1. Welcome the patient
2. Use the patient’s name
3. Introduce yourself and identify specific role
4. Ensure patient readiness and privacy
5. Remove barriers to communication (sit down)
6. Ensure comfort and put the patient at ease

It begins with the onset of the illness. Onset determines whether the illness is acute or chronic.

As the character and sequence of the symptom are being elicited, they are interpreted for their clinical significance.  

This requires knowledge of the pathogenesis, pathology, and pathophysiology of disease.

Details of the causes and and pathophysiology of symptoms and signs are found in Making the Diagnosis and Management.

 

Obtain list of all issues patient wants to discuss; specific symptoms, requests, expectations, understanding (e.g. “…but before we do that, it would help me to get a list of the things you wanted to discuss today.” “Is there something else?”)

Begin the interview that helps the patient to express her/himself

1. Start with open-ended request/question (“Tell me about your headache.”)
2. Use non-focusing open-ended skills (attentive listening): silence, neutral utterances, nonverbal encouragement
3. Obtain additional data from nonverbal sources:   nonverbal cues, physical characteristics, autonomic changes, accoutrements, environment, Self. In clinical interviewing, the goal is not only to collect verbal information (what the patient tells you) but also to observe nonverbal data — subtle cues that reveal physical, emotional, or psychological states that words alone might conceal. These observations help you:

• Verify or question verbal statements

• Detect distress, deception, or discomfort

• Understand the patient’s coping style and rapport

• Identify unspoken needs or risks

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🔹 The Nonverbal Sources

1. Nonverbal Cues

These are observable behaviors that communicate emotions or attitudes.
Examples in clinical settings:

• Facial expression: a grimace when discussing pain

• Posture: slumped (depression), rigid (anxiety)

• Gestures: fidgeting, clenched fists

• Eye contact: avoiding (shame, anxiety), fixed (anger, suspicion)

• Voice tone: monotone (depression), pressured (mania)

💡 Clinical value: Nonverbal cues may contradict verbal reports. A patient saying, “I’m not worried” but wringing their hands may in fact be anxious.

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2. Physical Characteristics

These are observable bodily features that may reflect health status, personality, or emotional state.
Examples:

• Body habitus: underweight (eating disorder, chronic illness), obese (metabolic syndrome, depression)

• Hygiene and grooming: poor hygiene (neglect, depression), meticulous grooming (OCD, mania)

• Facial appearance: pallor (anemia), jaundice (liver disease), mask-like face (Parkinson’s)

• Gait and movement: slow (depression), restless (anxiety, akathisia)

💡 Clinical value: Physical appearance often provides objective clues that supplement subjective complaints.

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3. Autonomic Changes

These are involuntary physiologic signs that occur under stress or emotional arousal.
Examples:

• Flushing, sweating, pallor

• Trembling hands

• Pupillary dilation or constriction

• Changes in respiratory pattern or heart rate

💡 Clinical value: Autonomic signs can signal anxiety, fear, anger, or pain even when the patient denies these feelings.

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4. Accoutrements

These are the personal items or adornments that reflect a person’s identity, lifestyle, or social status.
Examples:

• Clothing style (clean, disheveled, eccentric, appropriate for weather)

• Jewelry or religious symbols

• Tattoos and body art

• Assistive devices (cane, glasses, hearing aid)

• Hospital bracelet, nicotine stains, medical alert tag

💡 Clinical value: Accoutrements give context about self-image, culture, occupation, or health needs.

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5. Environment

The setting in which you see the patient (home, hospital room, clinic) provides indirect information.
Examples:

• Cluttered home (possible neglect or cognitive decline)

• Isolation or lack of support (social withdrawal, depression)

• Safety hazards (fall risk, abuse clues)

💡 Clinical value: The environment reveals social determinants of health and can guide discharge planning, safety evaluation, or support referrals.

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6. Self

This refers to your own internal reactions as the interviewer — your feelings, intuitions, and bodily sensations during the encounter.
Examples:

• Feeling unusually sleepy, tense, or irritable during the interview

• Sensing fear, sadness, or distrust that mirrors the patient’s emotions

💡 Clinical value: Your internal responses can serve as a diagnostic instrument — a way to sense the patient’s unconscious communication or affect (“using yourself as an instrument of assessment”).

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✅ Summary Table for Clinical Interviewing

Source	Description	Clinical Example	Significance
Nonverbal cues	Facial expression, gestures, tone	Says “I’m fine” but tearful	Reveals hidden emotion
Physical characteristics	Body, grooming, posture	Poor hygiene, slumped posture	Suggests depression or neglect
Autonomic changes	Physiologic reactions	Sweating, tremor, flushing	Indicates anxiety or stress
Accoutrements	Clothing, jewelry, devices	Cross necklace, medical ID	Reflects identity or health status
Environment	Surroundings	Cluttered room, empty fridge	Suggests social/functional issues
Self	Clinician’s feelings or intuition	Feeling anxious around patient	Reflects interpersonal dynamics

The presence of a symtpom or sign determines the probability of the presence of a certain diseae.

The patient's history leads the physician, even as he or she is eliciting it, to think of “things to look for” on physical examination, and physical findings stimulate further historical questions.

This fluid oscillation, the ongoing back-and-forth between these two pillars of diagnosis, is important to grasp.

Physical findings intertwine with the history and vice versa.

This leads to the differential diagnosis of a symptom or sign

Description of symptoms, using focusing open-ended skills such as:  Echoes (repeat the patient’s words, e.g. “Excruciating pain?”)  Requests (“That sounds important; can you tell me more about it?”)   Summaries (“First you had a fever, then two days later your knee began to hurt, and yesterday you began to limp.”)

Broader personal/psychosocial context of symptoms, patient beliefs/attributions.