NU556 Unit 2 The Patient Interview

Student Name

Purdue University Globle 

NU566 NP I – Introduction to Primary Care for the Nurse Practitioner

Prof. Name

Date

NU556 Unit 2 The Patient Interview

Patient interviews are the foundation of accurate diagnosis, patient-centered care, and effective clinical decision-making. A structured interview helps healthcare providers gather complete medical information, identify health risks, build trust, and develop an appropriate treatment plan. By following a systematic approach—from the chief complaint to the review of systems—clinicians can improve diagnostic accuracy while ensuring patients feel heard and respected.

Preparing for the Patient Interview

A successful patient interview begins before the first question is asked. Healthcare providers should create an environment that promotes privacy, comfort, and open communication while minimizing distractions. Introducing yourself professionally and verifying the patient’s identity establishes trust and ensures patient safety.

A professional introduction may include:

• Introduce yourself with your name and role.

• Ask the patient how they prefer to be addressed.

• Confirm their preferred pronouns.

• Verify their full name and date of birth.

• Explain that you will be providing care during the visit.

Establishing rapport early encourages honest communication and improves the quality of the information collected.

Chief Complaint (CC)

The Chief Complaint (CC) is the patient’s primary reason for seeking medical care. It is typically documented as a brief phrase containing two or three words that summarize the patient’s main concern.

Examples include:

• Chest pain

• Persistent cough

• Headache

• Abdominal pain

Useful interview questions include:

• Why are you here today?

• What brings you to the clinic?

• How are you feeling today?

The chief complaint guides the remainder of the clinical interview.

History of Present Illness (HPI)

The History of Present Illness (HPI) provides a detailed description of the patient’s current health concern. It explains when symptoms began, how they have changed, associated symptoms, previous treatments, and factors that influence symptom severity.

One of the most widely used frameworks for documenting the HPI is OLD CARTS.

O – Onset

Determine when the symptoms started and whether they appeared suddenly or gradually.

Questions include:

• When did your symptoms begin?

• Did they start suddenly or gradually?

• Are you still experiencing the symptoms?

L – Location

Identify where the symptoms occur.

Ask:

• Where is the pain or discomfort located?

• Does it spread anywhere else?

D – Duration

Understand how long symptoms last and whether they are continuous or intermittent.

Questions include:

• How long does each episode last?

• Have the symptoms become worse over time?

C – Characteristics

Ask the patient to describe the symptoms.

Examples include:

• Sharp

• Dull

• Burning

• Throbbing

• Aching

A – Aggravating Factors

Determine what worsens the symptoms.

Examples include:

• Movement

• Eating

• Walking

• Position changes

• Stress

R – Relieving Factors

Identify what improves the symptoms.

Ask about:

• Rest

• Medication

• Heat or ice

• Position changes

T – Treatments

Review any previous attempts to manage the symptoms.

Ask:

• What medications have you taken?

• What dosage did you use?

• Did the treatment help?

S – Severity

Assess symptom intensity.

A standard pain scale is commonly used:

“On a scale from 0 to 10, with 10 representing the worst pain imaginable, how severe is your pain?”

Using the OLD CARTS framework helps ensure no essential clinical information is overlooked.

Medication History

A comprehensive medication history includes all substances the patient currently takes.

This includes:

• Prescription medications

• Over-the-counter medications

• Vitamins

• Herbal supplements

• Dietary supplements

Document:

• Medication name

• Dose

• Frequency

• Route

• Reason for use

Example question:

“What prescription or over-the-counter medications do you currently take?”

Allergy Assessment

Medication allergies and adverse reactions must always be documented before treatment begins.

Ask patients about:

• Medication allergies

• Food allergies

• Environmental allergies

• Latex allergy

Clarify the specific reaction experienced, such as:

• Rash

• Swelling

• Difficulty breathing

• Gastrointestinal symptoms

• Anaphylaxis

Example questions include:

• Are you allergic to any medications?

