First Aid for the USMLE Step 2 CS

Section 2. The Patient Encounter

Taking The History

Your ability to take a detailed yet focused history is essential to the formulation of a differential diagnosis and workup plan. The discussion that follows will help guide you through this process in a manner that will maximize your chances of success.

Guidelines

You may take the history while standing in front of the patient or while sitting on the stool that is provided, which is usually located near the bed. You will find a sheet placed on this stool. Begin by removing the sheet and draping the patient. Do this before taking the history to make sure you get credit for doing so early on.

Don’t cross your arms in front of your chest when talking to the patient, especially with the clipboard in your hands. Instead, it is best to sit down on the stool, relax, and keep the clipboard on your lap. If you decide to stand, maintain a distance of approximately two feet between yourself and the patient.

As noted, the interview as a whole should take no more than 7-8 minutes. You can start your interview by asking the patient an open-ended question such as “So what brought you to the hospital/clinic today?” or “How can I help you today?” See Figure 2-2 for an overview of the process.

Additional Tips

Once the interview has begun, be sure to maintain a professional yet friendly demeanor. You should speak clearly and slowly, and your questions should be short, well phrased, and simple. Toward that end, avoid the use of medical terms; instead, use simple words that a layperson can understand (eg, don’t use the term renal calculus; use kidney stone instead). If you find yourself obliged to use a medical term that the patient may not understand, offer a quick explanation. Don’t wait for the patient to ask you for the meaning of a term, or you may lose credit.

If you don’t understand something the patient has said, you may ask him or her to explain or repeat it (eg, “Can you please explain what you mean by that?” or “Can you please repeat what you just said?”). At the same time, do not rush the patient. Instead, give him or her ample time to respond. In interacting with the patient, you should always remember to ask questions in a neutral and nonjudgmental way.

FIGURE 2-2. History-Taking Overview

You should also remember not to interrupt the patient unless it is absolutely necessary. If the patient starts telling lengthy stories that are irrelevant to the chief complaint, you can interrupt politely but firmly by saying something like “Excuse me, Mr. Johnson. I understand how important those issues are for you, but I’d like to ask you some additional questions about your current problem.” You can also redirect the conversation by summarizing what the patient has told you thus far and then move to the next step (eg, “So as I understand it, your abdominal pains are infrequent, last a short time, and are always in the middle of your belly. Now tell me about . . .”).

It is critical to summarize what the patient has told you, not only to verify that you have understood him but also to ensure that you receive credit. You need to use this summary technique no more than once during the encounter in order to get credit, but you may use it more often if you consider it necessary. It is recommended, however, that you give a summary (1) after you have finished taking the history and before you start examining the patient, or (2) just after you have finished examining the patient and before you give him your medical opinion. In either case, your summary should include only the points that are relevant to the patient’s chief complaint.

Minor transitions may also be used during the history. For example, when you want to move from the history of present illness (HPI) to the patient’s past medical history or social and sexual history, you can say something like “I need to ask you some questions about your health in the past,” or “I’d like to ask you a few questions about your lifestyle and personal habits.”

To ensure that you stay on track in gathering information, you will also need to watch the patient carefully, paying attention to his or her every word, move, or sign. Remember that clinical encounters are staged, so it is uncommon for something to occur for no reason. Although accidents do happen (for example, an SP once started to hiccup inadvertently), an SP will most likely cough in an encounter because he or she is intending to depict bronchitis, not because of an involuntary reflex.

By the same logic, you should address every sign you see in the patient (eg, “You look sad; do you know the reason?” or “You look concerned; is there anything that is making you worry?”). If your patient is coughing, ask about the cough even if it isn’t cited as the reason for the visit. If the patient is using a tissue, ask to see it so that you can check the color of the sputum. A spot of blood on the tissue may take you by surprise!

Finally, take brief notes throughout the interview, mainly to record relevant yet easy- to-forget pieces of information such as the duration of the chief complaint or the number of years the patient smoked. To facilitate this note taking, you will be given a clipboard with 12 blank blue sheets, one for each encounter. The extent of your note taking inside the encounter will depend on how much you trust your memory. Before you finish your interview and move to the physical exam, you may ask the patient something like “Is there anything else you would like to tell me about?” or “Is there anything else you forgot to tell me about?”

Common Questions to Ask the Patient

In this section, we will cover a wide spectrum of questions that you may need to pose in the course of each of your patient interviews. This is not intended to be a complete list, nor do you have to use all the questions outlined below. Instead, be selective in choosing the questions you ask in your efforts to obtain a concise, relevant history. You should also be sure to ask only one question at a time. If you ask complex questions (eg, “Is there any redness or swelling?”), the SP will likely answer only the last question you posed. Instead, you should slow down and ask about one symptom at a time.

Opening of the encounter:

 “Mr. Jones, hello; I am Dr. Singh. It’s nice to meet you. I’d like to ask you some questions and examine you today.”

 “How can I help you today?”

 “What brought you to the hospital/clinic today?”

 “What made you come in today?”

 “What are your concerns?”

Pain:

 “Do you have pain?”

 “When did it start?”

 “How long have you had this pain?”

 “How long does it last?”

 “How often does it come on?”

 “Where do you feel the pain?”

 “Can you show me exactly where it is?”

 “Does the pain travel anywhere?”

 “What is the pain like?”

 “Can you describe it for me?”

 “What is the character of the pain? For example, is it sharp, burning, cramping, or pressure-like?”

 “Is it constant, or does it come and go?”

 “On a scale of 1 to 10, with 10 being the worst pain you have ever felt, how would you rate your pain?”

 “What brings the pain on?”

 “Do you know what causes the pain to start?”

 “Does anything make the pain better?”

 “Does anything make it worse?”

 “Have you had similar pain before?”

Nausea:

 “Do you feel nauseated?”

 “Do you feel sick to your stomach?”

Vomiting:

 “Did you vomit?”

 “Did you throw up?”

 “What color was the vomit?”

 “Did you see any blood in it?”

Cough:

 “Do you have a cough?”

 “When did it start?”

 “How often do you cough?”

 “During what time of day does your cough occur?”

 “Do you bring up any phlegm with your cough, or is it dry?”

 “Does anything come up when you cough?”

 “What color is it?”

 “Is there any blood in it?”

 “Can you estimate the amount of the phlegm? A teaspoon? A tablespoon? A cupful?”

 “Does anything make it better?”

 “Does anything make it worse?”

Headache:

 “Do you get headaches?”

 “Tell me about your headaches.”

 “Tell me what happens before/during/after your headaches.”

 “When do your headaches start?”

 “How often do you get them?”

 “When your headache starts, how long does it last?”

 “Can you show me exactly where you feel the headache?”

 “What causes the headache to start?”

 “Do you have headaches at certain times of the day?”

 “Do your headaches wake you up at night?”

 “What makes the headache worse?”

 “What makes it better?”

 “Can you describe the headache for me, please? For example, is it sharp, dull, pulsating, pounding, or pressure-like?”

 “Do you notice any change in your vision before/during/after the headaches?”

 “Do you notice any numbness or weakness before/during/after the headaches?”

 “Do you feel nauseated? Do you vomit?”

 “Do you notice any fever or stiff neck with your headaches?”

Fever:

 “Do you have a fever?”

 “Do you have chills?”

 “Do you have night sweats?”

 “How high is your fever?”

Shortness of breath:

 “Do you get short of breath?”

 “Do you get short of breath when you’re climbing stairs?”

 “How many steps can you climb before you get short of breath?”

 “When did it first start?”

 “When do you feel short of breath?”

 “What makes it worse?”

 “What makes it better?”

 “Do you wake up at night short of breath?”

 “Do you have to prop yourself up on pillows to sleep at night? How many pillows do you use?”

 “Have you been wheezing?”

 “How far do you walk on level ground before you have shortness of breath?”

 “Have you noticed any swelling of your legs or ankles?”

Urinary symptoms:

 “Has there been any change in your urinary habits?”

 “Do you have any pain or burning during urination?”

 “Have you noticed any change in the color of your urine?”

 “How often do you have to urinate?”

 “Do you have to wake up at night to urinate?”

 “Do you have any difficulty urinating?”

 “Do you feel that you haven’t completely emptied your bladder after urination?”

 “Do you need to strain/push during urination?”

 “Have you noticed any weakness in your stream?”

 “Have you noticed any blood in your urine?”

 “Do you feel as though you need to urinate but then very little urine comes out?”

 “Do you feel as though you have to urinate all the time?”

 “Do you feel as though you have very little time to make it to the bathroom once you feel the urge to urinate?”

Bowel symptoms:

 “Has there been any change in your bowel movements?”

 “Do you have diarrhea?”

 “Are you constipated?”

 “How long have you had diarrhea/constipation?”

 “How many bowel movements do you have per day/week?”

 “What does your stool look like?”

 “What color is your stool?”

 “Is there any mucus or blood in it?”

 “Do you feel any pain when you have a bowel movement?”

 “Did you travel recently?”

 “Do you feel as though you strain to go to the bathroom or a very small amount of feces comes out?”

 “Have you lost control of your bowels?”

 “Do you feel as though you have very little time to make it to the bathroom once you have the urge to have a bowel movement?”

Weight:

 “Have you noticed any change in your weight?”

 “How many pounds did you gain/lose?”

 “Over what period of time did it happen?”

 “Was the weight gain/loss intentional?”

Appetite:

 “How is your appetite?”

 “Has there been any change in your appetite?”

 “Are you getting full too quickly during a meal?”

Diet:

 “Has there been any change in your eating habits?”

 “What do you usually eat?”

 “Did you eat anything unusual lately?”

 “Are there any specific foods that cause these symptoms?”

 “Is there any kind of special diet that you are following?”

Sleep:

 “Do you have any problems falling asleep?”

 “Do you have any problems staying asleep?”

 “Do you have any problems waking up?”

 “Do you feel refreshed when you wake up?”

 “Do you snore?”

 “Do you feel sleepy during the day?”

 “How many hours do you sleep?”

 “Do you take any pills to help you go to sleep?”

Dizziness:

 “Do you ever feel dizzy?”

 “Tell me exactly what you mean by dizziness.”

 “Did you feel the room spinning around you, or did you feel lightheaded as if you were going to pass out?”

 “Did you black out or lose consciousness?”

 “Did you notice any change in your hearing?”

 “Do your ears ring?”

 “Do you feel nauseated? Do you vomit?”

 “What causes this dizziness to happen?”

 “What makes you feel better?”

Joint pain:

 “Do you have pain in any of your joints?”

 “Have you noticed any rash with your joint pain?”

 “Is there any redness or swelling of the joint?”

 “Are you having difficulty moving the joint?”

Travel history:

 “Have you traveled recently?”

 “Did anyone else on your trip become sick?”

Past medical history:

 “Have you had this problem or anything similar before?”

 “Have you had any other major illnesses before?”

 “Do you have any other medical problems?”

 “Have you ever been hospitalized?”

 “Have you ever had a blood transfusion?”

 “Have you had any surgeries before?”

 “Have you ever had any accidents or injuries?”

 “Are you taking any medications?”

 “Are you taking any over-the-counter drugs, vitamins, or herbs?”

 “Do you have any allergies?”

Family history:

 “Does anyone in your family have a similar problem?”

 “Are your parents alive?”

 “Are they in good health?”

 “What did your mother/father die of?”

 “Are your brothers or sisters alive?”

Social history:

 “Do you smoke?”

 “How many packs a day?”

 “How long have you smoked?”

 “Do you drink alcohol?”

 “What do you drink?”

 “How much do you drink per week?”

 “Do you use any recreational drugs such as marijuana or cocaine?”

 “Which ones do you use?”

 “How often do you use them?”

 “Do you smoke or inject them?”

 “What type of work do you do?”

 “Where do you live? With whom?”

 “Tell me about your life at home.”

 “Are you married?”

 “Do you have children?”

 “Do you have a lot of stressful situations on your job?”

 “Are you exposed to environmental hazards on your job?”

Alcohol history:

 “How much alcohol do you drink?”

 “Tell me about your use of alcohol.”

 “Have you ever had a drinking problem?”

 “When was your last drink?”

 Administer the CAGE questionnaire:

 “Have you ever felt a need to cut down on drinking?”

 “Have you ever felt annoyed by criticism of your drinking?”

 “Have you ever had guilty feelings about drinking?”

 “Have you ever had a drink first thing in the morning (‘eye opener’) to steady your nerves or get rid of a hangover?”

Sexual history:

 “I would like to ask you some questions about your sexual health and practice.”

 “Are you sexually active?”

 “Do you use condoms? Always? Other contraceptives?”

 “Are you sexually active? With men, women, or both?”

 “Tell me about your sexual partner or partners.”

 “How many sexual partners have you had in the past year?”

 “Do you currently have one partner or more than one?”

 “Have you ever had a sexually transmitted disease?”

 “Do you have any problems with sexual function?”

 “Do you have any problems with erections?”

 “Do you use any contraception?”

 “Have you ever been tested for HIV?”

Gynecologic/obstetric history:

 “At what age did you have your first menstrual period?”

