The doctor may also learn more about the illness from the way the patient tells the story than from the story itself.

James B. Herrick, MD

In the beginning of the interview, you used the first two patient-centered steps to welcome the patient (Step 1) and set the agenda for the visit (Step 2). You then obtained the first portion of the history of present illness (HPI) by eliciting the patient’s unique description of her or his chief concern and its personal and emotional contexts (Steps 3 and 4). In Step 5, you informed the patient of the transition to the middle of the interview.

The data you collected in the beginning of the interview, while essential, are rarely complete. In the middle of the interview, you will gather more detailed information on the patient’s HPI and other active problems (OAP). You will also ask about other symptoms, the patient’s life and medical history to help you make a diagnosis, identify medical issues other than the chief concern, assess for disease risk, and come to know the patient better. This additional information falls under the headings of past medical history (PMH), social history (SH), family history (FH), and review of systems (ROS). We will cover each of these in detail in Chapter 5.

In the middle of the interview, you will be more directive, guiding the topics discussed by using the clinician-centered interviewing skills as contrasted with the patient-centered interviewing skills you used in the beginning of the interview. Clinician-centered skills, such as “coning-down”—following open-ended questions with closed-ended ones (see Chapter 2)—help you to clarify and explore details of the patient’s symptoms in order to test hypotheses and make a diagnosis, as well as to efficiently gather the large amount of data required. Even though you will be asking lists of clinician-centered questions, it is important to remain alert to the patient’s emotional state and any verbal or nonverbal cues of emotion, and respond with emotion-seeking and empathy skills (NURS) as needed.

Your first goal in the middle of the interview is to have as complete and precise a characterization as possible of the patient’s symptom story. To do this, you will use symptom-defining skills. Just as you learned facilitating skills before conducting the beginning of the interview, symptom-defining skills will help you perform the middle of the interview.

But first, what is a symptom? Generally speaking, a symptom is an indicator of the existence of something else. In medicine, we take it to mean the subjective evidence of the patient’s underlying problem. In this way, it differs from a sign, which is the objective evidence of a disease or disorder. The patient tells the clinician about a symptom (chest pain, shortness of breath), while the clinician observes a sign on physical examination (tender ribs, heart murmur). You will learn about signs in physical diagnosis courses and on clinical rotations. But, before you can learn all you can about the patient’s symptom, you need to ask: Is the patient describing a symptom?

We introduce the review of systems (Table 4-1) here because it lists and organizes most known symptoms related to underlying diseases. Symptoms are important because they are the language you will use to convert a patient’s concerns to a diagnosis. Table 4-1 lists isolated symptoms according to the body system they are usually associated with, although many occur in more than one system. The review of systems listing is not exhaustive. Preclinical students should not worry if they don’t understand what diagnosis a given symptom points to. You can make a diagnosis only after you have obtained and synthesized enough data about the patient. Medical terminology for some symptoms is noted in parentheses. Remember, though, that you need to remain bilingual, using technical terms with your colleagues and plain lay language with your patients.

Preclinical students should learn all 19 categories of the ROS and know a few symptoms in each. Clinical level students are advised to memorize all symptoms in each category, a necessary prerequisite for effective clinician-centered interviewing.1 You must come to know and understand the language into which you translate the patient’s concerns—it is the basis for diagnosis and treatment.

Sometimes, instead of describing a symptom such as, “My head aches” or “My big toe is hurting,” a patient will say, “I have a migraine,” or “I think it’s the gout.” While the patient may well be correct, she or he is describing a disease in each case, not a symptom. Symptoms are the patient’s area of expertise and no verification is necessary. This is primary data.2 Secondary data are any data apart from a patient’s direct experiences. They are less reliable and more in need of verification. Nonsymptom information obtained from the patient (such as a disease or disorder, treatment, procedure, medication, cause of the problem, or a laboratory test result) are secondary data that differ from the patient’s actual symptoms. While these secondary data are less important,2 they often guide the clinician to areas requiring verification and additional information. We discuss how to incorporate secondary data into the interview in Chapter 5.

Patients often speak in nonmedical terms (Table 4-2) that you must convert to medically meaningful symptom terms. When the patient tells you that she has the “blahs,” a “wrung-out feeling,” or “bad blood,” what does she mean and how is the information to be used medically? If you weren’t able to clarify it in the beginning of the interview using patient-centered facilitating skills, you need to use symptom-defining skills in the middle of the interview: start with a brief open-ended question (focused on the symptom) and follow up with enough closed-ended questions to adequately understand: