NR I509 IMidterm I Study IGuide
Basic and Advanced Interviewing Techniques
I I I I I
Basic Imaximize Ipatient's Icomfort, Iavoid Iunnecessary Ichanges Iin Iposition, Ienhance
Iclinical Iefficiency, Imove Ihead Ito Itoe, Iexamine Ithe Ipatient Ifrom Itheir Iright Iside
Active Ilistening, Iempathic Iresponses, Iguided Iquestioning, Inonverbal Icommunication,
Ivalidation,Ireassurance, Ipartnering, Isummarization, Itransitions, Iempowering Ithe Ipatient
Active IListening- Iclosely Iattending Ito Iwhat Ithe Ipatient Iis Icommunicating, Iconnecting Ito
ItheIpatient’s Iemotional Istate Iand Iusing Iverbal Iand Inonverbal Iskills Ito Iencourage Ithe Ipatient
ItoIexpand Ion Ihis Ior Iher Ifeelings Iand Iconcerns.
Empathic IResponses-the Icapacity Ito Iidentify Iwith Ithe Ipatient Iand Ifeel Ithe Ipatient’s Ipain Ias
IyourIown, Ithen Irespond Iin Ia Isupportive Imanner.
Guided IQuestioning- Ishow Iyour Isustained Iinterest Iin Ithe Ipatient’s Ifeelings Iand Ideepest
Idisclosures Iand Iallows Ithe Iinterviewer Ito Ifacilitate Ifull Icommunication, Iin Ithe Ipatient’s IownIwords,
Iwithout Iinterruption.
Non-verbal- Iincludes Ieye Icontact, Ifacial Iexpression, Iposture, Ihead Iposition Iand Imovement
IsuchIas Ishaking Ior Inodding, Iinterpersonal Idistance, Iand Iplacement Iof Ithe Iarms Ior Ilegs-crossed,
Ineutral, Ior Iopen.
Validation- Ihelps Ito Iaffirm Ithe Ilegitimacy Iof Ithe Ipatient’s Iemotional Iexperience.
IReassurance- Ian Iappropriate Iway Ito Ihelp Ithe Ipatient Ifeel Ithat Iproblems Ihave Ibeen
IfullyIunderstood Iand Iare Ibeing Iaddressed.
Partnering- Ibuilding Irapport Iwith Ipatients, Iexpress Iyour Icommitment Ito Ian Iongoing
Irelationship.ISummarization- Igiving Ia Icapsule Isummary Iof Ithe Ipatient’s Istory Iduring Ithe Icourse
Iof Ithe Iinterview Ito Icommunicate Ithat Iyou Ihave Ibeen Ilistening Icarefully.
Transitions- Iinform Iyour Ipatient Iwhen Iyou Iare Ichanging Idirections Iduring Ithe Iinterview.
IEmpowering Ithe IPatient- Iempower Ithe Ipatient Ito Iask Iquestions, Iexpress Itheir Iconcerns, Iand
Iprobe Iyour Irecommendations Iin Iorder Ito Iencourage Ithem Ito Iadopt Iyour Iadvice, Imake
IlifestyleIchanges, Ior Itake Imedications Ias Iprescribed.
Advanced: IDetermine Iscope Iof Iassessment: IFocused Ivs. IComprehensive: Ipg5
IComprehensive: IUsed Ifor Ipatients Iyou Iare Iseeing Ifor Ithe Ifirst Itime Iin Ithe Ioffice Ior Ihospital.
IIncludes Iall Ithe Ielements Iof Ithe Ihealth Ihistory Iand Icomplete Iphysical Iexamination. IA Isource
Ifundamental Iand Ipersonalized Iknowledge Iabout Ithe Ipatient, Istrengthens Ithe Iclinician-
patientIrelationship.
