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6 CHAPTER 1: Diagnosis
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this is still a mysterious cognitive process, even to the clinician performing
the task.
Pattern recognition. The whole of the patient’s illness is greater than the sum
of its parts. Mechanical application of likelihood ratios is far less accurate
than the patterns that emerge in a skilled examiner’s mind from the totality of
observations. For example, it is easy to identify hundreds of faces at a glance,
but identication is much more difcult if observations are limited to one or
two features in isolation. The persistent unity of the whole allows recognition
of familiar faces even when much of the face is covered. Pattern recognition is
one of the most powerful properties of the human brain.
Create an anatomic and physiologic story matching the patient’s narrative in time and tempo indicating where and by what pathophysiologic
mechanism(s) the illness is being produced. Then identify diseases known to
have this pathophysiology producing these or similar symptoms and signs.
Listing all possible diagnoses is rarely helpful. For isolated symptoms and
signs a list of potential diagnoses is possible, but there is no means to differentiate their probabilities. Rather, use this specic patient’s ndings to estimate
the probability of each diagnosis. This is the
a pretest probability. Because the clues distinguishing diseases of high and low
probability are unique to this patient, differential diagnosis is only possible for
an individual patient, not a problem.
Probability. The clinician must know the incidence and prevalence of diseases in the population represented by the patient. This is the starting place
for determining the probability of each disease for this patient, but never the
actual probability. If the incidence and prevalence were the whole story, rare
diseases would almost never be considered. The population statistics are adjusted for a hypothetical population of the patient’s same age, gender, ethnicity, history, and concurrent conditions.
differential diagnosis, each with
Anatomic and Pathophysiologic Diagnostic Hypotheses:
Anatomic hypotheses. All disease processes take place somewhere in the
patient. Predict the likely sites of disease pathology. Be precise; visualize
which systems, organs, tissues, and cells within each organ are involved. For
example, jaundice results from prehepatic hemolysis, hepatocellular damage,
intrahepatic biliary obstruction (canicular or larger ducts), or extrahepatic
obstruction. If the latter, nd clues suggesting the location relative to the cystic duct, pancreatic ducts, and duodenum. Many disease processes involve
multiple organs. The tissues involved in each organ may suggest a pattern,
e.g., multiple enlarged organs with few effects on function is the pattern of
deposition diseases like amyloidosis.
Pathophysiologic hypotheses. There are a limited number of physiologic
mechanisms by which disease is produced. Any classication scheme is somewhat arbitrary with signicant overlaps since one mechanism often triggers
a second, e.g., autoimmune thyroid disease produces the metabolic changes
of hypothyroidism or hyperthyroidism. The scheme presented below is a
guide to critical thinking assuring that all mechanisms are considered. Fuzzy
boundaries between categories, with many ways to get to the same place, are
a strength making it less likely to overlook something.
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Congenital Degenerative/Idiopathic
Endocrine Infectious (includes infestations)
Immune/Inflammatory Mechanical/Traumatic
Metabolic (includes toxins) Neoplastic
Neurologic Psychosocial
Vascular
Congenital. This is not a physiologic mechanism but rather a reminder
that each specic mechanism may result from an abnormality present at
birth (congenital) in the hardware (developmental anomalies) or software
(genome). This category includes developmental anomalies, familial genetic
disease (germline mutations), somatic mutations during embryonic growth,
and inborn errors of metabolism. Genetic abnormalities usually present in
infancy and childhood but also appear in adults at any age, e.g., adrenoleukodystrophy, atrial septal defect, anomalous vasculature, hypertrophic cardiomyopathy, and multiple endocrine neoplasia, to name a few.
Degenerative/Idiopathic. Again, not a mechanism, rather a loose collection
of diseases and structural abnormalities whose precise mechanism is uncertain but the incidence of which generally increases with age and/or increased
exposure to specic structural or metabolic stresses. Aging itself, though quite
normal, falls into this category. Other examples are the dementias, osteoarthritis, osteoporosis, emphysema, and atherosclerosis.
Endocrine. This includes functional and structural abnormalities of the ductless glands: pituitary, thyroid, parathyroid, pancreatic islets, testes, ovaries,
adrenal, and neuroendocrine tissues. Onset of endocrine disorders is often
indolent, delaying recognition. Symptoms are systemic without localization.
Signs may be few and missed if not specically sought by directed exam, e.g.,
goiter, lid lag, tremor, lagging reexes, tetany, change in testicle size, and consistency. Acute endocrine disorders are not common but are often life threatening if not treated promptly, e.g., thyroid storm, pituitary apoplexy, adrenal
hemorrhage, and pheochromocytoma.
Infectious (including infestations). Humans are susceptible to attack by
innumerable viruses, bacteria, fungi, and parasites. Congenital or acquired
defects in the innate or adaptive immune systems and disruption of surface
barriers (skin, intestinal mucosa) increase the risk of infection. Infection is commonly, but not always, associated with signs of inammation. Organisms can
also cause illness by release of toxins, e.g., toxic shock syndrome and tetanus.
Intracellular organisms have adapted to life within host cells. These unique
organisms shield themselves from the immune response so signs of inammation may be minimal or absent. They always require specic consideration.
Immune/Inammatory. When present, fever and/or inammation indicate
an immune response. Though they frequently coexist, do not equate inammation with infection. Many immunologically mediated diseases do not
cause clinical inammation, e.g., Hashimoto thyroiditis and celiac disease.
Autoimmune diseases may or may not incite an inammatory response and
8 CHAPTER 1: Diagnosis
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can be limited to one organ, e.g., thyroiditis, or systemic involving multiple
organs, e.g., vasculitis and systemic lupus. Specic cytokines induce systemic
responses manifest as fever, fatigue, malaise, and loss of appetite.
Mechanical/Traumatic. Obstructions within the genitourinary and gastrointestinal systems are examples of mechanical problems, often associated
with severe colic pain. Similarly, obstruction within the vascular system produces symptoms depending on the site of obstruction. Arterial obstruction
produces pallor and ischemic pain while venous obstruction produces tissue engorgement, cyanosis, and less severe pain. Congenital and acquired
mechanical problems of the heart and great vessels are common, e.g., aortic
stenosis, mitral insufciency, pericardial tamponade, and coarctation of the
aorta. Impingement by a mass, large or small, can compress and displace
adjacent structures, e.g., extruded intravertebral disk and common bile duct
obstruction by pancreas cancer. Fractures are mechanical failure of bone.
Visualization helps formulate mechanical hypotheses.
Metabolic/Toxic. Metabolism is highly complex and nely regulated. Inborn
errors of metabolism usually present in infancy or childhood, but not always.
Metabolic disturbances have systemic effects with symptoms and signs according to the pathway affected, but inammation is absent. Inability to properly
metabolize specic substrates underlies storage diseases often leading to organ
enlargement and dysfunction, e.g., amyloidosis and nonalcoholic fatty liver
disease. Ingested or injected toxins and drugs are examples of metabolic disturbances, e.g., cyanide uncouples mitochondrial electron transport.
Neoplastic. Neoplasms, benign and malignant, present at all ages with peaks
in childhood and later adult life. Symptoms may be local, e.g., pain, or systemic, e.g., anorexia and weight loss. Benign neoplasms usually present with
mechanical mass effects, except for endocrine neoplasms presenting with
unregulated hormone production, e.g., parathyroid adenoma producing the
metabolic effects of hypercalcemia. Some neoplasms produce systemic effects
by immune mechanisms, e.g., paraneoplastic neurologic disorders associated
with certain hematopoietic neoplasms. Others secrete hormones or hormone
mimics, so the presentations suggest a primary endocrine or metabolic problem, e.g., parathyroid-related-peptide and hypercalcemia, and antidiuretic
hormone from small cell lung cancer.
Neurologic. Though not a pathophysiologic mechanism, damage to the central or peripheral nervous systems by another mechanism is a common cause
of pain and altered perceptions in many body regions. Examples are complex regional pain syndrome, tabes dorsalis, diabetic polyradiculopathy, and
postherpetic neuralgia. The initial inciting pathophysiology (in the examples
two infections, one metabolic derangement, and previous injury) is rarely relevant to the current presentation. Recognition that the symptom, most often
pain, arises in the damaged nerves themselves, rather than the nerve transmitting pain from another source, is the key to making the correct diagnosis.
Psychosocial. Anorexia nervosa can lead to weight loss and depression to
weight loss or gain. Poverty and illiteracy are prevalent in adults and children, limiting access to proper nutrition or ability to obtain and correctly take
The Diagnostic Process 9
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medications. Poor response to a medication may indicate lack of nancial
resources or nonadherence. The living environment may contribute to incontinence by impeding access to bathroom facilities, e.g., use of a wheelchair or
walker, or inability to use the facilities due to cognitive impairment. Physical
and emotional violence produce protean effects and should always be considered when a presentation is ambiguous. Take a thorough family and social
history asking about literacy and the living environment.
Vascular. Vascular disorders can be acute, e.g., embolism or thrombus, or
chronic, e.g., peripheral vascular disease. They are local, e.g., aortic coarctation, or systemic, e.g., atherosclerosis and vasculitis. Arterial obstruction
(mechanical) due to atherosclerosis (metabolic) leads to tissue ischemia with
symptoms and signs corresponding to the affected organ, e.g., myocardial
infarction or stroke. Vasculitis is classied by the size of the affected vessels so
visualize which arteries are affected. Atherosclerosis is a generalized process
of large and small arteries. When only the aorta and its major branches are
affected, think Takayasu or giant cell arteritis. Venous disorders are usually
mechanical, either obstruction or valvular insufciency of leg veins. The latter produces secondary skin and subcutaneous inammation, which is often
mistaken for cellulitis. Bleeding is mechanical disruption of the vessel or a
failure of hemostasis.
Evaluate each hypothesis with laboratory tests and imaging studies
having appropriate likelihood ratios. The results change the probability of
each hypothesis to a posttest probability: some are now much more probable,
whereas others are much less probable. To reach a new, rened differential
diagnosis, return to the patient, review the history, and repeat specic parts
of the physical exam. This process is repeated until a diagnosis that fully
explains the illness is conrmed.
In this book, under many symptoms and signs, there is a list of
OCCURRENCES
. It is up to the clinician using this list as an organizational tool
CLINICAL
to generate a meaningful differential diagnosis which is pertinent to their
patient. Specic clues that will help rene the differential diagnosis are listed
after the DDX: symbol.
Many patients develop an acute problem on the background of two or
more chronic disorders. The new problem may result from an exacerbation of
a known disease or by a new superimposed disorder.
Verifying diagnoses. Verication of a working diagnosis, the current diagnostic hypothesis, tests its validity. Since the diagnostic process is inferential, all diagnostic hypotheses reect a belief or a conviction by the physician
regarding the underlying condition from which the patient suffers. Accepting
a diagnostic hypothesis before it is fully veried is known as premature closure.
Inappropriate and premature acceptance of a diagnostic hypothesis can be
avoided if physicians insist that all data is considered before accepting a diagnostic hypothesis as veried. Adequacy, coherency, and parsimony are cognitive aids that help to avoid making a premature or incorrect diagnosis. These
three tests are useful for deciding whether a diagnostic hypothesis qualies
as a working diagnosis.
1. Coherency. Is the working diagnosis pathophysiologically consis-
tent with all the clinical ndings, i.e., are all physiologic linkages,
10 CHAPTER 1: Diagnosis
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predisposing factors, and complications consistent with the hypothesis
in this patient? Causal reasoning is based on cause-and-effect relations
between clinical variables or chain of variables. It is a function of normal
anatomic, physiologic, and biochemical mechanisms and their consistent pathophysiology in disease.
2. Adequacy. Does the working diagnosis explain all the patient’s nd-
ings, normal and abnormal? A hypothesis is more likely to be correct if it
accounts for every symptom and sign.
3. Parsimony. Does the working diagnosis offer a simple explanation of
all the patient’s ndings? This is Occam’s razor: the simplest solution is
likely to be correct. When one diagnosis does not explain all the ndings,
those that are able to account for the greatest proportion of the patient’s
signs and symptoms are more likely to be correct. Parsimony is most
applicable to the previously well patient with an acute or subacute disease, the most common clinical challenge faced by Sir William Osler who
introduced Occam’s razor to medicine. However, sometimes multiple
diagnoses become necessary for a physiologically and causally consistent explanation of the patient’s ndings and clinical features. As we care
for more patients with one or more chronic diseases, bear in mind that
more than one pathologic process may be occurring.
Cognitive Tests of Diagnostic Hypotheses: When prioritizing the list of pos-
sible diagnoses, the following tools help identify the most likely diagnosis.
Chronology. It is possible to have a perfect match of attributes between
patient and disease, but if the epidemiology, onset, tempo, and course of illness are not congruent, the hypothesis is probably wrong.
