Table 1.5 Technique of Taking the History of the Present Illness 1. The technique used in taking the history of the present illness varies with the patient, the patient’s problem, and the physician. Allow the patient to talk about her chief symptom. Although this symptom may or may not represent the real problem (depending on subsequent evaluation), it is usually uppermost in the patient’s mind and most often constitutes the basis for the visit to the physician. During the phase of the interview, establish the temporal relation of the chief symptom to the total duration of the illness. Questions such as, “Then up to the time of this symptom, you felt perfectly well?” may elicit other symptoms that may antedate the chief one by days, months, or years. In this manner, the patient may recall the date of the first appearance of illness. Encourage the patient to talk freely and spontaneously about her illness from the established date of onset. Do not interrupt the patient’s account, except for minor promptings such as, “When did it begin?” and “How did it begin?,” which will help in developing chronologic order in the patient’s story. After the patient has furnished her spontaneous account (and before the next phase of the interview), it is useful to employ questions such as, “What other problems have you noticed since you became ill?” The response to this question may reveal other symptoms not yet brought forth in the interview.
Thus, in the first phase of the interview, the physician obtains an account of the symptoms as the patient experiences them, without any bias being introduced by the examiner’s direct questions. Information about the importance of the symptoms to the patient and the patient’s emotional reaction to her symptoms are also revealed.
2. Because all available data regarding the symptoms are usually not elicited by the aforementioned techniques, the initial phase of the interview should be followed by a series of direct and detailed questions concerning the symptoms described by the patient. Place each symptom in its proper chronologic order and then evaluate each in accordance with the directions for analyzing a symptom. In asking direct questions about the details of a symptom, take care not to suggest the nature of the answer. This particularly refers to questions that may be answered “yes” or “no.” If a leading question should be submitted to the patient, the answer must be assessed with great care. Subject the patient to repeated cross-examination until you are completely satisfied that the answer is not given just to oblige you.
Finally, before dismissing the symptom under study, inquire about other symptoms that might reasonably be expected under the clinical circumstances of the case. Symptoms specifically sought but denied are known as negative symptoms. These negative symptoms may confirm or rule out diagnostic possibilities suggested by the positive symptoms.
3.
The data secured by the techniques described in the first two phases of the interview should now suggest several diagnostic possibilities. Test these possibilities further by inquiring about other symptoms or events that may form part of the natural history of the suspected disease or group of diseases.
4.
These techniques may still fail to reveal all symptoms of importance to the present illness, especially if they are remote in time and seemingly unrelated to the present problem. The review of systems may then be of considerable help in bringing forth these data. A positive response from the patient on any item in any of the systems should lead immediately to further detailed questioning.
5.
Throughout that part of the interview concerning the present illness, consider the following factors: a.
The probable cause of each symptom or illness, such as emotional stress, infection, neoplasm. Do not disregard the patient’s statements of causative factors. Consider each statement carefully, and use it as a basis for further investigation. When the symptoms point to a specific infection, direct inquiry to water, milk, and foods eaten; exposure to communicable diseases, animals, or pets; sources of sexually transmitted disease; or residence or travel in the tropics or other regions where infections are known to exist. In each of the above instances, ascertain, if possible, the date of exposure, incubation period, and symptoms of invasion (prodromal symptoms).
b.