● Is Iappropriate Ifor Inew Ipatients Iin Ithe Ioffice Ior Ihospital
● Provides Ifundamental Iand Ipersonalized Iknowledge Iabout
I theIpatient
● Strengthens Ithe Iclinician–patient Irelationship
● I Helps Iidentify Ior Irule Iout Iphysical Icauses Irelated Ito
IpatientIconcerns
● Provides Ia Ibaseline I for I future I assessments
, ● Creates Ia Iplatform Ifor Ihealth Ipromotion Ithrough
IeducationIand Icounseling
● Develops Iproficiency Iin Ithe Iessential Iskills Iof
I physicalIexamination
Flexible IFocused Ior Iproblem-oriented Iassessment: IFor Ipatients Iyou Iknow Iwell Ireturning Ifor
Iroutine Icare, Ior Ithose Iwith Ispecific I“urgent Icare” Iconcerns Ilike Isore Ithroat Ior Iknee Ipain. IYou Iwill
Iadjust Ithe Iscope Iof Iyour Ihistory Iand Iphysical Iexamination Ito Ithe Isituation Iat Ihand, Ikeeping
Iseveral Ifactors Iin Imind: Ithe Imagnitude Iand Iseverity Iof Ithe Ipatient’s Iproblems; Ithe Ineed Ifor
Ithoroughness; Ithe Iclinical Isetting—inpatient Ior Ioutpatient, Iprimary Ior Isubspecialty Icare; Iand
ItheItime Iavailable.
● Is Iappropriate Ifor Iestablished Ipatients, Iespecially
IduringIroutine Ior Iurgent Icare Ivisits
● Addresses I focused I concerns I or I symptoms
● Assesses I symptoms I restricted I to Ia I specific I body Isystem
● Applies Iexamination Imethods Irelevant Ito Iassessing Ithe
Iconcern Ior Iproblem Ias Ithoroughly Iand Icarefully Ias Ipossible
Tangential Ilighting: IJVD, Ithyroid Igland, Iand Iapical Iimpulse Iof Iheart.
Components of the Health History Jenna/Ashley
I I I I I
Initial Iinformation
Identifying Idata Iand Isource Iof Ithe Ihistory; Ireliability
IIdentifying Idata- Iage, Igender, Ioccupation, Imarital Istatus
Source Iof Ihistory- Iusually Ipatient. ICan Ibe: Ia Ifamily Imember Ior Ifriend, Iletter Iof Ireferral, Ior
IclinicalIrecord.
Reliability- IVaries Iaccording Ito Ithe Ipatient’s Imemory, Itrust, Iand Imood.IChief
IComplaint
Chief IComplaint- IMake Ievery Iattempt Ito Iquote Ithe Ipatient’s Iown
Iwords.IPresent IIllness
Complete, Iclear Iand Ichronological Idescription Iof Ithe Iproblem Iprompting Ithe Ipatient
IvisitIOnset, Isetting Iin Iwhich Iit Ioccurred, Imanifestations Iand Iany Itreatments
Should Iinclude I7 Iattributes Iof Ia Isymptom:
● Location
● Quality
● Quantity Ior Iseverity
● Timing, Ionset, Iduration, Ifrequency
● Setting Iin Iwhich Iit Ioccurs
● Aggravating Ior Irelieving Ifactors
● Associated I manifestations
-Differential Idiagnosis Iis Iderived Ifrom Ithe I“pertinent Ipositives” Iand I“pertinent Inegatives”
Iwhen Idoing IReview Iof ISystems Ithat Iare Irelevant Ito Ithe Ichief Icomplaint. IA Ilist Iof Ipotential
Icauses IforIthe Ipatients Iproblems.
-Present Iillness Ishould Ireveal Ipatient’s Iresponses Ito Ihis Ior Iher Isymptoms Iand Iwhat Ieffect
IthisIhas Ion Itheir Ilife.
,-Each Isymptom Ineeds Iits Iown Iparagraph Iand Ia Ifull Idescription.
-Medication Ishould Ibe Idocumented, Iname, Idose, Iroute, Iand Ifrequency. IHome Iremedies, Inon-
Iprescriptions Idrugs, Ivitamins, Iminerals Ior Iherbal Isupplements, Ioral Icontraceptives, Ior
IborrowedImedications.
-Allergies-foods, Iinsects, Ior Ienvironmental, Iincluding Ispecific Ireaction
I Tobacco Iuse, Iincluding Ithe Itype. IIf Isomeone Ihas Iquit, Inote Ifor Ihow Ilong
-Alcohol Iand Idrug Iuse Ishould Ialways Ibe Iinvestigated Iand Iis Ioften Ipertinent Ito Ithe
IPresentingIIllness.
Past Ihistory
-Childhood IIllness: Imeasles, Irubella, Imumps, Iwhooping Icough, Ichickenpox, Irheumatic
Ifever,Iscarlet Ifever, Iand Ipolio. IAlso Iinclude Iany Ichronic Ichildhood Iillness
-Adult Iillnesses: IProvide Iinformation Iin Ieach Iof Ithe I4 Iareas:
● Medical: Idiabetes, Ihypertension, Ihepatitis, Iasthma Iand IHIV;
Ihospitalizations; Inumber Iand Igender Iof Isexual Ipartners; Iand
IriskItaking Isexual Ipractices.
● Surgical: Idates, Iindications, Iand Itypes Iof Ioperations
● Obstetric/gynecologic: IObstetric Ihistory, Imenstrual
Ihistory,Imethods Iof Icontraception, Iand Isexual Ifunction.
● Psychiatric: IIllness Iand Itime Iframe,
Idiagnoses,Ihospitalizations, Iand Itreatments.
-Health IMaintenance: IFind Iout Iif Ithey Iare Iup Ito Idate Ion Iimmunizations Iand Iscreening
Itests.IReview ITb Itests, Ipap Ismears, Imammograms, Istool Itests Ifor Ioccult Iblood, Icolonoscopy,
Icholesterol Ilevels Ietc..
Family Ihistory
Outlines Ior Idiagrams Iage Iand Ihealth, Ior Iage Iand Icause Iof Ideath, Iof Isiblings, Iparents,
IandIgrandparents
Documents Ipresence Ior Iabsence Iof Ispecific Iillnesses Iin Ifamily, Isuch Ias Ihypertension,
I coronaryIartery Idisease, Ielevated Icholesterol Ilevels, Istroke, Idiabetes, Ithyroid Ior Irenal Idisease,
Iarthritis, Ituberculosis, Iasthma Ior Ilung Idisease, Iheadache, Iseizure Idisorder, Imental Iillness,
Isuicide, Isubstance Iabuse, Iand Iallergies, Iand Isymptoms Ireported Iby Ipatient.
Ask Iabout Ihistory Iof Ibreast, Iovarian, Icolon, Ior Iprostate
IcancerIAsk Iabout IGenetically Itransmitted Idiseases
Personal Ior Isocial Ihistory
Describes Ieducational Ilevel, Ioccupation, Ifamily Iof Iorigin, Icurrent Ihousehold, Ipersonal
Iinterests,Iand Ilifestyle
, Capture Ithe Ipatients Ipersonality Iand Iinterests, Isources Iof Isupport, Icoping Istyle, Istrengths,
IandIconcerns
Includes Ilifestyle Ihabits Ithat Ipromote Ihealth Ior Icreate Irisk, Isuch Ias Iexercise Iand Idiet,
IsafetyImeasures, Isexual Ipractices, Iand Iuse Iof Ialcohol, Idrugs, Iand Itobacco
Expanded Ipersonal Iand Isocial Ihistory Ipersonalizes Iyour Irelationship Iwith Ithe Ipatient Iand
IbuildsIa Irapport
Review Iof Isystems Ipg I11-13
Documents Ipresence Ior Iabsence Iof Icommon Isymptoms Irelated Ito Ieach Iof Ithe Imajor
IbodyIsystems
Understanding Iand Iusing IReview Iof ISystems Iquestions Imay Iseem Ichallenging Iat Ifirst. IThese
I“yes-no” Iquestions Ishould Icome Iat Ithe Iend Iof Ithe Iinter- Iview. IThink Iabout Iasking Ia Iseries Iof
Iquestions Igoing Ifrom I“head Ito Itoe.” IIt Iis Ihelpful Ito Iprepare Ithe Ipatient Iby Isaying, I“The Inext IpartIof
Ithe Ihistory Imay Ifeel Ilike Ia Ihundred Iquestions, Ibut Iit Iis Iimportant Ito Imake Isure Iwe Ihave
InotImissed Ianything.”