 “How often do you get your menstrual period?”

 “How long does it last?”

 “When was the first day of your last menstrual period?”

 “Have you noticed any change in your periods?”

 “Do you have cramps?”

 “How many pads or tampons do you use per day?”

 “Have you noticed any spotting between periods?”

 “Have you ever been pregnant?”

 “How many times?”

 “How many children do you have?”

 “Have you ever had a miscarriage or an abortion?”

 “Do you have pain during intercourse?”

 “Do you have any vaginal discharge?”

 “Do you have any problems controlling your bladder?”

 “Have you had a Pap smear before?”

Pediatric history:

 “Was your pregnancy full term (40 weeks or 9 months)?”

 “Did you have routine checkups during your pregnancy? How often?”

 “Did you have any complications during your pregnancy/during your delivery/ after delivery?”

 “Was an ultrasound performed during your pregnancy?”

 “Did you smoke, drink, or use drugs during your pregnancy?”

 “Was it a vaginal delivery or a C-section?”

 “Did your child have any medical problems after birth?”

 “When did your child have his first bowel movement?”

Growth and development:

 “When did your child first smile?”

 “When did your child first sit up?”

 “When did your child start crawling?”

 “When did your child start talking?”

 “When did your child start walking?”

 “When did your child learn to dress himself?”

 “When did your child start using short sentences?”

Feeding history:

 “Did you breast-feed your child?”

 “When did your child start eating solid food?”

 “How is your child’s appetite?”

 “Does your child have any allergies?”

 “Is your child’s formula fortified with iron?”

 “Are you giving your child pediatric multivitamins?”

Routine pediatric care:

 “Are your child’s immunizations up to date?”

 “When was the date of your child’s last routine checkup?”

 “Has your child had any serious illnesses?”

 “Is your child taking any medications?”

 “Has your child ever been hospitalized?”

Psychiatric history:

 “Tell me about yourself and your future goals.”

 “How long have you been feeling unhappy/sad/anxious/confused?”

 “Do you have any idea what might be causing this?”

 “Would you like to share with me what made you feel this way?”

 “Do you have any friends or family members you can talk to for support?”

 “Has your appetite changed lately?”

 “Has your weight changed recently?”

 “Tell me how you spend your time/day.”

 “Do you have any problems falling asleep/staying asleep/waking up?”

 “Has there been any change in your sleeping habits lately?”

 “Do you enjoy any hobbies?”

 “Do you take interest or pleasure in your daily activities?”

 “Do you have any memory problems?”

 “Do you have difficulty concentrating?”

 “Do you have hope for the future?”

 “Have you ever thought about hurting yourself or others?”

 “Do you think of killing yourself or ending your own life?”

 “Do you have a plan to end your life?”

 “Would you mind telling me about it?”

 “Do you ever see or hear things that others can’t see or hear?”

 “Do you hold beliefs about yourself or the world that other people would find odd?”

 “Do you feel as if other people are trying to harm or control you?”

 “Has anyone in your family ever experienced depression?”

 “Has anyone in your family ever been diagnosed with a mental illness?”

 “Would you like to meet with a counselor to help you with your problem?”

 “Would you like to join a support group?”

 “What do you think makes you feel this way?”

 “Have you lost any interest in your social activities or relationships?”

 “Do you feel hopeless?”

 “Do you feel guilty about anything?”

 “How is your energy level?”

 “Can you still perform your daily functions or activities?”

 “Whom do you live with?”

 “How do they react to your behavior?”

 “Do you have any problems in your job?”

 “How is your performance on your job?”

 “Have you had any recent emotional or financial problems?”

 “Have you had any recent traumatic event in your family?”

Daily activities (for dementia patients):

 “Tell me about your day yesterday.”

 “Do you need any help bathing/getting dressed/feeding yourself?”

 “Do you need any help going to the toilet?”

 “Do you need any help transferring from your bed to the chair?”

 “Do you ever have accidents with your urine or bowel movements?”

 “Do you ever not make it to the toilet on time?”

 “What do you need help with when you eat?”

 “Do you need any help taking your medications/using the telephone/shopping/ preparing food/cleaning your house/doing laundry/getting from place to place/ managing money?”

Abuse:

 “Are you safe at home?”

 “Is there any threat to your personal safety at home or anywhere else?”

 “Does anyone (your husband/wife/parents/boyfriend) treat you in a way that hurts you or threatens to hurt you?”

 “Can you tell me about the bruises on your arm?”



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