HISTORY TAKING IN ADULTS WITH CVD OS 213

John C. Añonuevo, MD,FPCP, FPCC, FACC | January 15, 2024 Exam 01-Trans 02

OUTLINE Calgary-Cambridge Model

I. The Medical History III. Content of Medical ● Process of the consultation beginning from initiating the
A. History Taking History session, gathering information, providing structure to the
B. Consultation Models A. Gathering Content consultation, building a relationship, and closing the
II. Calgary-Cambridge B. Comprehensive session
Guide Adult Health History ● Most recent and widely used
A. Initiating the C. Cardiovascular ● Books for reference:
Session Symptoms → Skills for Communicating with Patients
B. Gathering D. Review of → Teaching and Learning Communication Skills in
Information Symptoms Medicine
C. Physical E. Past Medical → Authors: Silverman, Kurtz, & Draper
Examination History
D. Explanation and F. Family History
Planning G. Personal Social
E. Closing the Session History
F. Providing Structure IV. Smith’s
and Building Patient-Centered
Relationship Interview
G. Key Principles of V. Further Learning
Patient Assessment Opportunities
H. Gathering VI. References
Information Figure 1. Calgary-Cambridge Consultation Guide

I. THE MEDICAL HISTORY ● Most practical and patient-centered approach [2026 Trans]
→ Provides structure
Definition of the Medical History → Promotes sharing of agenda
● Structured assessment conducted to generate a → Involves building of relationship
comprehensive picture of a patient’s health and health → Needs to demonstrate empathy
problems II. CALGARY-CAMBRIDGE GUIDE
● Essential in formulating initial diagnosis
● Guides the clinician in doing the physical examination ● Three components:
● With a good history and PE, doctors can get the correct → Preparation
diagnosis 90% of the time → Establishing rapport
→ Identifying the reason for consultation
A. HISTORY TAKING
A. INITIATING THE SESSION
● Asking questions to patients to obtain information that will
aid in the diagnosis General Preparation
● Gathering data that are both objective and subjective ● Reviewing the medical record
● For the purpose of: → For patients that have been seen prior
→ Generating differential diagnosis → For new patients, avoid looking at medical records
→ Evaluating progress following a specific because this will lead to bias
treatment/procedure ● Setting goals for the interview
→ Evaluating change in the patient’s condition or the ● Reviewing clinical behavior and appearance
impact of a specific disease process ● Adjusting the environment
B. CONSULTATION MODELS Prepare Yourself
Helmann’s Folk Model ● Be aware of your personal appearance
● Centers on the patient’s story using empathy to address → A professional approach is important
the patient’s questions ● Complete any outstanding tasks and be in the right frame
→ “What happened to me?” of mind for the consultation
→ “Why has it happened?” ● Clarify, in your mind, the purpose of the conversation
→ “Why has it happened now?” → “Why are you there?”
→ “What should I do about it?” → If delivering bad news, it may change the patient’s
→ “What will happen if I do nothing about it?” world
● Though you may be doing a lot of consultations each day,
Pendleton Model for the patient and their loved ones, it is a unique and
● Introduced the concept of eliciting the patient’s ideas, vital conversation
concerns, and expectations Prepare the Environment
Inner Consultation ● Establish a therapeutic space
● Suggests summarizing throughout the consultation to ● Ensure privacy and avoid interruptions
clarify that the physician’s understanding of the problem is → When possible, put a sign on the door
the same as the patient’s → If at bedside, take necessary steps to respect the
patient’s privacy

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 ● Switch off or turn to silent mode any electronic devices Common Pitfalls of History Taking
● Have a pen, paper, healthcare record, and any necessary ● Providing false reassurance
equipment for the history taking ● Giving unwanted advice
● Check the setting: → “Dapat po hindi ninyo iyan ginawa, ganito po dapat
→ Conducive for the interview ginawa ninyo”
→ Find a chair ● Using authority
○ Do not sit on the bed → “Hindi po pwede, kailangan i-test kita, ‘yun ang
○ Do not stand over the patient assignment ko”
→ ALWAYS consider privacy ● Using ”why” question
Establish Rapport → “Bakit po hindi kayo nagpatingin? Bakit ngayon lang po
● Main components: kayo?”
→ Initial greeting (with a smile) ● Using professional jargons
→ Introductions (full name and role) → Patient won’t understand
○ E.g., Dr. Juan Dela Cruz, a medical student → Refrain from using English (i.e. PGH setting)
→ Seek consent ● Using leading or biased questions
→ Respect the patient ● Talking too much
● Be approachable and friendly → Let the patient talk
● Address the patient with their title and surname and ● Interrupting or changing the subject
preferred form of addressing him/her/them → Let them finish, but keep the discussion directed
● Explain reason/s for interview B. GATHERING INFORMATION
● Remember SOLER ● Most important part of the consultation guide
→ S: Sits square on facing the patient ● Involves exploration of the patient’s problems in order to
→ O: Maintains open body position discover the following:
→ L: Leans slightly forward → Biomedical perspective (Disease)
→ E: Eye contact is maintained → Patient’s perspective (Illness)
→ R: Relaxed (in an appropriate posture) → Background information (Context)
Identifying the Reason for the Consultation ● Disease/Illness Distinction Model acknowledges the
● Identifying why you are there and asking the patient why different, yet complementary perspectives of the clinician
he/she/they are seeking consultations and the patient
● Listen attentively to the opening statement without → Disease: explanation that the clinician brings to the
interruption symptoms
● Acknowledge problems mentioned (i.e. reflecting back) ○ The way that the clinician organizes what he or she
● Write down each problem as it is mentioned learns from the patient that leads to a clinical
● Summarize the problem list back to the patient/reflect diagnosis
back → Illness: how the patient experiences all aspects of the
→ Important to summarize so as not to forget what the disease
patient has previously mentioned ○ Includes the disease’s effects on the relationships,
● Explain your wish to gather information about the problems function, and sense of well-being
in detail and their health in general ● Contents of a comprehensive adult health history:
● Open-ended questions: → Identifying history and source of the history; reliability
→ Best questions to start with in the consultation → Chief complaint/s
→ Always start with an open-ended question → Present illness
→ Take time to listen to the patient’s story → Past medical history
→ Let the patient tell more → Family history
→ “How can I help you?” → Personal and social history
→ “What concerns bring you here today?” → Review of systems
→ “You said you have pain on movement, can you tell me Establishing the Agenda
which movements make your pain worse?” ● What is the reason why the patient sought consultation?
● Close-ended questions: → “Ano po ang pinunta ninyo sa ospital?”
→ Once the patient has completed their narrative, ● Identify the primary cardiac complaint
close-ended questions that clarify and focus on aspects ● Identify other associated complaints or problems
can be used
→ Used toward the end Explore the Patient’s Problems
→ Answerable by yes or no; can also be answered with ● Inviting the patient’s story
specific answers ● Use open-ended questions at the start of the interview
→ “Are you still taking the aspirin your physician ● Close-ended questions may also be used later to clarify
prescribed?” ● Avoid bias in the patient’s story - do not inject new
→ “Is that an accurate summary of your symptoms?” information and do not interrupt
● Leading questions (never used): ● Show that you are listening
→ Questions based on your own assumptions that lead ● Maintain eye contact
the patient to the answer you want to hear should not ● Follow the patient leads
be used at all ● Mention back to the patient significant points of the story
→ “You are not allergic to anything, are you?” ● Periodically summarize
→ “Are your joints painful in the cold weather?” → You can stop the patient and summarize what the
patient patient has relayed to you
→ Clarify if what you said is correct

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Explore the Patient’s Perspective: FIFE ● Clarify plan of care
● Feelings → Final check that the patient agrees and is comfortable
→ Including fears or concerns about the problem with plan
● Ideas about the nature and the cause of the problem ● Discuss options and provide information on action or
→ “Anong opinion niya sa sakit niya?” treatment offered
● Effect of the problem on the patient’s life and Function ● Elicit acceptability of plans and encourage patient to be
● Expectations of the disease, of the clinician, or of health involved in implementing plans
care; often based on prior personal or family experiences ● Therefore, closing the session would include:
→ “Ano po sa palagay ninyo and sakit ninyo?” → Telling the patient that the consultation covered
→ “Ano po sa palagay ninyo ang mangyayari?” everything
→ Checking that the patient has nothing more to add
Expanding and Clarifying the Patient’s Story: Symptom → Summarizing
Analysis → Explaining the next step
● Ask about the following: → Thanking the patient
→ OLD CART F. PROVIDING STRUCTURE AND BUILDING RELATIONSHIP
→ OPQRST
● It is essential to be able to provide structure and build
→ SOCRATES
relationship from the initiation of the session until the
● See Table 2 under III. Content of Medical History - B.
closing
Comprehensive Adult Health History
Providing Structure
C. PHYSICAL EXAMINATION
● Reflect on your approach to the patient ● Making organization overt, clear
● Adjust the lighting and the environment ● Knowing the information needed
● Check your equipment ● Taking notes
● Always make the patient comfortable ● Attending to flow and follow a logical sequence
● Choose the sequence of examination → Address topics in a logical sequence
→ If the consultation digresses, gently redirect
Table 1. Pre-Physical Examination Steps
Building Relationship
W Wash hands
I Introduce yourself ● Appropriate non-verbal behavior
→ Eye contact
Permission/consent sought → Facial expression
P ● “I will be examining you. Please tell me if it is → Proper posture
not okay with you.” → Vocal cues
Expose patient for exam purposes → Tone
E → Physical contact
● Make sure to maintain privacy
● Establishing and sustaining rapport
R Repositioning the patient
→ Accept the patient’s views and feelings without any
D. EXPLANATION AND PLANNING judgment
→ Acknowledge feelings and predicament
→ Be supportive
→ Be sensitive with embarrassing or disturbing topics
● Involving the patient
→ It is encouraged to share thoughts with the patient
→ Explain the rationale for the questions being asked
● Respond to the patient’s needs
→ Acknowledge any discomfort that patient might be
experiencing
→ E.g. If the patient is having difficulty of breathing,
acknowledge and address problem and do not simply
continue history taking

Figure 2. Calgary-Cambridge Guide: The 4th step in this method would be

explanation and planning
● Achieving a shared understanding
→ Relates explanation to the patient’s illness framework
→ What is the next step?
→ What do you think the patient has?
→ What will be done to this patient?
● Planning and shared decision-making
→ Negotiates a mutually acceptable plan
→ Checks with the patient about the plan of action
E. CLOSING THE SESSION
● The final stage which emphasizes:
→ Forward planning
→ Ensuring appropriate point of closure Figure 3. Calgary-Cambridge Model Layout: Detailed with objectives
● Briefly summarize the consultation with the patient

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 G. KEY PRINCIPLES OF PATIENT ASSESSMENT Patient’s Perspective (Illness)
● It is estimated that 80% of diagnoses are based on history ● Ideas and beliefs
taking alone ● Concerns
● Use a systematic approach (five steps) ● Expectations
→ Initiating the session ● Effects on life
→ Gathering information ● Feelings
→ Physical examination Patient’s Perspective (Disease)
→ Explanation and planning
→ Closing the session ● Past Medical History
● Practice infection control techniques ● Drug and Allergy History
● Establish a good rapport with the patient ● Review of Symptoms (ROS)
● Ensure the patient is as comfortable as possible B. COMPREHENSIVE ADULT HEALTH HISTORY[2026 Trans]
● Listen to what the patient is saying
General Data/Identifying Data
● Ensure consent has been gained
● Always maintain privacy and dignity ● Name of patient
● Summarize each stage of the history taking process ● Age
● Involve the patient in the history taking process ● Gender
● Always maintain an objective approach ● Address
● Ensure that the documentation is clear, accurate, and ● Date of Birth
legible ● Religion
● Civil Status
Chief Complaint
● Most important part of history taking
● Main symptoms for consult/admission
→ Why did the patient go to the hospital?
● For symptoms volunteered or elicited, it is important to
qualify them
History of Present Illness
● Amplifies the chief complaint
● Describes how each symptom developed
● Includes patient’s thoughts and feelings about the
illness
● Pulls in relevant portions of the review of systems
→ Pertinent positives and negatives
● May include medications, allergies, and habits of
smoking and alcohol, which are frequently pertinent to
the present illness
→ Belongs to personal and social history but it is pertinent
to the present illness
Figure 4. Summary and Key Principles of Patient Assessment ● Should reveal the patient responses to his or her
H. GATHERING INFORMATION symptoms and what effects the illness has had on the
patient’s life
Process Skills for Exploration of the Patient’s Problems
● “The data flow spontaneously from the patient but the task
● Patient’s narrative of oral and written organization is yours”
● Question style: Open to closed cone
Gathering Information
● Attentive listening
● Facilitative response ● Expanding and clarifying the patient’s story
● Picking up cues → “Do not leave a symptom without the analysis. They
● Clarification may help at arriving at a good list of differential
● Time-framing diagnoses”
● Internal summary Table 2. Symptom Analysis Mnemonics
● Appropriate use of language
OLD CART
● Additional skills for understanding patient’s perspective
III. CONTENT OF MEDICAL HISTORY O Onset
A. GATHERING CONTENT[2026 Trans] L Location
● Done through extensive medical history taking which D Duration
involves
C Character
→ Biomedical perspective from the clinician
→ Patient’s perspective from the patient A Aggravating/Alleviating Factors
→ Background information
R Radiation
Biomedical Perspective (Disease)
T Timing
● Sequence of events
● Symptom analysis OPQRST
● Relevant systems review O Onset

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 P Palliating/Provoking Factors Associated Features Precipitation by exertion, exposure to
cold, psychogenic stress
Q Quality
R Radiation S4 gallop or MR murmurs during pain
S Site
Angina [Braunwald's Heart Disease, 11th ed]
T Timing ● Term used to refer to cardiac chest pain
SOCRATES ● Typical angina satisfies these 3 criteria:
→ Substernal discomfort
S Site → Initiated by exertion or stress
O Onset → Relieved with rest or sublingual nitroglycerin
● Atypical angina
C Character → Chest discomfort with two of the above criteria
R Radiation (of pain or discomfort) ● Non-anginal pain
→ Pain with one or none of the above criteria
A Alleviating Factors Table 5. Canadian CVS Society: Functional Classification of Angina
T Timing Class Description
E Exacerbating Factors Angina only with strenuous exertion
S Severity Class I
Ordinary physical activity does not
C. CARDIOVASCULAR SYMPTOMS cause angina
Table 3. Mnemonic for Cardiovascular Symptoms
Angina with moderate exertion
CARDIAC Class II
C Chest Pain, claudication Slight limitation of ordinary activity
A Ankle swelling (edema) Angina with mild exertion
Class III
R Reduced exercise, tolerance
Marked limitation of ordinary activity
D Dyspnea, orthopnea, PND Angina at rest
I Irregular heartbeat or palpitations
Class IV
A Altered color of lips (cyanosis) Inability to carry on any physical
activity without discomfort
C Consciousness, reduced or loss (syncope)
Differential Diagnosis of Chest Pain
Chest Pain
● Non-cardiac pain is characterized by:
● Most common symptom in cardiology (usual problem that
→ Sharp
prompts consult to a cardiologist)
→ Pleuritic pain
● Can be anginal, ulcer, or musculoskeletal chest pain
→ Positional
→ Reproducible with palpation
● Differential diagnosis of chest pain other than being
cardiac chest pain is important to know
→ Most common differential diagnoses for anginal chest
pain are GI causes
→ Refer to Table 6
Table 6. Differential Diagnosis of Chest Pain [HPIM]
Condition Esophageal Gallbladder Musculoskeletal
Reflux Disease Disease
Figure 5. Etiology of Chest Pain. Duration 10-60 minutes Prolonged Variable
From L to R: anginal, ulcer, musculoskeletal [Section of Cardiology, UP-PGH]
Quality Burning Burning, Aching
Table 4. Characteristics of cardiac chest pain [HPIM] pressure
Characteristic Cardiac Chest Pain Presentation
Location Substernal, Epigastric, Variable
Duration More than 2 and less than 10 minutes epigastric RUQ,
(longer in acute myocardial infarction) substernal
Quality Pressure, tightness, squeezing, Associated Worsened by May follow Aggravated by
heaviness, burning Features postprandial after a meal movement
Location Retrosternal, often radiate to or isolated recumbency
discomfort in neck, jaw, shoulders, or
Common Questions About Chest Pain in Filipino
arms (frequently on the left); unlikely
cardiac if highly localized ● Location
→ “Saang bahagi po ng dibdib ang sumasakit?”

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 ● Characteristic ● If you try to characterize the description of dyspnea of your
→ “Paano po ninyo mailalarawan ang nararamdaman patients, you might be able to specifically come up with a
ninyong sakit sa dibdib?” diagnosis dependent on the description of dyspnea of your
○ “Parang may nakadagan na mabigat?“ patient
○ “Parang tinutusok?” Table 7. Differential Diagnosis of Dyspnea
● Aggravating and alleviating factors Public System Private System
→ “Ano po ang ginagawa ninyo noong sumasakit ang ● Bronchoconstriction
dibdib ninyo?” Chest tightness or ● Interstitial edema
→ “Ano-ano pa pong mga gawain ang nagpapasakit ng constriction → Asthma
inyong dibdib?” → MI
● Duration ● Airway obstruction
→ “Gaano po tumagal ang sakit sa dibdib?” → COPD
● Radiation Increased work or effort → Moderate-severe asthma
→ “Saan po kumalat ang sakit niyo sa dibdib?” of breathing ● Neuromuscular disease
● Timing → Myopathy
→ “Gaano po kadalas nangyayari ang pagsakit ng inyong → Kyphoscoliosis
dibdib?”
● Increases drive to breathe
● “Ano po ang mga gawain na nagpapawala ng sakit ng
→ CHF
inyong dibdib?” Air Hunger (need or
→ Pulmonary embolism
● “May iba pa po bang sintomas na kasama ang pagsakit ng urge to breathe)
→ Moderate-severe airflow
inyong dibdib?”
obstruction
Claudication [Bickley, Bates Guide to Physical Exam] ● Hyperinflation
● Pain or cramping in the legs during exertion that is → Asthma
Unable to get a deep
relieved by rest within 10 minutes → COPD
breath; unsatisfying
● Intermittent claudication ● Restricted tidal volume
breath
→ Defined as the Pain within a defined group of muscles → Pulmonary fibrosis
that is induced and relieved with rest → Chest wall restriction
● Perception of claudication ranges from bothersome Table 8. New York Heart Association Classification of Stages of Heart Failure
discomfort or little consequence to a severe, debilitating
pain that becomes lifestyle-limiting Class Description
● Usually associated with diagnosis of Peripheral Arterial No limitation of physical activity
Disease (PAD) I
PAD “Warning Signs”[Bickley, Bates Guide to Physical Exam] Comfortable at rest and with ordinary physical activity

● Fatigue, aching, numbness, or pain that limits walking or With slight limitations of physical activity
exertion in the legs
→ Identifying the location associates pain with a particular II Comfortable at rest.
artery Ordinary physical activity causes fatigue, palpitation,
○ Lower leg pain - lower arterial distribution or dyspnea.
○ Pain in the buttocks - might be located a little With marked limitations of physical activity
higher, like the iliac arteries
● Any poorly healing or non-healing wounds of the legs or III Comfortable at rest.
feet Less than ordinary activity causes fatigue, palpitation,
● Any pain present when at rest in the lower leg or foot and or dyspnea
changes when standing or in supine Unable to carry on any physical activity without
● Abdominal pain after meals and associated “food fear” discomfort
→ Usually a manifestation of blockages in superior
mesenteric arterial circulation IV Symptoms of heart failure at rest.Symptoms of
● Any first-degree relatives with an abdominal aortic cardiac insufficiency or of the anginal syndrome may
aneurysm (AAA) also be present.
SHORTNESS OF BREATH Discomfort increases with physical activity.
*Note: All stages involve patients with cardiac disease
● Three types
→ Dyspnea Orthopnea
→ Orthopnea ● Shortness of breath when lying flat
→ Paroxysmal Nocturnal Dyspnea → Relieved by sleeping propped up or sitting down
Dyspnea [Am J Respir Crit Care Med, 2012; 185(4):435] ● Due to reduced pooling of fluid in the lower extremities
with blood displaced from the extrathoracic to the thoracic
● A subjective experience of breathing discomfort that
component
consists of quantitatively distinct sensations that vary in
● Suggests congestive heart failure
intensity
● An uncomfortable awareness of breathing that is Paroxysmal Nocturnal Dyspnea
inappropriate to a given level of exertion ● Severe shortness of breath and coughing, generally
● Derived from interactions among multiple physiological, occurring at night
psychological, social, and environmental factors, and may → Usually awakens the patient after 1 or 2 hours of sleep
induce secondary physiological and behavioral responses → Relieved in the upright position

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 ● Due to fluid buildup in the lungs, decreased ● Due to a temporary reduction in blood flow and therefore a
responsiveness of the respiratory center in the brain, and shortage of oxygen to the brain
or decreased activity in the myocardium during sleep ● Hysteria and hyperventilation DO NOT fall in this category
Easy Fatigability because they cause “light headedness” through respiratory
alkalosis brought on by blowing off CO2 too fast
● Reduced capacity for physical activity ● Psychogenic causes of fainting is also NOT included
● Can be quantified by asking:
→ “How many blocks or flights of stairs can you walk Table 10. Differential Diagnosis for Dyspnea
before experiencing fatigue?” Cardiac Syncope Seizure
→ Ano yung mga bagay na dating nagagawa ninyo na
ngayon ay nahihirapan kayong gawin? Shorter duration (<6 sec) Variable
Edema
● Accumulation of excess fluid in the extravascular interstitial Palpitations are less Sudden onset or brief aura
space common
● Due to either local or systemic causes
● Focus on the location, timing, and setting of the swelling Blue, not pale Blue face, no pallor
and associated symptoms Incontinence can occur Frothing at the mouth
● Pitting Edema Brief clonic movement can Prolonged duration
→ When pressure is applied, the pit (or indentation) occur Tongue biting
persists for some time Eye deviation
→ Due to water retention due to excess salt retention Elevated pulse and BP
→ Suggests systemic diseases: congestive heart failure; Incontinence more likely
liver pathologies; renal pathologies; pregnancy
Residual symptoms Aching muscles
uncommon (unless Disoriented – no recollection
prolonged unconsciousness) of what happened
Fatigue

Oriented (patient is usually Headache

“back to normal” right after Slow recovery (“Post-ictal
syncope) state”)

● Vasovagal syncope
→ Occurs through abnormal reflexes regulating the heart
and the blood vessels
Figure 6. Pitting edema. [Section of Cardiology, UP-PGH]
→ It is due to abrupt bradycardia and vasodilatation
Table 9. Assessment of Pitting Edema
→ Certain situations may trigger the syncope
Class Pit Size (mm) Time Until Pit Disappears ○ e.g. cough syncope, micturition syncope
I ≤2 Immediately → After a couple of minutes on the floor, the patient is
revived with no ensuing symptoms
II 2-4 10-15 seconds
→ Related to prolonged standing [UPCM 2026]
III 4-6 1 minute
Cyanosis
IV 6-8 2-5 minutes
● Bluish or purplish tinge to the skin and mucous
● Non-pitting Edema membranes due to excessive concentration of
→ When pressure is applied, indentation does not deoxyhemoglobin in the blood caused by deoxygenation
persist Table 11. Two Types of Cyanosis
→ Associated with: lymphedema, lipedema, myxedema Description Pathophysiology
Palpitations ● Around the core, lips, and tongue
● Second most common symptom of chest pain in the ● Due to arterial unsaturation; the
Central
outpatient setting aortic blood is carrying reduced
● Unpleasant awareness of the forceful rapid or irregular hemoglobin (Hemoglobin w/o O2)
beating of the heart ● Only in the extremities or fingers
→ Patient is able to feel each beat of the heart ● Excessive amount of reduced
● Sensation as a rapid fluttering in the chest, flip-flopping in Peripheral/
hemoglobin in the venous blood
the chest, or a pounding sensation in the chest or neck Dependent
as a result of extensive oxygen
● Symptoms are usually dependent on where in the heart extraction at the capillary level
the electrical signal is generated and whether the signal
can generate a heartbeat D. REVIEW OF SYSTEMS
● Manifestation of atrial irregularity would be different from ● Review any illness/symptoms focused on other systems
an irregularity that is from the ventricle [UPCM 2026] (that is not part of chief complaint) to identify any
Syncope symptoms which may otherwise be missed
→ E.g., ask for GI problems that weren’t mentioned;
● Syncope is a partial or complete loss of consciousness
check each system one by one [UPCM 2026]
with interruption of awareness of oneself and one’s
surrounding

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● Often useful to assess manifestations of the patient's ○ Present a warm persona to put the patient at ease
problem in other systems or the present problem can be ○ Set the stage
part of a multi-system problem ➢ To prepare the patient for the next part of the
● Asking a series of questions from “head to toe” interview
answerable by yes or no ➢ Forecast what will happen in the interview
● May start with general questions then shift to more specific → Step 2: Chief concern and set agenda
questions ○ Use patient-centered skills to draw out patient’s
● May uncover problems that the patient has overlooked story in their own words
D. PAST MEDICAL HISTORY ○ Obtain list of all issues patient wants to discuss
→ Step 3: Begin with Non Focusing Actions and
● Previous illnesses Questions
→ e.g., myocardial infarction, diabetes mellitus, ○ Let the patient tell the story why he/she is coming
hypertension, congestive heart failure, infections into the hospital
● Hospital admissions ○ Use some non-focusing open-ended skills, primarily
● Past operations or investigations silence, to draw out that story for a little bit
→ e.g., angioplasty, bypass surgeries ○ Pay attention to non-verbal cues
● Accidents and injuries ➢ Is the patient tired?
● Medications being taken ➢ Is the patient happy?
→ e.g., anti-hypertensive medications ○ Use open-ended beginning request/question
D. FAMILY HISTORY ○ Summarize afterwards
● Illnesses of family members ○ Step 3 is just to get the patient talking
→ Family history of coronary artery disease (CAD) → Step 4: Continue the Patient-Centered HPI
○ First-degree relatives who have suffered a heart ○ Briefly summarize what the patient says and probe
attack before the age of 55 (M) and 65 (F) further as needed
→ Familial hypercholesterolemia and hypertension ○ If the patient mentions personal context, you may
→ Familial history of diabetes and stroke either choose to explore the personal context
● Details about health of parents and siblings further or to ask more symptom-focused questions
● Details on early onset CVD, dyslipidemia, heart diseases, in an open-ended way
hypertension, diabetes, allergies, asthma, etc. → Step 5: Transition to Middle Portion of the Interview
○ Become much more directive and more
G. PERSONAL SOCIAL HISTORY biomedically focused
● Lifestyle, environment, and personal habits which can put ● Middle: use doctor-centered skills to draw out psychosocial
them at risk from illness or have a bearing on established and symptom data and to generate the routine database
diseases that we need
● Smoking or alcoholic beverage intake → Remember to always return to patient-centered skills, if
→ How much alcohol does he take every day? needed
→ How many sticks does he smoke? ● Physical Exam
● Work/Occupation ● End with patient education and counseling
→ Where does he/she work? ● A physician’s job is to integrate the two stories obtained
→ Look at occupational hazards from the beginning and middle parts of the interview into a
○ Many diseases associated with only certain unified biopsychosocial story
occupations V. FURTHER LEARNING OPPORTUNITIES
● Recent or previous travel, especially when checking for
infectious diseases ● Practice, practice, practice!
→ e.g. malaria-like symptoms after travel to ● Observe fellow health professionals undertaking patient
Palawan/Africa assessments
● Educational attainment ● Reflect on the practice of others and on your own abilities
and experiences
IV. SMITH’S PATIENT-CENTERED INTERVIEW ● Evaluation of the patient with known or suspected CVD
Note from TG: begins with a directed history following a consultation
● This section is based on the supplementary video entitled, model, e.g., Calgary-Cambridge Consultation Guide
“Building Efficiency and Effectiveness through ● A thorough history-taking and targeted physical
Patient-Centered Interviewing” examination should provide most of the information
needed to make a diagnosis
● Smith’s Patient-Centered Interviewing
→ Developed by Robert Smith at Michigan State VI. REFERENCES
University Añonuevo,J.C. (2023). History Taking in Adults with CVD. [Lecture Video]
→ Has been shown in at least one RCT to be very UPCM 2027. (2023). History Taking in Adult Patients with CV Disease.
efficient and efficient in getting the benefits of Bickley, L. (2013). Guide to Physical Examination and History Taking. (11th
patient-centered interviewing Edition).
Fortin, A.H., Dwamema, R.M., Frankel, R.M., Lepisto, B.L., & Smith, R.C.
● Beginning: use patient-centered skills to draw out (n.d.). Building Efficiency and Effectiveness through Patient-Centered
psychosocial and symptom data Interviewing. Retrieved from
→ Step 1: Set the stage (Greet) https://accessmedicine.mhmedical.com/MultimediaPlayer.aspx?Multime
○ Introduce yourself and indicate your role dialD=16633716
○ Use the patient’s name
○ Take a quick look if there is any barriers to
communication
○ Check if the patient is comfortable

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