THE MEDICAL INTERVIEW

PRIMER
INFORMATION GATHERING
Guidance for collecting data during a medical interview
CLINICAL HYPOTHESIS TESTING
Approach to testing clinical hypothesis during a medical interview
INTERPERSONAL SKILLS
Communications Skills Checklist
MEDICAL HISTORY WRITE UP
Guidance for recording the medical history
ASSESSMENT AND DIFFERENTIAL DIAGNOSIS
Guidance for developing an assessment and differential diagnosis
PITFALLS
Common pitfall in differential diagnosis

Andrew Adler MD

GATHERING INFORMATION
The outline below provides some very specific ways to operationalize the information
gathering and clinical hypothesis testing skills listed on the clinical skills checklist. This
should be helpful to you as you watch the gateway videos during small group.
1. Get the story of the illness
a. Open ended questions
i. What brought you in today?
ii. Could you tell me what happened?
b. Verbal facilitation
i. Go on
ii. Tell me more
iii. Could you describe that?
iv. Is there anything else?
v. Reflection I see, you..(repeat what the patient just said)
c. Non-verbal facilitation
i. Nod
ii. Uh-uh
iii. Silence
2. Clarify the story
a. Time line
i. What happened first? or When did this begin?
ii. What happened next?
b. Setting
i. What were you doing when you first notice/experienced this?
ii. How did this begin?
c. Associated Symptoms
i. Did you notice/experience anything else? Tell me about that.
d. Seven dimensions of the symptom
i. Closed-ended questions to get the dimensions still missing
ii. Closed ended questions to explore pertinent positives and pertinent
negatives not revealed.
3. Summarize the story and confirm (Use this time to consider what diagnoses or
organ systems you plan to explore).
TEST CLINICAL HYPOTHESES
1. Consider possible organ systems or diagnoses that may be involved
a. Close-ended question are derived from the organ specific list of symptoms
in the ROS (include GENERAL as well). This provides you with the
pertinent negatives as well as positives.
2. Identify risk factors for the conditions that may be involved
a. Close-ended questions that explore risk factors (PMH, Social & Family
history provides the source material)
REMEMBER TO USE EMPATHY WHENEVER THE OPPORTUNITY ARISES
Empathy serves to improve information gathering in addition to developing rapport.
Empathy is the ability to recognize something (worry, fear, concern, discomfort, confusion,
etc.) in a patient and communicate that recognition back to the patient.

INTERPERSONAL COMMUNICATIONS SKILL SET

Initiating the Interview
Introduces oneself to the patient
Greets the patient warmly
Establishes patient's reason for seeking care by asking open-ended
questions about reasons for the encounter
Allows patient to complete opening statements without interruption
Gathering Information - technique
Uses open-ended questions to begin and sustain an interview.
Facilitates responses that encourage and clarify the patients story
Uses reflective listening
Uses transitions from open to closed-ended questions
Clarifies symptoms
Establishes a timeline
Uses verbal transitions to move from one area of inquiry to another
Summarizes
Information Gathering - content
Elicits a chief complaint
Inquires about the 7 dimensions of the symptoms
Develops a coherent timeline for the HPI
Inquires about past medical history, family history, social history and ROS
Inquires about the patients concerns and fears
Elicits the patient's agenda - inquire about needs and wants
Developing Rapport
Sets the stage
Introduces oneself in an appropriate and respectful manner
Makes eye contact
Maintains an open posture (body language)
Avoids interrupting
Uses empathy to encourage, support and understand patients feelings
Recognizes patients verbal and non-verbal clues
Uses reflection to demonstrate empathy
Validates patients concerns, values and fears
Summarizes patients concerns as well as symptoms to assure accuracy
Providing Closure
Elicits questions and concerns before transitioning into closure
Alerts the patient to the fact that the encounter is ending
Summarizes and clarify the plans
Checks for patient understanding
Arranges interim contact and follow-up plans
Makes a truthful and personal goodbye

THE WRITE-UP
CC: Age, gender, presenting complaint, time frame
Patient is a 43 year old man with a 2 day history of diarrhea.
HPI
Begin with a repetition of the chief complaint (no need to repeat the gender or age)
Present the story in a clear chronological fashion
The patient was well until 2 days ago when he first began to experience
diarrhea.
Expand the history by recording the 7 dimensions of the symptom which should also
include the pertinent negatives not just the pertinent positive associated symptoms.
Record the pertinent risk factors for the possible diagnoses you are considering.
These are derived from the PMH, FH, SH dont forget to include medications and
travel history if pertinent.
DO NOT
Do not record physical findings in the HPI
Do not offer diagnoses in the HPI
Do not include data that is not relevant to the presenting problem
PMH
Include all previous medical, surgical, psychiatric and obstetrical diagnoses.
Include dates of diagnoses if known; all medications with their dosages if known
If chronic, state the status of the condition
Allergies and their clinical presentation
FH
Parents, siblings, children ages, cause of death if known, known medical conditions
Ask and record if there is any family history of heart disease, diabetes or cancer in the
family.
SH
Social history can vary but should contain at a minimum:
Living arrangements where and with whom
Occupation (exposures if relevant)
Habits alcohol, tobacco, drugs
Sexual History orientation, current partner(s), whether actively engaged or not
ROS
Should include all the organ systems
Includes only symptoms, not diagnoses or physical findings
If symptoms are already included in the HPI there is no need to repeat them in the ROS.
You can say see HPI.
A positive symptom should be elaborated on.

PE
Records the findings of all the organ systems
Descriptive; avoids normal except as shown in the manual.
Describes & elaborates upon abnormal findings if present (e.g. swollen R knee without
tenderness or erythema, no effusion, active and passive range of motion normal not just
swollen knee; 2/6 holosystolic murmur heart best at apex, radiating to axilla not just
murmur).
Includes extensive examination of all problematic areas identified in the history. For
example, if during the ROS the patient reports a rash, you should do a complete
dermatologic exam with a detailed description of the rash. If the patient has a history of
rheumatoid arthritis, you should do a complete musculoskeletal exam. Of course, you
should do an extensive exam relating to the problem that brought the patient to the
hospital.
SUMMARY
Consists of 3-5 complete sentences summarizing the most important findings from the
history, physical and laboratory studies (in that order)
Includes pertinent negatives, as well as pertinent positives
PROBLEM LIST
List the problems in order of priority first the problem that brought the patient in, then
chronic active problems, symptoms discovered in the ROS that are not part of the
presenting problem, chronic stable problems, and social problems
Include Health Care Maintenance; prevention (need for vaccine, screening tests etc.)


ASSESSMENT
DIAGNOSTIC REASONING
PREREQUISITES a sufficient knowledge base of medical conditions and their mode of
presentation; skill to gather a thorough medical history; skill to conduct a competent
physical examination
Knowledge Base facts acquired through conscientious study and reading of
background sources; familiarity with clinical presentations acquired through the
experience of seeing patients.
Medical History a record and characterization of symptoms (7 dimensions,
review of symptoms) and a thorough patient profile (past medical history, family
and social history), acquired through competent interviewing techniques.
Physical Examination a record of physical signs acquired through conducting a
competent examination of the patient.
With the information gathered from a competent interview and physical examination at
hand the physician applies a cognitive process to establish a prioritized list of clinical
hypotheses, i.e. the differential diagnoses.
PROCESS organizing and analyzing the information gathered from the medical
interview and physical examination aided by ones knowledge base to prioritize a list of
probable diagnoses
Organize select the information gathered that is relevant to the patients
condition. These can be grouped into 4 essential categories.
Demographics age, gender, ethnicity, social groups
Chronology acute, sub-acute or chronic
Signs and symptoms include both positive and pertinent negatives
Risk factors
Analyze select and prioritize diagnoses that may fit the patients data as
previously organized; prioritization is determined by sensitivities, specificities,
probabilities and likelihood ratios. Prioritization may be accomplished by the novice
through hypothetico-deductive reasoning and by experts through a heuristic
process. Frequently, experts as well as novices use algorithmic reasoning when
heuristics are insufficient to develop a diagnosis. Experts also use hypotheticodeductive reasoning when stumped, i.e. heuristics fail them.

Differential Diagnosis
Developing a differential diagnosis is a portion of the overall assessment that physicians
make when managing patients. Besides making diagnoses, an assessment may include
an analysis of factors that may have precipitated a known problem (diagnoses) and a
description of the status of known chronic problems. (See the paragraph below entitled
Writing Assessments). The key features of this portion of the assessment are as follows:
Shows your thinking about the problem.
1-3 paragraphs
The Differential Diagnosis should be specific to your patient, not a generic
differential for the problem. In preparing an assessment discuss which
elements in the history and physical examination (H&P) argue for or against
specific diagnoses. Based on this evidence, determine which diagnosis you think
is most likely. An assessment of differential diagnoses should draw from the 3
sources of data (history, physical examination, and labs).
Writing Assessments
There is an assessment for each problem.
Shows your thinking about the problem.
1-3 paragraphs for the primary problem.
If the diagnosis is unknown discusses differential diagnoses. The Differential
Diagnosis should be specific to this patient, not a generic differential for the
problem. You should discuss which elements in the H&P argue for or against specific
diagnoses and based on this evidence, which diagnosis you think is most likely. You
must cite from the 3 sources of data (history, physical examination, and labs) to support
possible diagnoses.
If the diagnosis is known, the assessment provides the evidence from the H&P that
supports that diagnosis, as well as the patients risk factors that may have contributed to
the diagnosis. This discussion should be patient specific.
If the problem is an exacerbation of a chronic problem (e.g. a diabetic with
hyperglycemia), the assessment provides the evidence from the H&P that indicates it is
an exacerbation, and discusses why you think the problem got worse when it did. This
discussion should be patient specific, not a general discussion of what might cause an
exacerbation of this problem.
If a problem is chronic and stable, can simply state stable or well controlled.
Includes status & severity as appropriate (e.g. Lung Cancer metastatic and refractory
to chemotherapy).
Plans
Includes diagnostic and/or treatment plan for each problem.
Plan should demonstrate an understanding of the purpose of all tests and goals of
therapy.
Plan should be specific to the patient.
The problem list is usually combined with the assessment and plan. Under each
problem, you write out an assessment and your plan. See Sample Write-ups for
examples.

Pitfalls in Formulation of a Differential Diagnosis

Disembodied Differential Diagnosis:
Student presents a generic differential for the initial complaint rather than a differential
specific to the patient and his/her clinical findings.
Silo Differential Diagnosis:
Student presents a separate Differential Diagnosis for each symptom or key finding,
rather than a differential for the constellation of findings taken together.
Frozen Differential Diagnosis:
Student continues to include items on the Differential Diagnosis that have been ruled out
by new information or continues to present a multi-item differential after a final
diagnosis has been confirmed.
Unprioritized/inappropriately prioritized Differential Diagnosis:
Student assigns inappropriate weight/probability to items on the Differential Diagnosis.
Zebra Differential Diagnosis:
Differential Diagnosis includes one or more rare, esoteric, highly unlikely diagnoses.