Most IReview Iof ISystems Iquestions Ipertain Ito Isymptoms, Ibut Ion Ioccasion, Isome
I cliniciansIinclude Idiseases Ilike Ipneumonia Ior Ituberculosis.
Note Ithat Ias Iyou Ielicit Ithe IPresent IIllness, Iyou Imay Ialso Idraw Ion IReview Iof ISystems
IquestionsIrelated Ito Isystem(s) Irelevant Ito Ithe IChief IComplaint Ito Iestablish I“pertinent Ipositives
Iand Inegatives” Ithat Ihelp Iclarify Ithe Idiagnosis.
For Iexample, Iafter Ia Ifull Idescription Iof Ichest Ipain, Iyou Imay Iask, I“Do Iyou Ihave Iany Ihistory Iof
Ihigh Iblood Ipressure I. I. I. Ipalpitations I. I. I. Ishortness Iof Ibreath I. I. I. Iswelling Iin Iyour Iankles Ior Ifeet?”Ior
Ieven Imove Ito Iquestions Ifrom Ithe IRespiratory Ior IGastrointestinal IReview Iof ISystems
The IReview Iof ISystems Iquestions Imay Iuncover Iproblems Ithat Ithe Ipatient Ihas Ioverlooked,
Iparticularly Iin Iareas Iunrelated Ito Ithe IPresent IIllness. ISignificant Ihealth Ievents, Isuch Ias
IpastIsurgery, Ihospitalization Ifor Ia Imajor Iprior Iillness, Ior Ia Iparent’s Ideath, Irequire Ifull
Iexploration. IKeep Iyour Itechnique Iflexible.
Remember Ithat Imajor Ihealth Ievents Idiscovered Iduring Ithe IReview Iof ISystems Ishould Ibe
ImovedIto Ithe IPresent IIllness I Past IHistory Iin Iyour Iwrite-up.
Some Iexperienced Iclinicians Ido Ithe IReview Iof ISystems Iduring Ithe Iphysical Iexamination,
I askingIabout Ithe Iears, Ifor Iexample, Ias Ithey Iexamine Ithem. IIf Ithe Ipatient Ihas Ionly Ia Ifew
Isymptoms, IthisIcombination Ican Ibe Iefficient. IIf Ithere Iare Imultiple Isymptoms, Ihowever, Ithis Ican
Idisrupt Ithe Iflow Iof Iboth Ithe Ihistory Iand Iexamination, Iand Inecessary Inote Itaking Ibecomes
Iawkward
The IReview Iof ISystems: IPg. I12-13 IROS IChart ICopied Ifrom Ionline Ibook
General: IUsual Iweight, Irecent Iweight Ichange, Iclothing Ithat Ifits Imore Itightly Ior
Iloosely Ithan Ibefore; Iweakness, Ifatigue, Ior Ifever. ISkin: IRashes, Ilumps, Isores, Iitching,
Idryness,Ichanges Iin Icolor; Ichanges Iin Ihair Ior Inails; Ichanges Iin Isize Ior Icolor Iof Imoles.
Head, IEyes, IEars, INose, IThroat I(HEENT): IHead: IHeadache, Ihead Iinjury, Idizziness,
Ilightheadedness. IEyes: IVision, Iglasses Ior Icontact Ilenses, Ilast Iexamination, Ipain, Iredness,
Iexcessive Itearing, Idouble Ior Iblurred Ivision, Ispots, Ispecks, Iflashing Ilights, Iglaucoma,
Icataracts.IEars: IHearing, Itinnitus, Ivertigo, Iearaches, Iinfection, Idischarge. IIf Ihearing Iis
Idecreased, Iuse Ior Inonuse Iof Ihearing Iaids. INose Iand Isinuses: IFrequent Icolds, Inasal Istuffiness,
Idischarge, Ior
Basic and Advanced Interviewing Techniques
I I I I I
Basic Imaximize Ipatient's Icomfort, Iavoid Iunnecessary Ichanges Iin Iposition, Ienhance
Iclinical Iefficiency, Imove Ihead Ito Itoe, Iexamine Ithe Ipatient Ifrom Itheir Iright Iside
Active Ilistening, Iempathic Iresponses, Iguided Iquestioning, Inonverbal Icommunication,
Ivalidation,Ireassurance, Ipartnering, Isummarization, Itransitions, Iempowering Ithe Ipatient
Active IListening- Iclosely Iattending Ito Iwhat Ithe Ipatient Iis Icommunicating, Iconnecting Ito
ItheIpatient’s Iemotional Istate Iand Iusing Iverbal Iand Inonverbal Iskills Ito Iencourage Ithe Ipatient
ItoIexpand Ion Ihis Ior Iher Ifeelings Iand Iconcerns.
Empathic IResponses-the Icapacity Ito Iidentify Iwith Ithe Ipatient Iand Ifeel Ithe Ipatient’s Ipain Ias
IyourIown, Ithen Irespond Iin Ia Isupportive Imanner.
Guided IQuestioning- Ishow Iyour Isustained Iinterest Iin Ithe Ipatient’s Ifeelings Iand Ideepest
Idisclosures Iand Iallows Ithe Iinterviewer Ito Ifacilitate Ifull Icommunication, Iin Ithe Ipatient’s IownIwords,
Iwithout Iinterruption.
Non-verbal- Iincludes Ieye Icontact, Ifacial Iexpression, Iposture, Ihead Iposition Iand Imovement
IsuchIas Ishaking Ior Inodding, Iinterpersonal Idistance, Iand Iplacement Iof Ithe Iarms Ior Ilegs-crossed,
Ineutral, Ior Iopen.
Validation- Ihelps Ito Iaffirm Ithe Ilegitimacy Iof Ithe Ipatient’s Iemotional Iexperience.
IReassurance- Ian Iappropriate Iway Ito Ihelp Ithe Ipatient Ifeel Ithat Iproblems Ihave Ibeen
IfullyIunderstood Iand Iare Ibeing Iaddressed.
Partnering- Ibuilding Irapport Iwith Ipatients, Iexpress Iyour Icommitment Ito Ian Iongoing
Irelationship.ISummarization- Igiving Ia Icapsule Isummary Iof Ithe Ipatient’s Istory Iduring Ithe Icourse
Iof Ithe Iinterview Ito Icommunicate Ithat Iyou Ihave Ibeen Ilistening Icarefully.
Transitions- Iinform Iyour Ipatient Iwhen Iyou Iare Ichanging Idirections Iduring Ithe Iinterview.
IEmpowering Ithe IPatient- Iempower Ithe Ipatient Ito Iask Iquestions, Iexpress Itheir Iconcerns, Iand
Iprobe Iyour Irecommendations Iin Iorder Ito Iencourage Ithem Ito Iadopt Iyour Iadvice, Imake
IlifestyleIchanges, Ior Itake Imedications Ias Iprescribed.
Advanced: IDetermine Iscope Iof Iassessment: IFocused Ivs. IComprehensive: Ipg5
IComprehensive: IUsed Ifor Ipatients Iyou Iare Iseeing Ifor Ithe Ifirst Itime Iin Ithe Ioffice Ior Ihospital.
IIncludes Iall Ithe Ielements Iof Ithe Ihealth Ihistory Iand Icomplete Iphysical Iexamination. IA Isource
Ifundamental Iand Ipersonalized Iknowledge Iabout Ithe Ipatient, Istrengthens Ithe Iclinician-
patientIrelationship.
