Chapter 12 Key Terms: History Taking

Question 1

Chief complaint

Answer 1

Primary medical problem as defined by the patient; important, because it focuses the clinical history toward the single most important issue.

Question 2

Chronology

Answer 2

Time element of the history, usually including the onset, duration, frequency, and course of the symptoms.

Question 3

Clinical history

Answer 3

Information available regarding a patient’s condition; traditionally comprises data on localization, quality, quantity, chronology, setting, aggravating or alleviating factors, and associated manifestations.

Question 4

Leading questions

Answer 4

Undesirable method of questioning; provides information that may direct answers toward a suggested symptom or complaint.

Question 5

Localization

Answer 5

Determination of a precise area, usually through gentle palpation or careful wording of questions.

Question 6

Objective

Answer 6

Perceptible to the external senses.

Question 7

Quality

Answer 7

Description of the character of the symptoms -for example, the color, quality, and consistency of blood or other body, substances; size or number of lumps or lesions; frequency of urination, or coughing; or character of pain. 

Question 8

Subjective

Answer 8

Pertaining to or perceived only by the affected individual; not perceptible to the senses.

Question 9

Severity

Answer 9

The severity of a condition describes the intensity, quantity, or extent of the problem.

Question 10

Onset

Answer 10

Describing the onset of the complaint involves the patient explaining what they were doing, when the illness or condition began.

Question 11

Aggravating or Alleviating Factors

Answer 11

The circumstances that produce the problem or intensify it should be well defined, including anything that aggravates, alleviates, or otherwise modifies it.

Question 12

Associated Manifestations

Answer 12

It may be necessary to find out whether other symptoms accompany the chief complaint in order to determine whether all of the symptoms relate to the chief complaint or are related to a separate condition.

Question 13

Questioning Skills-Techniques

Answer 13

Open-ended questions: None directed, non-leading, let the patient tell the story.

Facilitation: Nod, or say, “yes, ok, go on…” encourages elaboration.

Silence: To give the patient time to remember, facilitates accuracy and elaboration.

Probing questions: To focus the interview, provide more detail.

Repetition: Rewording, clarifies information.

Summarization: Condensing, verifies accuracy.

Question 14

Localization
Chronology
Quality
Severity
Onset
Aggravating or Alleviating Factors
Associated Manifestations

Answer 14

Sacred Seven: