Medical Interviewing Flashcards
Introduction
ID: title/rank, sur-name
My name is ENS Moore, I’m a Medical Student and I’ll be interviewing you today. Would you like me to call you Title/rank + Name or First name?
Adjust room to be conducive atmosphere – TV, lights, seating, family members
Confirms Age/DOB
Before e start off can I have you confirm your DOB & last 4 of you SSN. Great, thank you.
Belly button pointing at PT
C/C
So what brings you in today?
Set the agenda
This is what we’re going to do/discuss
Does that sound like a plan? Is there anything else you’d like to include/address/discuss
Hx of CC
How did all of this start?
How long has this been going on?
Start Open ended questions – WWWWWH and get more focused
OPQRSTU
Onset Has it slowly gotten better/worse, all of the sudden, duration & frequency
Provocation What were you doing when it started
Quality
Region, Radiation, Reoccurance
Severity 1-10 scale/faces
Time & Place It started
U What have YOU done for it = Interventions
Does anything make it better/worse? Meds taken
What concerns you most about this (illness, event, disease process, etc)?
What do you think is going on?/ What do you think is the root of all this?
If I could wave a magic stethoscope, what would you make happen with this appointment? Medication/referral/etc.
Medical Hx
Childhood illnesses
Infections/immunizations
Medical diagnoses/infections & dates diagnosed
What have you been to a doctor for/taken
medication/supplement for in the past?
Surgical hx & dates/hospitals/Docs
Allergies
And what happens when they take them?
Medications
Are you taking any prescribed medications?
Any medications not prescribed to you?
Vitamins?
Supplements? - Herbal/dietary
Medications, Vitamins & Herbal Supplements
Dosage/Route
Frequency
Compliant?
Substance Abuse/CAGE questions
Tabacco – dip/ecigarettes/smoking
ETOH
Drugs – Ever used any drugs
Caffeine intake How much caffeine do you consume a day? (coffee/energy drinks/ 5 hour energy)
CAGE: C - Need to CUT down drinking? A - Others ANNOYED by your drinking? G - Ever feel GUILTY about drinking? E - Ever need an EYE-opener?
Family History
Medical & Surgical
Social (11)
1) Occupation What did you do in the _____?
2) Marital Status/Kids
3) Sexual Activity
1) Are you sexually active?
2) How many partners?
3) Male/Female/Both?
4) Do you use protection?
5) Are you satisfied with your current level of sexual
activity?
4) Sleep On average how many hours/night do you sleep?
5) Typical Day What does a typical day look like for you?
6) Diet What is an average day’s meals look like?
7) Exercise How much do you get to exercise?
8) Social Do you feel like you have a good support system of friends, colleagues or family? What do you do for fun?
9) Psych Do you feel safe when you go home? Do you ever feel really down of have the desire to hurt yourself?
10) Death Advanced Directive? Will?
11) Spiritual Do you have a religious preference? How is your spiritual life?
Summary Back to Patient
Summarize to the patient what was discussed
Is there anything else you wanted to discuss or ask me today?
I’m going to go talk with my Attending Physican and be back.
Plan
Reassure/follow up with why they came in – address/reassure their needs
Make sure PT understands the next steps/process
Written form for patient to have/remember
My downfalls
Be comfortable with allowing/using silences Echo patient if stumbling with an issue Make sure understands and medication/diseases/big words Watch leading qestions Watch stacked question Watch physical space No legs crossed/No spinning chair Watch customer service voice
