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 C 1 to 10.)
^ 4. Timing. When did (does) it start? How long did (does) it last? How often did (does) it come?
Setting in which it occurs. Include environmental factors, personal activities, emotional reactions, or other circumstances that may have contributed to the illness.
C 5. Remitting or exacerbating factors. Does anything make it better or worse? T 7. Associated manifestations. Have you noticed anything else that accompanies it?
As you explore these attributes, be sure that you use language that is understandable and appropriate to the patient. Although you might ask a trained health professional about "dyspnea," the customary term to use for patients is "shortness of breath." It is easy to slip into using medical language with patients, but beware. Technical language confuses the patient and often blocks communication. Appropriate questions about symptoms are suggested in each of the chapters on the regional physical examinations. Whenever possible, however, use the patient's words, making sure you clarify their meaning.
To fill in specific details, learn to facilitate the patient's story by using different types of questions and the techniques of skilled interviewing described on pp. - . Often you will need to use directed questions (see p._) that ask for specific information the patient has not already offered. In general, an interview moves back and forth from an open-ended question to a directed question and then on to another open-ended question.
Establishing the sequence and time course of the patient's symptoms is important. You can encourage a chronologic account by asking such questions as "What then?" or "What happened next?"
Generating and Testing Diagnostic Hypotheses (the Clinician's Perspective). As you listen to the patient's concerns, you will begin to generate and test diagnostic hypotheses about what disease process might be the cause. Identifying the various attributes of the patient's symptoms and pursuing specific details are fundamental to recognizing patterns of disease and differentiating one disease from another. As you learn more about diagnostic patterns, listening for and asking about these attributes will become more automatic. For additional data that will contribute to your analysis, use items from relevant sections of the Review of Systems. In these ways you build evidence for and against the various diagnostic possibilities. This kind of clinical thinking is illustrated by the tables on symptoms found in the regional examination chapters and further discussed in Chapter 18, Clinical Reasoning, Assessment, and Plan.
Creating a Shared Understanding of the Problem. Recent literature makes clear that delivering effective health care requires exploring the deeper meanings patients attach to their symptoms. While the "seven attributes of a symptom" add important details to the patient's history, the disease/illness distinction model helps you understand the full range of what every ood interview needs to cover. This model acknowledges the dual but very ferent perspectives of the clinician and the patient. Disease is the explana-that the clinician brings to the symptoms. It is the way that the clinician organizes what he or she learns from the patient into a coherent picture that leads to a clinical diagnosis and treatment plan. Illness can be defined as how the patient experiences symptoms. Many factors may shape this experience, including prior personal or family health, the effect of symptoms on everyday life, individual outlook and style of coping, and expectations about medical care. The health history interview needs to take into account both of these views of reality.
■Ev en a chief complaint as straightforward as sore throat can illustrate these divergent views. The patient may be most concerned about pain and difficulty swallowing, a cousin who was hospitalized with tonsillitis, or missing time from work. The clinician, however, may focus on specific points in the history that differentiate streptococcal pharyngitis from other etiologies or on a questionable history of allergy to penicillin. To understand the patient's expectations, the clinician needs to go beyond just the attributes of a symptom. Learning about the patient's perception of illness means asking patient-centered questions in the six domains listed below. Doing so is crucial to patient satisfaction, effective health care, and patient follow-through.
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