THCME Clinical Learning Resources
GATHERING THE BACKGROUND INFORMATION
The Patient Medical Interview
How do you conduct a patient interview? Here's how you start.
The medical interview is a foundation for clinical practice. The skills necessary to perform the medical interview
should be considered to be a part of the basic science of medicine. Your goals are:
- To determine the nature of patients' problems and monitor the patient's health status
- To develop, nurture, and/or complete therapeutic relationships
- To implement treatment plans and educate patients about their health status
Start by asking general questions about the chief complaint (most important symptom). Ask about the duration of
the problem and whether the patient has had similar problems before. Ask about the severity of the symptoms and
question the patient in order to get more specific details about the problem at hand.
The Patient's Medical History
How important is the patient's medical history to the problem at hand?
- 70% of diagnoses can be made based on history alone.
- 90% of diagnoses can be made based on history and physical exam alone.
- Expensive tests often confirm what is found during the history and physical examination.
Once you have established a rapport with the patient, you can begin to get details of the patient picture
that will help you to evaluate the information you will obtain during the physical examination. Ask questions here
about medications (both over-the-counter (OTC) and prescription drugs), lifestyle considerations, family history, and
the patient's past medical history.
THE PHYSICAL EXAMINATION
Essentials of Patient Care¾ Review of Systems
Illustrates the content of a complete review of systems.
PUTTING IT ALL TOGETHER
How do you figure out the most likely diagnosis? What is a differential diagnosis? Resources Available:
SkolarMD Online
TRY THIS ONE FIRST; IT'S COMPREHENSIVE (IU Network ID required)
The Merck Manual of Diagnosis and Therapy
A complete reference for diseases, tests, and diagnoses.
Harrison's Online: one of the most trusted Internal Medicine textbooks.
Gives descriptions and mechanisms for all medical conditions.
The Case Summary
What do you do when you think you have the patient's problem figured out? Here's the way to discuss the patient's
medical problems with other medical professionals.
Online Patient Cases
Click above to beta test online patients. See the links above for information on the patient interview, taking the medical history,
the physical exam, and the resources you will need to make the diagnosis and prepare the
case summary.
Last updated 1-24-2008. This material was created as part of a medical education project by Mary T. Johnson, Ph.D., Eugene Paik, MD, and Jeremy Geib, B.S.