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Approach To Clinical Interview

The document outlines the approach to clinical interviews, emphasizing their purpose as purposeful communication between a clinician and a patient for diagnosis and management. It details components of the interview process, including the establishment of rapport, history taking, and specific areas to cover such as presenting complaints, medical history, and social factors. Additionally, it highlights the qualities of a good clinical interview, such as good communication skills and confidentiality.

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5 views3 pages

Approach To Clinical Interview

The document outlines the approach to clinical interviews, emphasizing their purpose as purposeful communication between a clinician and a patient for diagnosis and management. It details components of the interview process, including the establishment of rapport, history taking, and specific areas to cover such as presenting complaints, medical history, and social factors. Additionally, it highlights the qualities of a good clinical interview, such as good communication skills and confidentiality.

Uploaded by

eddynathan4lyf
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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APPROACH TO CLINICAL INTERVIEW

What is an interview
- Purposeful verbal communication between two individuals
Types of interview
- Job interview, promotion interview, social interview, clinical interview etc.
Components of an interview
- Introduction
- Opening
- Body
- Closing
Setting – home, office, restaurant, consulting room, medical wards, emergency
wards etc.
Clinical interview
- Also called history taking
- Verbal communication between a clinician and a patient with aim of
making a diagnosis and aiding management of disease condition
- Peculiarities depending on clinical specialty – medicine, psychiatry,
obstetrics and gynaecology
History taking in Internal Medicine
- Components
 Introduction and establishment of rapport
 Biodata
 Presenting complaint
 History of presenting complaint
 Past medical and surgical history
 Drug and allergy history
 Family history
 Social history
 Ideas, concerns and expectations
 Review of systems

Introduction
 Greetings, pleasantries and establishment of rapport
 Biodata – name, age, sex, address, religion, occupation, marital status etc.
Presenting complaint
 Main reason patient is seeking medical attention e.g. leg swelling,
headache, frequent passage of urine, cough etc.
 Duration of presenting complaint
 May be more than one but should not be too many
 What brings you here? how may I be of help to you? etc.
History of presenting complaint
 Detailed information about presenting complaints
 Course
 Cause
 Precipitating, aggravating and relieving factors
 Associations
 Care
Past medical and surgical history
 Relevant ones – DM, HTN, ASTHMA, SCD etc.
 Surgeries and blood transfusion – may be relevant in suspected cases of
viral hepatitis, HIV etc.
Drug and allergy history
 Gives an idea of previous sickness and chronic diseases
 Serves as guide on avoidance of precipitant of allergic reactions
Family history
 Important because some diseases run in families e.g. genetic diseases
Social history
 Alcohol intake, tobacco smoking, multiple sexual partners, living
conditions and environment etc.
Ideas, concerns and expectations
 What does the patient know about the disease condition?
 What are his or her major concerns and worries
 What are his or her expectations
Review of systems
 As relevant to the presenting complaint
 CNS, CVS, Respiratory, gastrointestinal etc.
Summary
 Concise form of the history with all the relevant information
Formulation of diagnosis
 Most likely diagnosis based on information from history
 Most times diagnosis can correctly be made with history alone
Differential diagnosis
 Other possible diagnosis apart from the most likely one
Qualities of good clinical interview
 Comportment
 Good communication skill
 Good time management skill
 Confidentiality
 Safety
 Privacy etc.

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