Severity of illness. The global severity assessment made by an experienced
clinician includes many intangibles, often based upon prior knowledge and
experience with the patient. Experience-based emotional cues are essential
to this assessment. An inexperienced clinician may diagnose a URI, whereas
a more experienced clinician hypothesizes pneumonia because the patient
looks too sick for just a URI. Severity of illness is valid and diagnostically
useful.
Prognosis: At presentation, it is more important not to miss a serious condition than
to make the correct nal diagnosis. The clinician should proceed rst to lower
the probability of life and function-threatening conditions to below a reasonable probability, then proceed with evaluation of the other hypotheses. For
instance, acute severe pelvic pain in fertile women is an ectopic pregnancy
until proven otherwise; all other diagnoses can wait.
Therapeutic trial. If the uncertainty is between an untreatable morbid disease
and one with potentially successful therapy, consider a therapeutic trial. Each
trial must have a protocol that explicitly states the intervention and duration, the objective and subjective end points for interpretation at a specied
time, and the planned response to a successful outcome or treatment failure. Experience shows that such trials are often inconclusive if they fail to
adhere to these parameters, exposing patients to prolonged and hazardous
The Diagnostic Process 11
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treatments of little or no benet. Doing something is not necessarily better
than observation and close follow-up.
Selecting Diagnostic Tests: Select diagnostic investigations to test the hypoth-
eses generated from the history and physical exam. Unfocused testing or an
uncritical search for unlikely diagnoses frequently leads to more testing,
without leading to an explanatory diagnosis. This cascade effect heightens
the patient’s anxiety, is hazardous, expensive, and often delays treatment. See
Chapter 17 for a discussion of an appropriate testing strategy. Tests are performed to answer specic diagnostic, prognostic, or therapeutic questions,
and should not be a response to curiosity.
Rare Diseases: Some physicians, especially the inexperienced, tend to search
and test for rare diseases. It is good to recall that rare diseases occur rarely.
The proverb “when you hear hoofbeats think horses, not zebras” works in
America, but not in Africa. It is necessary to know the epidemiology of a
population of patients like yours to really know what is common and what is
rare in each clinical setting.
Certainty and Diagnosis: How certain should the clinician be that a diagnosis is
correct before it is accepted? There is no accepted scale for degrees of certainty.
A diagnosis may be dened by an image, laboratory test, culture, or the biopsy
result. A fractured tibia is diagnosed by X-ray with assurance. Many types of
neoplasia and inammatory diseases are diagnosed by biopsy. Culture, serology, or polymerase chain reaction identify specic organisms establishing the
diagnosis of an infectious disease. Laboratory tests are specic for endocrine
and metabolic diseases. On the other hand, for many diseases and syndromes,
there are no denitive diagnostic tests. For each clinical scenario the clinician
must establish a stopping rule, the level of certainty required to stop further
investigation. This decision is based upon the severity of illness, an estimate
of the prognosis, and whether a specic diagnosis is needed to guide a decision between mutually exclusive interventions which would harm the patient if
applied to the wrong disease. When a satisfactory diagnosis has not been established, the following steps should be considered, in addition to close follow-up.
Consultation. Obtaining consultation from an excellent generalist or appropriate subspecialist may produce a diagnosis, but even if not, the patient and
physician are reassured. It is better to offer this option than to wait for the
patient to insist out of frustration. However, avoid excessive consultation or
visits to multiple physicians. Like excessive laboratory testing, this is more
likely to add confusion than clarity.
Repeat the history and physical exam. The patient or a family member may
recall additional information stimulated by the rst inquiry. Talk to more relatives and attendants to conrm or deny the original story and to add details.
Obtain copies of patient records from all previous caregivers. Carefully repeat
the physical exam to conrm your previous evaluation and to search for signs
that were originally overlooked.
Repeat selected laboratory tests. Specimens may have been mixed up on the
initial evaluation, or an error in the rst test may be uncovered. As always,
12 CHAPTER 1: Diagnosis
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each test should provide the answer to a specic question; do not search for
diagnostic ideas in the laboratory.
Defer diagnosis. Carefully explaining the uncertainty helps to secure
the patient’s condence so that follow-up occurs. Time, study, and reection often lend perspective to the case. Present the case to colleagues as an
unknown for their suggestions. Retain the problem list marking the record
“Diagnosis Deferred.” Do not let medical records rules, or an insurance company, force a premature diagnosis. Remember, when a diagnosis is made, thinking
often stops.
