As you gain experience listening to patient concerns, you will deepen your skills of clinical reasoning. You will generate and test diagnostic hypotheses about which disease process might be present. Identifying all the features of each symptom is fundamental to recognizing patterns of disease and to generating the differential diagnosis. It is important to fully flesh out the patient's story. This avoids the common trap of premature closure, or shutting down the patient's story too quickly, which can lead to errors in diagnosis.
It is helpful to visualize the process of evoking a full description of each symptom as "the cone" (Fig. 1).
FIGURE 1. Gather a full description of each symptom.
Each symptom has its own "cone," which becomes a paragraph in the History of Present Illness in the written record.
Questions about clusters of symptoms in common clinical entities are also found in "The Health History" section of each of the regional physical examination chapters. The interview is your primary source of evidence for and against various diagnostic possibilities. The challenge is to avoid a cliniciancentered agenda, letting focused questions take over that obscure the patient's perspective and limit your opportunity to create an empathic therapeutic connection.
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