● Is Iappropriate Ifor Inew Ipatients Iin Ithe Ioffice Ior Ihospital
● Provides Ifundamental Iand Ipersonalized Iknowledge Iabout
I theIpatient
● Strengthens Ithe Iclinician–patient Irelationship
● I Helps Iidentify Ior Irule Iout Iphysical Icauses Irelated Ito
IpatientIconcerns
● Provides Ia Ibaseline I for I future I assessments
, ● Creates Ia Iplatform Ifor Ihealth Ipromotion Ithrough
IeducationIand Icounseling
● Develops Iproficiency Iin Ithe Iessential Iskills Iof
I physicalIexamination
Flexible IFocused Ior Iproblem-oriented Iassessment: IFor Ipatients Iyou Iknow Iwell Ireturning Ifor
Iroutine Icare, Ior Ithose Iwith Ispecific I“urgent Icare” Iconcerns Ilike Isore Ithroat Ior Iknee Ipain. IYou Iwill
Iadjust Ithe Iscope Iof Iyour Ihistory Iand Iphysical Iexamination Ito Ithe Isituation Iat Ihand, Ikeeping
Iseveral Ifactors Iin Imind: Ithe Imagnitude Iand Iseverity Iof Ithe Ipatient’s Iproblems; Ithe Ineed Ifor
Ithoroughness; Ithe Iclinical Isetting—inpatient Ior Ioutpatient, Iprimary Ior Isubspecialty Icare; Iand
ItheItime Iavailable.
● Is Iappropriate Ifor Iestablished Ipatients, Iespecially
IduringIroutine Ior Iurgent Icare Ivisits
● Addresses I focused I concerns I or I symptoms
● Assesses I symptoms I restricted I to Ia I specific I body Isystem
● Applies Iexamination Imethods Irelevant Ito Iassessing Ithe
Iconcern Ior Iproblem Ias Ithoroughly Iand Icarefully Ias Ipossible
Tangential Ilighting: IJVD, Ithyroid Igland, Iand Iapical Iimpulse Iof Iheart.
Components of the Health History Jenna/Ashley
I I I I I
Initial Iinformation
Identifying Idata Iand Isource Iof Ithe Ihistory; Ireliability
IIdentifying Idata- Iage, Igender, Ioccupation, Imarital Istatus
Source Iof Ihistory- Iusually Ipatient. ICan Ibe: Ia Ifamily Imember Ior Ifriend, Iletter Iof Ireferral, Ior
IclinicalIrecord.
Reliability- IVaries Iaccording Ito Ithe Ipatient’s Imemory, Itrust, Iand Imood.IChief
IComplaint
Chief IComplaint- IMake Ievery Iattempt Ito Iquote Ithe Ipatient’s Iown
Iwords.IPresent IIllness
Complete, Iclear Iand Ichronological Idescription Iof Ithe Iproblem Iprompting Ithe Ipatient
IvisitIOnset, Isetting Iin Iwhich Iit Ioccurred, Imanifestations Iand Iany Itreatments
Should Iinclude I7 Iattributes Iof Ia Isymptom:
● Location
● Quality
● Quantity Ior Iseverity
● Timing, Ionset, Iduration, Ifrequency
● Setting Iin Iwhich Iit Ioccurs
● Aggravating Ior Irelieving Ifactors
● Associated I manifestations
-Differential Idiagnosis Iis Iderived Ifrom Ithe I“pertinent Ipositives” Iand I“pertinent Inegatives”
Iwhen Idoing IReview Iof ISystems Ithat Iare Irelevant Ito Ithe Ichief Icomplaint. IA Ilist Iof Ipotential
Icauses IforIthe Ipatients Iproblems.
-Present Iillness Ishould Ireveal Ipatient’s Iresponses Ito Ihis Ior Iher Isymptoms Iand Iwhat Ieffect
IthisIhas Ion Itheir Ilife.
,-Each Isymptom Ineeds Iits Iown Iparagraph Iand Ia Ifull Idescription.
-Medication Ishould Ibe Idocumented, Iname, Idose, Iroute, Iand Ifrequency. IHome Iremedies, Inon-
Iprescriptions Idrugs, Ivitamins, Iminerals Ior Iherbal Isupplements, Ioral Icontraceptives, Ior
IborrowedImedications.