• Do you have any allergies?

• What reaction do you experience?

Past Medical History

Past medical history provides valuable context for the patient’s current condition.

Review previous diagnoses such as:

• Hypertension

• Diabetes

• Asthma

• Heart disease

• Mental health disorders

• Cancer

• Chronic kidney disease

Additional information may include:

• Pregnancy history

• Childhood illnesses

• Previous diagnostic testing

Example questions:

• Can you tell me about your medical history?

• Have you been diagnosed with any chronic medical conditions?

Past Surgical History and Hospitalizations

Previous surgeries and hospital admissions often influence current healthcare decisions.

Document:

• Surgical procedures

• Dates (if known)

• Hospitalizations

• Reasons for admission

• Complications

Example question:

“Have you ever had surgery or been hospitalized?”

Family History

Family history helps identify inherited diseases and genetic risk factors.

Important conditions include:

• Heart disease

• Diabetes

• Hypertension

• Stroke

• Cancer

• Mental illness

• Autoimmune disorders

Example questions:

• Do any close family members have significant medical conditions?

• Are your parents and siblings healthy?

Social History

A thorough social history provides insight into lifestyle factors that may affect health.

Assess:

• Education

• Employment

• Living arrangements

• Marital or relationship status

• Tobacco use

• Alcohol use

• Recreational drug use

• Sexual history

• Safety at home

• Exposure to violence

• Exercise habits

Examples include:

• What type of work do you do?

• Do you smoke or use tobacco products?

• How much alcohol do you drink?

• Do you feel safe at home?

If tobacco use is reported, ask about:

• Duration of smoking

• Daily cigarette consumption

• Previous quit attempts

Preventive Health History

Preventive care identifies whether patients are receiving recommended screening tests and vaccinations appropriate for their age, sex, and risk factors.

Common preventive assessments include:

• Immunization status

• Cervical cancer screening (Pap smear)

• Breast cancer screening

• Mammography

• Colonoscopy

• Prostate screening

• Testicular self-examinations

• Breast self-awareness

• Bone density screening when indicated

Example questions:

• Are your vaccinations current?

• When was your last colonoscopy?

• When was your last Pap smear?

Review of Systems (ROS)

The Review of Systems (ROS) is a structured head-to-toe assessment that identifies symptoms affecting each major body system. Even when unrelated to the chief complaint, ROS findings may reveal additional health concerns.

General

Assess for:

• Fever

• Chills

• Fatigue

• Weight changes

• Night sweats

• Changes in energy level

Skin

Review:

• Rashes

• Bruising

• Delayed wound healing

• Skin discoloration

• Changes in moles

Eyes

Assess:

• Vision changes

• Blurred vision

• Corrective lens use

Ears

Evaluate:

• Hearing loss

• Ear pain

• Ringing in the ears

• Ear discharge

Nose, Mouth, and Throat

Assess:

• Nasal congestion

• Nosebleeds

• Difficulty swallowing

• Hoarseness

• Dental problems

• Sore throat

Breast

Review:

• Breast lumps

• Pain

• Skin changes

• Nipple discharge

Hematologic, Lymphatic, and Endocrine

Assess:

• Swollen lymph nodes

• Easy bruising

• Blood transfusion history

• Excessive thirst

• Heat or cold intolerance

• Increased appetite

Cardiovascular

Review:

• Chest pain

• Palpitations

• Swelling

• Orthopnea

• Paroxysmal nocturnal dyspnea

Respiratory

Assess:

• Cough

• Wheezing

• Shortness of breath

• Hemoptysis

• Previous tuberculosis

• History of pneumonia

Gastrointestinal

Review:

• Abdominal pain

• Nausea

• Vomiting

• Diarrhea

• Constipation

• Ulcers

• Hepatitis

• Black or bloody stools

Genitourinary and Gynecologic

Assess:

• Urinary frequency

• Urgency

• Burning during urination

• Sexual activity

• Sexually transmitted infections

• Contraceptive use

For female patients:

