1 and Table 2)
• Body structure: height, habitus, sexual development, fat distribution,
symmetry, body posture and position, bony abnormalities (see Figure 2)
• Mobility: gait (normally, shoulder-width base, with smooth, even strides),
range of motion, involuntary movements (see Geriatric Exam and
Neurological Exam, p.69 and 171 respectively)
• Behavior: facial expression, mood, affect, speech (articulation, fluency,
hoarseness)
• Any odors of the breath or body
Head
• Look for diagnostic facies, color abnormalities, swelling, scalp lesions,
and abnormal hair distribution (alopecia, hirsutism)
Hands and Nails
• Inspect the hand for abnormal color or morphology
7. VITAL SIGNS
Temperature
• Body temperature is influenced by age, the diumal cycle, the menstrual
cycle, and exercise
Pulse Measurement
• Use the radial or carotid artery to determine:
o Rhythm: regular, regularly irregular, irregularly irregular
o Rate:
» Regular rhythm: count for 30 s
» Regularly irregular: count for 1 min
» Irregularly irregular: count for 1 min using apex beat
o Magnitude: normal, diminished, or increased
o Symmetry: left vs. right
• Before palpating the carotid artery, auscultate for carotid bruits
• Never palpate both carotid arteries at the same time
• Normal adult pulse rate is 50-1 00 bpm8
o Bradycardia: an abnormally slow heart rate (<60 bpm)
o Tachycardia: an abnormally fast heart rate (>1 00 bpm)
Respiratory Assessment
• Look for signs of respiratory distress (the use of accessory muscles,
intercostal indrawing, pursed lip breathing, tripod positioning, heaving or
audible wheezing)
• RR most reliably measured when patient is distracted from his/her own
conscious breathing (e.g. pretending to take their pulse)
• Count for 30 s if breathing is normal and for 1 min if you suspect
abnormality
• Normal adult RR is 16-25 breaths/min7
o Bradypnea: an abnormal decrease in RR (<16 breaths/min)
o Tachypnea: an abnormal increase in RR (>25 breaths/min)
o Apnea: absence of breathing, either periodic or sustained (i.e.
cardiac arrest, CNS lesion)
Blood Pressure Measurement
• Terminology
o Systolic blood pressure (SBP): maximum arterial pressure during left
ventricular contraction (see Table 5)
o Diastolic blood pressure (DBP): resting arterial pressure between
ventricular contractions (see Table 5)
o Pulse pressure= SBP- DBP
o Korotkoff sounds: arterial sounds heard during blood pressure
measurement by auscultation
o Auscultatory gap: transient loss of Korotkoff sounds during
measurement of SBP
Preparation
Patient should be relaxed, sitting with his/her back supported and
feet flat on the floor
o Wrap cuff around upper arm, 2-3 em above antecubital fossa, with
brachial marker over brachial artery
o Ask the following questions:
:. •1n the last 30 min, have you smoked, had caffeine, or exercised?"
:. *Is there any reason that you should not have your blood pressure
taken on either of your arms?"
• Systolic Pressure by Palpation
o Usually performed to avoid missing the auscultatory gap which could
result in underestimating SBP
o Palpate radial artery on arm
o Inflate blood pressure cuff until radial pulse disappears
o Slowly deflate approximately 2 mmHg/s
o SBP is estimated when radial pulse can be felt again
• Systolic and Diastolic Pressure by Auscultation (see Figure 4)
o Note in which arm BP is being measured
o Support upper arm at heart level
o Place stethoscope over brachial artery
o Inflate cuff to 20-30 mmHg above estimated SBP
o Slowly deflate approximately 2 mmHgls
o SBP is read at the first Korotkoff sound
o DBP is read when the Korotkoff sounds disappear
o Repeat using other arm to assess symmetry
• Orthostatic Hypotension Measurement
o Measure BP with the patient supine, then standing
o Positive test: ~20 mmHg fall in SBP or ~10 mmHg fall in DBP upon
standing*
o Patients may also experience symptoms of cerebral hypoperfusion
upon standing: dizziness, weakness, lightheadedness, visual
blurring, darkening of visual fields, syncope (due to abrupt peripheral
vasodilation without compensatory increase in cardiac output)
• Introduce yourself and explain your role
• If a third party is present, explain his/her role in the interview (e.g.
evaluator, tutor, colleague)
• Explain to the patient that the contents of the interview will be kept
confidential. Recognize, however, that certain cases (e.g. child abuse,
gunshot wounds, certain infectious diseases) may require mandatory
reporting depending on government policies
• Posture and Positioning: sit at the same or at a lower level than the
patient, in a position that permits but does not force eye contact. It is
preferable to be on the patient's right side, at a comfortable distance
that facilitates conversation but does not invade the patient's personal
space
• Maintain eye contact and show interest
• Ask the patient how he/she would like to be addressed
• If the patient is accompanied by someone, suggest that he/she wait
outside while you conduct the interview and physical exam
EBM: Perspective on Greetings In Medle~~l Encounters ~
Physicians are encouraged to shake hands with patients but should · ·
remain sensitive to nonverbal cues that might Indicate whether
patients are open to this behavior or not. As a general rule for the
lnltlallntervlew, physicians should use both first and last names when Introducing
themselves and addressing patients.
Makoul G, Lick A, Green M. 2007. Arch tntem Mtd 167{11}:1172-1176.
2. GENERAL HISTORY
The general history is organized into the following sections:
• Identifying data (ID)
• Chief complaint (CC)
• History of the present illness (HPI)
• Past medical history (PMHx)
• Family history (FHx)
• Medications (MEDS) and Allergies (ALL)
• Social history (SHx)
• Review of systems or functional inquiry (ROS/FI)
Identifying Data
• Record date of interview
• Patient's name, age, gender, relationship status, dependents,
occupation, ethnicity, and living status
• If applicable, document translators and family members present during the
interview
Chief Complaint
• Brief statement of why the patient is seeking medical attention using the
descriptors and words that the patient provides
• Include duration of symptoms
History of Present Illness
• A comprehensive and chronological account of the presenting chief
complaint
• Symptom characterization:
o 0 =Onset and duration
o P = Provoking and alleviating factors
o Q = Quality of pain (e.g. sharp, dull, throbbing)
o R = Does the pain radiate?
o S = Severity of pain ("on a scale from 1 to 1 0, 10 being the most
severe")
o T =Timing and progression ("Is the pain constant or intermittent?
Worse in the morning or at nighttime?")
o U = "How does it affect 'U' in your daily life?"
o v = Deja vu ("Has this happened before?")
o W ='What do you think it is?"
• Explore relevant risk factors, relevant past medical and family history,
and associated symptoms
• Include pertinent positive and negative symptoms in the HPI
• Explore the patient's thoughts/feelings of presenting problem
Past Medical History
• Inquire about childhood illnesses, past medical illnesses, injuries,
operations, gynecological and obstetrical history for women,
immunizations, and screening procedures (e.g. Pap smear,
mammogram, colonoscopy)
• Record dates
Family History
• Inquire about all serious illnesses within immediate family (first-degree
relatives); if relevant, include grandparents, aunts, and uncles
• Pay attention to illnesses/disorders that are familial or genetically
transmitted
• Construct a genogram (also called a family tree or pedigree); record
ages of family members, illnesses, and causes of death if applicable
o e.g. Mrs. Jill Hill, the consultant, and Mr. Jack Hill are consanguineous
in that their mothers are sisters. They have a healthy son and a
healthy daughter who is 16 weeks pregnant. Jack has a healthy older
sister and an older brother who died of an autosomal recessive (AR)
disease. Jill has a healthy younger brother. Jill's uncle (mother's
youngest brother) had a son who passed away of the same AR
disease and two other healthy boys
Medication
Record prescription drugs (name, dosage, frequency, and route
of administration), over-the-counter medications, all nutritional
supplements and herbal remedies
Allergies
• Record all environmental, ingestible, and drug-related allergies
• Include the response (rash, anaphylaxis) and timing (immediate or
delayed)
Social History
• Living arrangements
o Type of home (e.g. apartment, basement, house), location,
occupants, privacy
• Education (highest level obtained)
• Occupation (current and past)
o WHACS1: What do you do? How do you do it? Are you concerned
about any of your exposures or experiences? Coworkers or others
exposed? Satisfied with your job?
• Hobbies and leisure activities (e.g. sports, reading, traveling)
• Marital/relationship status, social support, finances, and living
conditions; primary caregiver if applicable
• Sexual history ("Do you have sex with men, women, or both?") (see
Review of Systems/Functional Inquiry and Difficult Interviews)
• Spirituality c·oo you have any religious beliefs conceming your health or
medical treatment?")
• Smoking ("Have you ever smoked?" to determine pack years)
o 1 pack year = (1 pack or 20 cigarettes a day) x (1 year)
• Alcohol (type, how much, how often)
o Use CAGE2 to assess alcoholism: Have you ever felt the need to Cut
down on your drinking? Have people Annoyed you by criticizing your
drinking? Have you ever felt bad or Guilty about your drinking? Have
you ever had a drink first thing in the morning to steady your nerves
or to get rid of a hangover- an Eye opener?
• Recreational drugs (type, how much, how often)
• Diet and stress
Review of Systems/Functional Inquiry
• A head-to-toe review of the patient's current state of health (•at this time
is there anything new?" or "has anything changed recently?u)
• Primarily yes/no questions: positive answers should be explored in
greater detail and be moved to HPIIPMHx if appropriate
• General: weight gain/loss, loss of appetite, fever, chills, fatigue, night
sweats
• Dermatological (DERM): rashes, lumps, sores, skin discoloration,
pruritus, changes to nails or hair
• Head: headaches, dizziness, light-headedness
• Eyes: visual changes, visual field deficits, dry eyes, excessive tearing,
red eyes, pain
• Ears: tinnitus, vertigo, hearing loss, earaches, discharges
• Nose: epistaxis, nasal stuffiness, sinus pain
• Mouth and Throat: dental disease, dry mouth, hoarseness, throat pain,
difficulty swallowing
• Neck: swollen glands, lumps, goiter
• Breasts: lumps, pain, nipple discharge, skin changes
• Respiratory (RESP): cough, dyspnea, sputum (color, quantity),
hemoptysis, wheezing, chest pain
• Cardiovascular (CV): chest pain, murmurs, dyspnea, orthopnea,
paroxysmal noctumal dyspnea, edema, palpitations, syncope,
intermittent claudication, leg cramps, change in color of fingers and toes
with cold exposure, varicose veins
• Gastrointestinal (GI): dysphagia, heartburn, abdominal pain, nausea,
vomiting and/or hematemesis, diarrhea, constipation, hemorrhoids, food
intolerance, hyperflatulence, changes in frequency of bowel movements
or stool appearance (e.g. color, size, melena, hematochezia)
• Urinary (GU): dysuria, frequency, urgency, polyuria, nocturia, hematuria,
and in males: hesitancy, dribbling or decrease in caliber of urinary stream
• Sexual: sexual orientation, interest and function, number of partners,
birth control methods, history of sexually transmitted diseases
o Female: age of menarche, regularity, frequency and duration of
periods, amount of bleeding, bleeding between periods or after
intercourse, last period, dysmenorrhea, age of menopause, vaginal
discharge, sores or lesions, pregnancies (number, type of delivery,
complications), abortions
o Male: penile discharge, genital sores, testicular pain or masses
• Endocrine: polydipsia, polyuria, skin or hair changes, heat or cold
intolerance, change in glove/shoe size
• Musculoskeletal (MSK}: joint pain, swelling, redness, arthritis,
myalgias, stiffness (note onset and timing)
• Neuropsychiatric (PSYCH): weakness, seizures, problems with gait,
paresthesia, memory loss, depression
• Hematologic: anemia, easy bruising or bleeding, blood transfusions
EBM: Accuracy of the History and PhysicaiiE:um ~
One study that surveyed hospitalists and senior residents found . · ·
that in correctly diagnosed cases, history alone was identified as the .
most useful tool20% of the time, whereas the physical examination ·
alone was most useful less than 1% of the time. A combination of both history and
physical examination was identified as most useful in 39% of correctly diagnosed
cases. Togethet these account for 60% of all correct diagnoses.
Paley L. et al. 2011 • .Arch Intern Med 171(15):1394-1396.