-Allergies-foods, Iinsects, Ior Ienvironmental, Iincluding Ispecific Ireaction
I Tobacco Iuse, Iincluding Ithe Itype. IIf Isomeone Ihas Iquit, Inote Ifor Ihow Ilong
-Alcohol Iand Idrug Iuse Ishould Ialways Ibe Iinvestigated Iand Iis Ioften Ipertinent Ito Ithe
IPresentingIIllness.
Past Ihistory
-Childhood IIllness: Imeasles, Irubella, Imumps, Iwhooping Icough, Ichickenpox, Irheumatic
Ifever,Iscarlet Ifever, Iand Ipolio. IAlso Iinclude Iany Ichronic Ichildhood Iillness
-Adult Iillnesses: IProvide Iinformation Iin Ieach Iof Ithe I4 Iareas:
● Medical: Idiabetes, Ihypertension, Ihepatitis, Iasthma Iand IHIV;
Ihospitalizations; Inumber Iand Igender Iof Isexual Ipartners; Iand
IriskItaking Isexual Ipractices.
● Surgical: Idates, Iindications, Iand Itypes Iof Ioperations
● Obstetric/gynecologic: IObstetric Ihistory, Imenstrual
Ihistory,Imethods Iof Icontraception, Iand Isexual Ifunction.
● Psychiatric: IIllness Iand Itime Iframe,
Idiagnoses,Ihospitalizations, Iand Itreatments.
-Health IMaintenance: IFind Iout Iif Ithey Iare Iup Ito Idate Ion Iimmunizations Iand Iscreening
Itests.IReview ITb Itests, Ipap Ismears, Imammograms, Istool Itests Ifor Ioccult Iblood, Icolonoscopy,
Icholesterol Ilevels Ietc..
Family Ihistory
Outlines Ior Idiagrams Iage Iand Ihealth, Ior Iage Iand Icause Iof Ideath, Iof Isiblings, Iparents,
IandIgrandparents
Documents Ipresence Ior Iabsence Iof Ispecific Iillnesses Iin Ifamily, Isuch Ias Ihypertension,
I coronaryIartery Idisease, Ielevated Icholesterol Ilevels, Istroke, Idiabetes, Ithyroid Ior Irenal Idisease,
Iarthritis, Ituberculosis, Iasthma Ior Ilung Idisease, Iheadache, Iseizure Idisorder, Imental Iillness,
Isuicide, Isubstance Iabuse, Iand Iallergies, Iand Isymptoms Ireported Iby Ipatient.
Ask Iabout Ihistory Iof Ibreast, Iovarian, Icolon, Ior Iprostate
IcancerIAsk Iabout IGenetically Itransmitted Idiseases
Personal Ior Isocial Ihistory
Describes Ieducational Ilevel, Ioccupation, Ifamily Iof Iorigin, Icurrent Ihousehold, Ipersonal
Iinterests,Iand Ilifestyle
, Capture Ithe Ipatients Ipersonality Iand Iinterests, Isources Iof Isupport, Icoping Istyle, Istrengths,
IandIconcerns
Includes Ilifestyle Ihabits Ithat Ipromote Ihealth Ior Icreate Irisk, Isuch Ias Iexercise Iand Idiet,
IsafetyImeasures, Isexual Ipractices, Iand Iuse Iof Ialcohol, Idrugs, Iand Itobacco
Expanded Ipersonal Iand Isocial Ihistory Ipersonalizes Iyour Irelationship Iwith Ithe Ipatient Iand
IbuildsIa Irapport
Review Iof Isystems Ipg I11-13
Documents Ipresence Ior Iabsence Iof Icommon Isymptoms Irelated Ito Ieach Iof Ithe Imajor
IbodyIsystems
Understanding Iand Iusing IReview Iof ISystems Iquestions Imay Iseem Ichallenging Iat Ifirst. IThese
I“yes-no” Iquestions Ishould Icome Iat Ithe Iend Iof Ithe Iinter- Iview. IThink Iabout Iasking Ia Iseries Iof
Iquestions Igoing Ifrom I“head Ito Itoe.” IIt Iis Ihelpful Ito Iprepare Ithe Ipatient Iby Isaying, I“The Inext IpartIof
Ithe Ihistory Imay Ifeel Ilike Ia Ihundred Iquestions, Ibut Iit Iis Iimportant Ito Imake Isure Iwe Ihave
InotImissed Ianything.”
Most IReview Iof ISystems Iquestions Ipertain Ito Isymptoms, Ibut Ion Ioccasion, Isome
I cliniciansIinclude Idiseases Ilike Ipneumonia Ior Ituberculosis.
Note Ithat Ias Iyou Ielicit Ithe IPresent IIllness, Iyou Imay Ialso Idraw Ion IReview Iof ISystems
IquestionsIrelated Ito Isystem(s) Irelevant Ito Ithe IChief IComplaint Ito Iestablish I“pertinent Ipositives
Iand Inegatives” Ithat Ihelp Iclarify Ithe Idiagnosis.
For Iexample, Iafter Ia Ifull Idescription Iof Ichest Ipain, Iyou Imay Iask, I“Do Iyou Ihave Iany Ihistory Iof
Ihigh Iblood Ipressure I. I. I. Ipalpitations I. I. I. Ishortness Iof Ibreath I. I. I. Iswelling Iin Iyour Iankles Ior Ifeet?”Ior
Ieven Imove Ito Iquestions Ifrom Ithe IRespiratory Ior IGastrointestinal IReview Iof ISystems
The IReview Iof ISystems Iquestions Imay Iuncover Iproblems Ithat Ithe Ipatient Ihas Ioverlooked,
Iparticularly Iin Iareas Iunrelated Ito Ithe IPresent IIllness. ISignificant Ihealth Ievents, Isuch Ias
IpastIsurgery, Ihospitalization Ifor Ia Imajor Iprior Iillness, Ior Ia Iparent’s Ideath, Irequire Ifull
Iexploration. IKeep Iyour Itechnique Iflexible.
Remember Ithat Imajor Ihealth Ievents Idiscovered Iduring Ithe IReview Iof ISystems Ishould Ibe
ImovedIto Ithe IPresent IIllness I Past IHistory Iin Iyour Iwrite-up.
Some Iexperienced Iclinicians Ido Ithe IReview Iof ISystems Iduring Ithe Iphysical Iexamination,
I askingIabout Ithe Iears, Ifor Iexample, Ias Ithey Iexamine Ithem. IIf Ithe Ipatient Ihas Ionly Ia Ifew
Isymptoms, IthisIcombination Ican Ibe Iefficient. IIf Ithere Iare Imultiple Isymptoms, Ihowever, Ithis Ican
Idisrupt Ithe Iflow Iof Iboth Ithe Ihistory Iand Iexamination, Iand Inecessary Inote Itaking Ibecomes
Iawkward
The IReview Iof ISystems: IPg. I12-13 IROS IChart ICopied Ifrom Ionline Ibook
General: IUsual Iweight, Irecent Iweight Ichange, Iclothing Ithat Ifits Imore Itightly Ior
Iloosely Ithan Ibefore; Iweakness, Ifatigue, Ior Ifever. ISkin: IRashes, Ilumps, Isores, Iitching,
Idryness,Ichanges Iin Icolor; Ichanges Iin Ihair Ior Inails; Ichanges Iin Isize Ior Icolor Iof Imoles.
Head, IEyes, IEars, INose, IThroat I(HEENT): IHead: IHeadache, Ihead Iinjury, Idizziness,
Ilightheadedness. IEyes: IVision, Iglasses Ior Icontact Ilenses, Ilast Iexamination, Ipain, Iredness,
Iexcessive Itearing, Idouble Ior Iblurred Ivision, Ispots, Ispecks, Iflashing Ilights, Iglaucoma,
Icataracts.IEars: IHearing, Itinnitus, Ivertigo, Iearaches, Iinfection, Idischarge. IIf Ihearing Iis
Idecreased, Iuse Ior Inonuse Iof Ihearing Iaids. INose Iand Isinuses: IFrequent Icolds, Inasal Istuffiness,
Idischarge, Ior