• Last menstrual period

• Pregnancy history

• Pap smear

• Mammogram

• Vaginal discharge

For male patients:

• Prostate concerns

• PSA testing

• Urinary symptoms

Musculoskeletal

Review:

• Joint pain

• Joint swelling

• Muscle weakness

• Fractures

• Osteoporosis

• Back pain

Neurological

Assess:

• Headaches

• Weakness

• Numbness

• Seizures

• Fainting

• Paralysis

Psychiatric

Review:

• Depression

• Anxiety

• Sleep disturbances

• Mood disorders

• Suicidal thoughts

• Previous psychiatric diagnoses

Transition to the Physical Examination

Once the interview is complete, explain the next step to the patient before beginning the examination.

A professional transition might be:

“Thank you for answering my questions. Next, I am going to perform your physical examination to gather additional information about your health.”

Clear communication helps patients understand what to expect and promotes a positive clinical experience.

Key Takeaways

A comprehensive patient interview is one of the most important components of clinical assessment. Collecting accurate information through a structured history improves diagnostic accuracy, supports clinical reasoning, strengthens provider-patient relationships, and contributes to safer, evidence-based healthcare. Following a consistent sequence—including the chief complaint, history of present illness, medications, allergies, medical history, family history, social history, preventive care, and review of systems—helps ensure that no essential information is missed.

Frequently Asked Questions

What is the purpose of a patient interview?

A patient interview gathers subjective health information, identifies the patient’s primary concerns, builds rapport, and provides the foundation for diagnosis, treatment planning, and clinical decision-making.

What does OLD CARTS stand for?

OLD CARTS is a clinical assessment tool used during the History of Present Illness and stands for Onset, Location, Duration, Characteristics, Aggravating factors, Relieving factors, Treatments, and Severity.

Why is the Chief Complaint important?

The chief complaint identifies the patient’s primary reason for seeking healthcare and guides the direction of the clinical assessment and diagnostic process.

What information should be included in the medication history?

A medication history should include prescription medications, over-the-counter drugs, herbal products, vitamins, supplements, medication dosages, frequency, route of administration, and the reason each medication is taken.

Why is the Review of Systems performed?

The Review of Systems systematically screens every major body system to identify symptoms that may not have been mentioned during the patient’s chief complaint but could influence diagnosis and treatment.

How should a healthcare provider conclude the interview?

After completing the health history, summarize the information, answer any patient questions, explain the next steps, and obtain consent before proceeding to the physical examination.

A structured patient interview enables healthcare professionals to collect accurate health information, establish therapeutic communication, support clinical reasoning, and improve diagnostic accuracy through a systematic assessment of the patient’s history, symptoms, medications, allergies, lifestyle, preventive care, and review of systems.

An effective patient interview follows a logical sequence that includes the chief complaint, history of present illness using the OLD CARTS framework, medication review, allergy assessment, past medical and surgical history, family and social history, preventive health screening, and a comprehensive review of systems before proceeding to the physical examination.

References

Bickley, L. S. (2024). Bates’ guide to physical examination and history taking (14th ed.). Wolters Kluwer. https://shop.lww.com/Bates–Guide-to-Physical-Examination-and-History-Taking/p/9781975210878

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel’s guide to physical examination: An interprofessional approach (10th ed.). Elsevier. https://www.elsevier.com/books/seidels-guide-to-physical-examination/ball/978-0-323-76395-6

Jarvis, C. (2024). Physical examination and health assessment (10th ed.). Elsevier. https://www.elsevier.com/books/physical-examination-and-health-assessment/jarvis/978-0-323-82462-6

NU556 Unit 2 The Patient Interview

Agency for Healthcare Research and Quality. (2023). Communication and patient safety. https://www.ahrq.gov/patient-safety/index.html

Centers for Disease Control and Prevention. (2024). Adult immunization schedule. https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html