One of the duties of the nursing staff, which receives a new patient on a unit, is to notify a member of the resident medical staff that the patient has arrived so that the resident or intern can take the history of the patient’s illness and previous illnesses, examine the patient, and write up initial orders. The interview is likely to be lengthy, and many of the questions will be reviewed by other members of the staff. The patient must cooperate to the best of his or her ability and should never insist that, because the family physician has already taken all of the details, repetition is unnecessary. Often, the patient forgets to tell his or her own physician about something, and this comes to light only during the interview at the hospital. This medical history is the most important single factor in helping the physician to make a diagnosis. It is more important than the physical examination, the tests, or the X rays, even with the sophisticated equipment available in today’s hospitals.
An intern usually comes to see you after you have settled into your room. He or she writes down all the details of your illness.
Giving a History
The resident physician begins the interview by introducing himself or herself and explaining who he or she is. Residents vary in interview technique, but commonly the resident begins by discussing the patient’s main symptoms, because obviously this is causing the patient the most concern. When the resident asks you what is wrong, you should explain the most prominent symptom or symptoms, such as shortness of breath or abdominal pain. The resident does not want your estimated diagnosis.
The questions that follow relate to the presenting symptom. For example, if you are complaining of abdominal pain, the resident will ask questions such as: has the pain changed position at all; has the pain become localized (concentrated in one area) or has it spread to other areas of the abdomen; and what type of pain is it (sharp, burning, spasmodic, or a dull ache).
