"
"
Ideally, ample time should be available to explore the medical history in
depth and in a relaxed manner. If time is short or the patient is too ill or
confused to be questioned at length, a limited interview, focused on the
immediate problem, is desirable. Later, as the patient improves, the history
can be completed.
The conversation might be initiated by asking the patient, "Tell me about
yourself." This friendly opening demonstrates that the physician is genuinely
interested in the person, not the disease. As Sir William Osier, the father of
American medicine, stated, "It is more important to know what sort of
patient has a disease than what sort of disease a patient has." The patient
should then be asked about his or her most important concerns and
current symptoms. At the outset, the physician encourages a spontaneous
flow of information with open-ended questions such as "Tell me about your
chest discomfort;’ After the patient has elaborated on his or her problem,
the physician can then follow up with more direct questions that favor or
dismiss a specific diagnosis: "Did the pain worsen with activity?"
The physician should be careful to avoid courtroom-type questions that
lead to premature closure of the subject and erroneous conclusions. The
experienced interviewer encourages the spontaneous flow of information
with comments such as "Go ahead;’ "mm-hmm," "Yes," "1 see," "What
else?" and "Tell me more." This technique, known as passive listening, is
enhanced by nonverbal communication such as open and receptive
posture, eye contact, and head nodding.
The physician should appear interested, sympathetic, and nonjudgmental
even if the patient becomes upset or hostile. If the patient becomes angry,
it may be helpful to say, "You seem upset." By actively listening to the
underlying feeling in the message and relaying this feeling back to the
patient, the physician demonstrates concern and understanding. For
example, the patient may say, "1 have a minor chest pain, but my wife
insists that you check out my heart." The physician might respond, "It’s
alarming to think that your chest pain could be due to a heart condition."
is important to recognize emotional and psychological overtones and their
implications. Revealing information may be obtained by asking, "What do
you think is wrong with your health?" The physician should also be alert
the possibility that the patient’s most distressing symptoms may not be
due to the most serious problem or that the patient may not be willing to
acknowledge certain potentially serious symptoms such as chest pain.
depth and in a relaxed manner. If time is short or the patient is too ill or
confused to be questioned at length, a limited interview, focused on the
immediate problem, is desirable. Later, as the patient improves, the history
can be completed.
The conversation might be initiated by asking the patient, "Tell me about
yourself." This friendly opening demonstrates that the physician is genuinely
interested in the person, not the disease. As Sir William Osier, the father of
American medicine, stated, "It is more important to know what sort of
patient has a disease than what sort of disease a patient has." The patient
should then be asked about his or her most important concerns and
current symptoms. At the outset, the physician encourages a spontaneous
flow of information with open-ended questions such as "Tell me about your
chest discomfort;’ After the patient has elaborated on his or her problem,
the physician can then follow up with more direct questions that favor or
dismiss a specific diagnosis: "Did the pain worsen with activity?"
The physician should be careful to avoid courtroom-type questions that
lead to premature closure of the subject and erroneous conclusions. The
experienced interviewer encourages the spontaneous flow of information
with comments such as "Go ahead;’ "mm-hmm," "Yes," "1 see," "What
else?" and "Tell me more." This technique, known as passive listening, is
enhanced by nonverbal communication such as open and receptive
posture, eye contact, and head nodding.
The physician should appear interested, sympathetic, and nonjudgmental
even if the patient becomes upset or hostile. If the patient becomes angry,
it may be helpful to say, "You seem upset." By actively listening to the
underlying feeling in the message and relaying this feeling back to the
patient, the physician demonstrates concern and understanding. For
example, the patient may say, "1 have a minor chest pain, but my wife
insists that you check out my heart." The physician might respond, "It’s
alarming to think that your chest pain could be due to a heart condition."
is important to recognize emotional and psychological overtones and their
implications. Revealing information may be obtained by asking, "What do
you think is wrong with your health?" The physician should also be alert
the possibility that the patient’s most distressing symptoms may not be
due to the most serious problem or that the patient may not be willing to
acknowledge certain potentially serious symptoms such as chest pain.
Symptoms
Do you experience:
chest discomfort or pain?
shortness of breath during moderate exertion?
shortness of breath when recumbent?
swelling of your ankles?
dizzy spells?
fainting spells?
palpitations, skipped heartbeats, or a racing heart?
significant unexplained fatigue?
coughing at night?
coughing up blood?
cramps or pain in your calves, thighs, or hips while walking that is
relieved by rest?
Do you:
have to elevate your head with more than one pillow to breathe
comfortably at night?
have to arise several times during the night to urinate?
have tender or swollen calves?
have varicose veins?
These questions should effectively screen for the presence of heart
disease that is producing physiologic impairment. When chest pains and
palpitations are excluded, the symptoms are traceable to secondary effects
of heart disease on other organs, particularly the lung, brain, kidney, and
blood vessels. If the patient answers any question affirmatively, the
symptom should be explored in more detail, using the approach outlined
in the previous chapter.
Etiology
The clinician should try to establish an etiology by asking questions
directed to known causes of cardiovascular disease. The scope and
number of questions are tailored to the patient, based on symptoms, prior
illnesses, physical findings, and other information gathered.
Do you experience:
chest discomfort or pain?
shortness of breath during moderate exertion?
shortness of breath when recumbent?
swelling of your ankles?
dizzy spells?
fainting spells?
palpitations, skipped heartbeats, or a racing heart?
significant unexplained fatigue?
coughing at night?
coughing up blood?
cramps or pain in your calves, thighs, or hips while walking that is
relieved by rest?
Do you:
have to elevate your head with more than one pillow to breathe
comfortably at night?
have to arise several times during the night to urinate?
have tender or swollen calves?
have varicose veins?
These questions should effectively screen for the presence of heart
disease that is producing physiologic impairment. When chest pains and
palpitations are excluded, the symptoms are traceable to secondary effects
of heart disease on other organs, particularly the lung, brain, kidney, and
blood vessels. If the patient answers any question affirmatively, the
symptom should be explored in more detail, using the approach outlined
in the previous chapter.
Etiology
The clinician should try to establish an etiology by asking questions
directed to known causes of cardiovascular disease. The scope and
number of questions are tailored to the patient, based on symptoms, prior
illnesses, physical findings, and other information gathered.
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