Make a provisional diagnosis. It may be appropriate to make a provisional
diagnosis understanding that it is difcult to avoid diagnosis creep: over
time a provisional diagnosis becomes an assumed diagnosis. Even though
the meticulous physician qualied the diagnosis as probable or provisional,
these modiers get dropped as the patient passes through several visits with
different physicians. Always review the original information to conrm that
each diagnosis has been conrmed.
Prognostic Uncertainty: If two hypotheses with widely differing prognoses
seem equally probable and neither can be proved nor disproved immediately,
inform the patient and review the diagnostic and prognostic possibilities.
Encourage discussion with the patient and family. It is best to help the patient
prepare for the bad prognosis, while maintaining hope for a better outcome.
Regular follow-up and frequent reevaluation are mandatory.
Summary of the Diagnostic Process:
Step 1: Take a History. Elicit symptoms and a timeline; begin a problem list.
Step 2: Develop Hypotheses. Generate a mental list of anatomic sites of dis-
Step 3: Perform a Physical Exam. Look for signs of the physiologic pro-
Step 4: Make a Problem List. List all the problems found during the history
Step 5: Create an Accurate Problem Representation. Briey summarize
Step 6:
Step 7: Test the Hypotheses. Select laboratory tests, imaging studies, and
Step 8: Modify Your Differential Diagnosis. Use the test results to reevalu-
Step 9:
ease, pathophysiologic processes, and diseases that might produce
the symptoms.
cesses and diseases suggested by the history while identifying new
ndings for the problem list.
and physical exam that require explanation.
the patient encounter translating the patient’s story into appropriate
medical terminology.
Generate a Differential Diagnosis. List the most probable diagnos-
tic hypotheses with an estimate of their pretest probabilities.
other procedures with appropriate likelihood ratios to evaluate your
hypotheses.
ate your hypotheses, eliminating some, adding others, then adjust
the probabilities.
Repeat Steps 1 to 7. Reiterate your process until you have reached
a working diagnosis or decided that a denite diagnosis is neither
likely nor necessary.
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Step 10: Make the Working Diagnosis or Diagnoses. When the tests of
Caveat: The complex process presented here is best suited to the complex
undifferentiated presentations encountered in internal medicine and pediatrics. The majority of patients seen by most physicians do not require such a
comprehensive process. Although the principles hold for all patients, variations from the described process may be appropriate for a given patient’s
condition and the medical or surgical specialty involved. A dermatologist can
make many diagnoses by visual inspection before hearing about symptoms.
On the other hand, the psychiatrist relies exclusively on the history given by
the patient, friends, relatives, and attendants. It follows that the scope of the
history and the extent of physical exam vary greatly among medical specialties and with the patient’s presenting complaints.
An Example of the Diagnostic Process: The objective of the diagnostic exami-
nation is to discover the physiologic cause of the patient’s complaint, identify
the specic disease, and determine its severity and prognosis. These are the
data needed to counsel a patient regarding treatment.
tom). You consider her age and select hypotheses including lymphoma, infection, and collagen vascular disease. She denies fever, itching, weight loss,
exposure to pets, tuberculosis, arthralgias, and Raynaud phenomenon. Exam
reveals a single, rm, 3-cm nontender lymph node in the right anterior cervical chain (sign); the spleen is not palpable and there are no other signs of
disease. The patient’s blood counts are normal (laboratory), and a biopsy of
the enlarged node (supplemental test) discloses Hodgkin disease. Bone marrow biopsy and imaging studies of the chest and abdomen fail to reveal more
disease (supplemental tests for staging and prognosis).
the patient and the prognosis with and without treatment is discussed with
the patient and her family. Treatment with radiotherapy and/or chemotherapy is discussed and oncology consultation is requested. Follow-up is scheduled for shortly after the consultation to provide an opportunity for questions
and more discussion as needed.
your hypotheses are of sufcient certainty that they meet your stopping rule, you have reached a diagnosis. If uncertain, consider a
provisional diagnosis or watchful waiting. Decide whether more
investigation (return to Step 1), consultation, treatment, or watchful observation is the best course based upon the severity of illness,
the prognosis, and comorbidities. If the diagnosis remains obscure,
retain a problem list of the unexplained symptoms and signs, as well
as laboratory and imaging ndings, assess the urgency for further
evaluation and schedule regular follow-up visits.
A 21-year-old woman presents with a painless lump in her neck (symp-
The diagnosis is stage I Hodgkin disease. The diagnosis is explained to
CHAPTER 2
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History Taking and the Medical Record
... [T]here is no more difcult art to acquire than the art of
observation, and for some men it is quite as difcult to record
an observation in brief and plain language.
– S W O
Safe high-quality medical care requires a medical record documenting the
observations and data needed for the patients’ care. Ideally, this record will be
accessible to all providers at any site at any time, a goal that electronic medical records make feasible. A standard format is used to record: demographics;
active and past medical problems; surgical history; medications, allergies, and
drug intolerances; family, social, and sexual history; personal habits; and preventive care services. A standard format facilitates rapid review and updating
of pertinent information at each visit. It is important to enter information so
that it is always current; for example, record the rst names of children and
siblings with their year of birth (rather than age).
OUTLINE OF THE MEDICAL RECORD
The medical history is recorded in a standard sequence. The following
sequence is suggested for adults.
1. Identication
2. Informant
3. Chief complaints (CCs)
4. History of present illness (HPI)
5. Past medical and surgical history (PMH)
a. General health
b. Chronic illnesses and conditions
c. Operations and injuries
d. Hospitalizations
6. Family history (FH)
7. Social history (SH)
8. Review of systems (ROSs)
9. Medications
10. Allergies and medication intolerances
11. Preventive services, including immunizations
12. Physical examination (PE)
13. Laboratory and imaging studies
14. Assessment/Problem list
15. Plan
14
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The medical history is the history of this person. The current illness cannot be fully understood without knowing the unique history of the person,
not just as patient, but as a person in society. The details of their family and
social history provide context for their medical care. All serious illnesses
including surgeries, injuries, and hospitalizations are recorded. The status of
preventative care is also established. Verication of these events by review of
the previous medical records is advised.
A medical history is more than a list of facts. It is a unique literary
form in which the physician writes an account of perceptions and events
as related by the patient. The history may be given spontaneously, or may
require some probing, returning to areas of uncertainty for clarication.
The history should record key statements in the patient’s words. A history is usually incomplete at the rst telling; repeat questioning after an
interval of hours or days will yield additional information. Take particular
care to establish the sequence of events. Neither the patient in the telling
nor the physician in the recording should introduce medical terms or jargon; be sure that the story is told in everyday language. The history is the
patient’s story of their illness, not the physician’s interpretation of the patient’s
history. The challenge is to understand the patient’s experience and inter-
pretation of their illness.
Scope of the History: The literature on history taking discusses the extended
history, which is complicated and demands maximal skill. However, it would
be folly to insist on an extended history for every patient; in many situations,
it is unnecessary, and unnecessarily time consuming. The experienced clinician adjusts their technique to the setting and the patient’s problem. When
seeking care for dermatitis, the necessary diagnostic history is brief, possibly
only a few sentences. For a fractured tibia, a long history is unnecessary and
even inhumane. In contrast, a chronic, obscure disease may require a long,
careful history, perhaps repeated and expanded, with supplementation as the
results of studies open new diagnostic possibilities.
How to Take a History: The patient–physician encounter is a ritual invested
with many layers of meaning; do not take it for granted. Accurate histories are
obtained by empathetic clinicians who inspire condence so that the patient
feels free to relate their symptoms, fears, and uncertainties. Communication
is much more than words; it is also inection, facial expression, and body
language. Patient listening, respecting pauses and silences, and avoiding the
appearance of impatience will put the patient at ease so that they feel safe
relating their story. As you learn more about the patient you will be better
prepared to draw out details of their history. You cannot learn to take a good
history from a book, this one included; prociency is only obtained by interviewing patients. Your condence and skill will improve as more is learned
of people, life, and disease.
Clinical experience and reection upon your experience are necessary
to link your knowledge of diseases with the history being obtained from the
patient. With this knowledge and experience, you can face the patient condently and adapt your questioning to the evolving history. There are only a
few principles to keep in mind: (1) listen actively; (2) do not interrupt; (3) ask
open-ended questions; and (4) be patient, give the patient time to think and
speak. It is most important to be a real person yourself; have a conversation.
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