Clinical Interview and Medical Consultation Guide
Practical guide for conducting a doctor-patient interview, focusing on gathering personal information, chief complaints, history of present illness, and identifying symptoms. Includes images to aid understanding.
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Medical Science Faculty of Sagua la Grande, Villa Clara Subject: English VII and VIII Professors MSc.Julian Cairo Molinet, Assistant professor BA. Miguel S nchez G mez, Assistant professor
Doctor-Patient Interview Objective: To make a doctor-patient interview putting into practice the clinical method
Getting Personal Information ( Social History) What s your name? Tell me your name, please. How old are you? What s your age? What s your date of birth? When were you born? What s your job / occupation? What sort of work do you do?
Getting Personal Information ( Social History) .What do you do for a living? .Where do you work? .What s your marital status? /.Are you married or single? .Do you live alone? .Who lives with you? .Do you have any children? .How many children do you have? .Where do you live? / What s your address? .Who is your next of kin?
Chief Complaint What is the main problem you wanted to see me about? What brings you to the clinic today? What is your number one complaint? What seems to be the trouble?
History of Present Illness When did it begin? Onset of the problem How long have you had it? When did you first notice it?
loss of appetite/chest pain/palpitations or shortness of breath/ headache/ cloudy or confused vision/ ringing in the ears/ nose bleeding ? Have you had Have you been troubled with shortness of breath? headaches? sore throat? that your vision is any worse lately? burning on urination? pressure or tightness in your chest? abdominal pain? nausea and vomiting? wheezing when you breathe? Have you noticed Symptoms Have you . coughed up blood? swelling of your ankles? trouble with your vision? difficulty urinating? trouble walking? fainting spell? dizzy spells? pins and needle sensation? Are you having any/Tell me if you have ever experienced Are you (or have you been) short of breath? Does walking or climbing stairs make you short of breath? Have you been awakened from sleep with breathlessness or cough?
Medication Do you take/are you taking any medication / contraceptive pill? What is the dose and frequency? Have you taken any medication for this problem? Have you ever received medical care? Was the care continuous or episodic? Are you allergic to any medication?
Previous History had this problem before? been treated for something like this? been hospitalized? had high blood pressure? Have you ever had a heart trouble? had a heart murmur? had rheumatic or scarlet fever as a child? had joint pain for which you were placed at bed rest? had angina pectoris or a heart attack? undergone any procedures, x-rays, CT scans, MRIs or other special testing?
Family History Has anyone in your family ever suffered from diabetes, heart diseases? Has any of your blood relatives had a heart attack/ high blood pressure/ diabetes/ high cholesterol in blood/ any other chronic disease? Is there any history of hypertension in your family? Has anyone in your family been sick recently?
Habits Do you smoke or drink? How long have you been drinking? How much do you usually drink? Have you ever smoked cigarettes? How many packs / cigarettes per day and for how many years? If you quit, when did this occur? Do you drink alcohol? How much per day and what type of drink? How much alcohol do you consume over a week or month? Do you drink coffee / tea?; How many cups a day do you drink?
Asking about Pain Site Where is it? Where exactly is your pain? Can you please, show me where the pain is? Time of onset When did the pain begin? When did you first notice this? What were you doing when you had the pain? How long ago did it start? Type of onset Did it start suddenly or come on gradually? How long has this been going on? How long does the pain last? How long have you had it? Duration
Asking about Pain Does the pain move? Radiation Does the pain go anywhere else? Does it stay in one place or does it move? Where does it go/move? Frequency How often do you get the pain? How often do you have it?
Character / Severity What s the pain like? Can you describe your pain? What kind of pain is it? How bad is the pain? Is the pain on and off? Is it a nagging pain? Is it localized? /diffuse? Does it come and go? Is it dull or sharp? s it stabbing/ piercing/ knife-like/oppressive/ burning/ throbbing/ cramping/? Is the pain mild/ bad/ severe/ terrible /awful/ agonizing/ excruciating? Do you have to stop what you are doing?
Has the pain changed in any way? Is it getting better or worse? Progress When do you get the pain? Do you get it at any special times? Does it come on before or after meals? Times of occurrence Have you noticed anything that brings it on? What brings it on? Does it come on before or after meals? /when you walk uphill? /when you eat fatty foods? Precipitating factors
What makes it worse? Aggravating factors Does lying down/sitting up/ drinking milk relieve it? Relieving factors Any other aches and pains? Dou you also have (vomit)? Are there any other problems Accompanying symptoms