3.1NTERVIEW SKILLS
• Progress from open-ended questions (•can you describe the pain?") to
directed questions (•Is the pain sharp, dull, or burning?", *Does the pain
radiate to your left arm?")
• Encourage the patient to continue (•uh-huh", "yes"} and do not interrupt
the patient
• Redirect the patient when necessary (•It seems this Is Important to you and
maybe we can discuss it further, but right now I would like to focus on ... ")
• Ask the patient to define vague terms (suddenly, a little, tired, dizzy,
hurts, sick, weak)
• Summarize to refocus the interview or to transition into a new topic
• Ask one question at a time
• Avoid leading questions ("You don't smoke, right?")
• Avoid jargon
At the end of the interview, summarize and ask the patient if there is
anything else they wish to add to ensure all has been covered
EBM: Verbal and NonveriNIIBehiiViors Assodated with Positive
Health Outcomes
Verbal behaviors associated with positive health outcomes include
empathy; support/encouragement for patient's questions; high
proportion of objective statements In the concluding part ofthe visit; positive
reinforcement; addressing problems of daily IMng, social relations, feelings and
emotions; increased time on health education, sharing medical data with the
patient; discussion of treatment effects; friendliness; courtesy; summarization,
talking at the patient's level, and clarifying statements; humor, and increased
encounter length.
Nonverbal behaviors associated with positive health outcome include forward
leaning, head nodding, uncrossed arms and legs, arm symmetry, and less mutual
eye contact.
Beck RS, Daughtridge R, Sloane PD. 2002.JABFP 15(1):25-38.
Emotion Handling Skills: NURSE3
• N: Name the emotion
• U: Show Understanding
• R: Handle the issue with Respect
• S: Show Support
• E: Ask the patient to Elaborate on the emotion
Understanding the Patient's Perspective: FIFE1
• F: Feelings and Fears ("'What concerns you the most?")
• 1: Ideas (-what do you think is going on?")
• F: Function ("How has your illness affected you day-to-day?")
• E: Expectations (•How do you expect this treatment to help?" "What do
you think will happen with your illness?")
Breaking Bad News: SPIKES4
• S: Setting up the interview
o Deliver the news while sitting
o Ensure privacy
o Involve significant others (if appropriate)
o Inform the patient about time constraints or interruptions
• P: Perception of the patient
o Use open-ended questions to assess the patient's understanding of
hislher situation
• 1: Invitation to disclose information
o Ask the patient what he/she would like to know
• K: Knowledge Giving
o Warn the patient (•Unfortunately I have some bad news ... ")
o Deliver information in small chunks using non-technical words
o Avoid being too blunt; be careful and considerate in your choice of
words and phrasing
• E: Empathizing with the Patient's Emotions
o Allow the patient to express his/her emotions, identify the reason
behind his/her emotions, and validate his/her emotions
• S: Strategize and Summarize
o Ask the patient to summarize his/her understanding of what was
discussed
o Elicit treatment goals and discuss suitable treatment plans
4. DIFFICULT INTERVIEWS
Sexual History
• It is especially important to take a sexual history if the patient presents
with:
o Urethral and/or vaginal discharge
o Painful urination
o Genital rash and/or ulcers
o Abdominal pain
o Pain during or after intercourse
o Anorectal symptoms
o Suspected sexually transmitted infection(s)
• Preface the interview by explaining why the sexual history is necessary,
and ask the patient for permission
• Ask about the last date of intercourse, number of partners (in the last
6 months and lifetime partners), pregnancy risk, condom use, whether
they have sex with men, women, or both, contact with sex workers, and
sexual practices
• Sexual abuse history may be relevant
Cross-Cultural History Taking
• To improve communication it is important to be familiar with diverse
cultures and beliefs
• Avoid using stereotypes
• If language is a barrier, use an interpreter who is not a relative of the
patient
• Introduce the interpreter to the patient and ask the interpreter to
translate in the patient's own words
• Maintain eye contact with and direct questions toward the patient
• Keep your sentences short and simple
• Ensure the patient's understanding of the content of the interview
Spousal/Partner Abuse
• Types of Abuse
o Physical: pushing, choking
o Sexual: forced sexual contact, pregnancy, abortion
o Emotional: name-calling
o Psychological: social isolation, controlling behavior
o Financial control
• Common Signs of Spousal Abuse5
6
o Unexplained traumatic injuries inconsistent with history taken
o Head or neck injuries: facial lacerations, fractures, bums, perforated
eardrums, fractured teeth, retinal detachment, orbital blow-out
fracture, retinal hemorrhages, skull fractures, subdural and epidural
hematomas, multiple bruises at different stages of healing
o Chest, abdominal, pelvic or back pain
o Multiple visits for nonspecific and often stress-related complaints
o Headaches, insomnia, anxiety, depression
o Suicidal ideation, suicide attempts
o Chronic pain syndromes
o Substance abuse
o Eating disorders
o Pregnancy complications (miscarriage, stillbirth, abruptio placentae,
premature labor) or injuries during pregnancy
o Recovery from illness/injury inappropriately delayed
o Nonadherence with medications, treatment or follow-up
appointments
o Partner appears overly supportive
o Cancelled appointments, especially if cancellation call was made by
partner
• Approach to History and Physical Exam
o Interview the patient alone (document if this is impossible)
o Ensure confidentiality
o Ask direct and specific questions:
» "What happens when your partner loses his/her temper?"
» "Do you feel safe at home?"
» "Does your partner ever hit or abuse your children?" (inform the
patient that suspected child abuse must be reported to Children's
Aid Society)
o Remind the patient he/she is not to blame
o Assess his/her risk
» Has the severity/frequency of assaults increased?
» Have threats of homicide or suicide been made? Have these
threats increased?
» Have threats to any children been made?
» Does your partner have access to a firearm?
» Do you know where to call for help in an emergency?
o If the patient is not in immediate risk, do not tell him/her what to do;
help the patient explore each option and be supportive
o If the patient is in immediate risk, help him/her develop a safety
plan that includes emergency numbers, key documents, a packed
suitcase and money
» Encourage the patient to stay with family, friends or at a shelter
o Provide information on available community resources
o Document the patienfs history, physical exam, and medical
treatment in detail as well as your suspicions
o If patient consents, take measurements or photographs of physical
injuries
o Arrange to follow-up
o Do not be frustrated if abuse is denied or help is declined; remain
empathic and nonjudgmental
EBM: Prevalence of Intimate Partner Violence ~
A group family practice clinic In Inner city Toronto surveyed their ·
female patients and found the overall prevalence of intimate partner -
violence in current or recent relationships to be 14.6%. Emotional
abuse was reported by 1 0.4%, threat of violence by 8.3%, and physical or sexual
violence by 7.6% of respondents.
Ahmad F, et al. 2007. Con Fam Physician 53(3):460-468.
S. PREPARATION FOR THE PHYSICAL EXAM
• Prepare the patient by explaining what you are about to do before
proceeding
• Ensure patient comfort, and proper draping, positioning and lighting
• By convention, examine patients from the right side
• Avoid showing extreme reactions during the examination
Principles of Infection Control
• Hand Hygiene
o If hands are not heavily soiled, use alcohol-based hand cleanser
before and after seeing each patient; if hands are soiled (i.e. with
dirt, blood, etc.) use soap and warm water for 15 s
• Barriers
o Body substances include blood, oral secretions, sputum, emesis,
urine, feces, wound drainage, and any additional moist body
substances (excluding tears or sweat)
o Assume that all patients are potentially infected with pathogens and
all body substances are potential sources of transmission
o Use barriers (gloves, gown, mask, eyewear) when appropriate (e.g.
gloves when in contact with any bodily substances, masks when
dealing with respiratory infections)
• Minimize Needlestick Injury
o Never recap needles; immediately dispose of any sharps in
designated containers
Note: additional precautions may apply when working with specific
airborne pathogens and antibiotic-resistant organisms
6. GENERAL INSPECTION
General Appearance
• Apparent state of health: any signs of distress (cardiac, respiratory,
pain, anxiety, depression)? Any lines or tubes present (e.g. Foley
catheter, IV line)? Quickly scan the room (e.g. bedside items, number of
pillows for orthopnea, etc.)
• Physical appearance: dress, grooming, personal hygiene, level of
consciousness, skin (color and obvious lesions), diagnostic facies,
appears stated age (see Table 1 and Table 2)
• Body structure: height, habitus, sexual development, fat distribution,
symmetry, body posture and position, bony abnormalities (see Figure 2)
• Mobility: gait (normally, shoulder-width base, with smooth, even strides),
range of motion, involuntary movements (see Geriatric Exam and
Neurological Exam, p.69 and 171 respectively)
• Behavior: facial expression, mood, affect, speech (articulation, fluency,
hoarseness)
• Any odors of the breath or body
Head
• Look for diagnostic facies, color abnormalities, swelling, scalp lesions,
and abnormal hair distribution (alopecia, hirsutism)
Hands and Nails
• Inspect the hand for abnormal color or morphology
7. VITAL SIGNS
Temperature
• Body temperature is influenced by age, the diumal cycle, the menstrual
cycle, and exercise
Pulse Measurement
• Use the radial or carotid artery to determine:
o Rhythm: regular, regularly irregular, irregularly irregular
o Rate:
» Regular rhythm: count for 30 s
» Regularly irregular: count for 1 min
» Irregularly irregular: count for 1 min using apex beat
o Magnitude: normal, diminished, or increased
o Symmetry: left vs. right
• Before palpating the carotid artery, auscultate for carotid bruits
• Never palpate both carotid arteries at the same time
• Normal adult pulse rate is 50-1 00 bpm8
o Bradycardia: an abnormally slow heart rate (<60 bpm)
o Tachycardia: an abnormally fast heart rate (>1 00 bpm)
Respiratory Assessment
• Look for signs of respiratory distress (the use of accessory muscles,
intercostal indrawing, pursed lip breathing, tripod positioning, heaving or
audible wheezing)
• RR most reliably measured when patient is distracted from his/her own
conscious breathing (e.g. pretending to take their pulse)
• Count for 30 s if breathing is normal and for 1 min if you suspect
abnormality
• Normal adult RR is 16-25 breaths/min7
o Bradypnea: an abnormal decrease in RR (<16 breaths/min)
o Tachypnea: an abnormal increase in RR (>25 breaths/min)
o Apnea: absence of breathing, either periodic or sustained (i.e.
cardiac arrest, CNS lesion)
Blood Pressure Measurement
• Terminology
o Systolic blood pressure (SBP): maximum arterial pressure during left
ventricular contraction (see Table 5)
o Diastolic blood pressure (DBP): resting arterial pressure between
ventricular contractions (see Table 5)
o Pulse pressure= SBP- DBP
o Korotkoff sounds: arterial sounds heard during blood pressure
measurement by auscultation
o Auscultatory gap: transient loss of Korotkoff sounds during
measurement of SBP
Preparation
Patient should be relaxed, sitting with his/her back supported and
feet flat on the floor
o Wrap cuff around upper arm, 2-3 em above antecubital fossa, with
brachial marker over brachial artery
o Ask the following questions:
:. •1n the last 30 min, have you smoked, had caffeine, or exercised?"
:. *Is there any reason that you should not have your blood pressure
taken on either of your arms?"
• Systolic Pressure by Palpation
o Usually performed to avoid missing the auscultatory gap which could
result in underestimating SBP
o Palpate radial artery on arm
o Inflate blood pressure cuff until radial pulse disappears
o Slowly deflate approximately 2 mmHg/s
o SBP is estimated when radial pulse can be felt again
• Systolic and Diastolic Pressure by Auscultation (see Figure 4)
o Note in which arm BP is being measured
o Support upper arm at heart level
o Place stethoscope over brachial artery
o Inflate cuff to 20-30 mmHg above estimated SBP
o Slowly deflate approximately 2 mmHgls
o SBP is read at the first Korotkoff sound
o DBP is read when the Korotkoff sounds disappear
o Repeat using other arm to assess symmetry
• Orthostatic Hypotension Measurement
o Measure BP with the patient supine, then standing
o Positive test: ~20 mmHg fall in SBP or ~10 mmHg fall in DBP upon
standing*
o Patients may also experience symptoms of cerebral hypoperfusion
upon standing: dizziness, weakness, lightheadedness, visual
blurring, darkening of visual fields, syncope (due to abrupt peripheral
vasodilation without compensatory increase in cardiac output)
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