Section II Inquisition

Dr. Zhuoren Lu

First Hospital

Xian Jiaotong University

The completeness and accuracy of the information collected by inquisition will contribute to the proper diagnosis, management and treatment of the patient’s problem.

Two major components of medical interviews:

content

technique

Content of the interview

introduction chief complaint history of the present illness past medical history review of systems personal history family history closure

Technique: interview skills Organization Timeline Transitional Statements Pacing of interview Questioning Skill-Type of Question Questioning Skill-Duplication Questioning Skill-Summarizing Questioning Skills-Lack of Medical Terms Questioning Skill-Documentation Rapport-Facilitative Behavior

Appearance and Courtesy Rapport-Facilitative Behavior Rapport-Positive Verbal Reinforcement Patient’s Perspective Impact on Patient and Family and Self Image Support system Patient’s Expectation Patient’s Understanding Admitting Lack of Experience Rapport-Encouragement of Question Closure of the interview

Five basic elements: AEIOU Audition: to listen to your patient cordially and

carefully. Evaluation: to judge the relevance of data you

obtained and importance to the patient’s problem. Inquiry: to obtain complete information, and

clarify and document this information. Observation: to watch the patient’s expression, Understanding: to understand the patient’s major

concern, elicit the patient’s perspective on his illness and explore the patient’s expectation regarding diagnosis and treatment.

Outline of Case Record

1. Biographical data

2. Chief complaint:

3. History of present illness

4. Past history

5. Review of system

6. Personal history

7. Marital history

8. Menstrual history

9. Childbearing (reproductive) history

10. Family history

11. Physical examination

12. Laboratory tests and instrumental examination

13. Summary

14. Primary diagnosis