Per CPT Assistant, April 1996
The clinician should have an understanding as to the location of the problem. For example, if a patient complains of pain, a physician may ask if the pain is diffuse or localized? Unilateral or bilateral? Fixed or migratory? Does it radiate or is it referred to another location(s)? The physician may also ask the patient to point to the specific symptomatic area.
The physician should encourage the patient to describe the quality of the symptom, since some diseases or conditions produce specific patterns of complaints. For example, pain may be described as sharp, dull, throbbing, stabbing, constant or intermittent, acute or chronic, or stable, improving or worsening.
The physician should get some idea about the severity of the discomfort or sensation or pain. The patient may describe the severity of the pain by employing a crude self-assessment scale to measure subjective levels (ie, 1 to 10, with 1 being no pain and 10 the worst pain experienced). The pain may be estimated through nonverbal signals of discomfort, such as the patient lying perfectly still or continuously pacing the floor. Another technique is to ask the patient to compare the pain quantitatively with a previously experienced pain (eg, kidney stone or labor). Can the patient continue to function with the pain or does it result in total immobilization?
Establishing the onset for each symptom or problem, and a rough chronology of the development of the problem, are also important. To do this, the physician may ask; is it primarily nocturnal, diurnal, or continuous? Or has there been a repetitive pattern for the symptom? (See also discussion of associated signs and symptoms.)
To understand the context, a physician may obtain a description of where the patient is and what the patient does when the symptoms or signs begin. Is the patient at rest or involved in an activity? Is the symptom aggravated or relieved, or does it recur with a specific activity? Has situational stress or some other factor been present preceding or accompanying it?
What has the patient attempted to do to obtain relief, or make him or herself better? Which make the symptom(s) worse? For example, does the local application of heat or cold relieve or exacerbate a symptom? Does eating relieve or exacerbate an abdominal discomfort? Does coughing irritate the pain? Have over-the-counter or prescribed medications been attempted? What were the results?
Associated Signs and Symptoms
A clinician's impressions formulated during the interview may lead to questioning about additional sensations or feelings. Examples may include: diaphoresis (marked sweating) associated with indigestion or chest pain; tremulousness; weakness and hunger pangs in patients with diabetes; or blurring vision accompanying a headache. Generalized symptoms, such as chills and/or fever (and its levels) headaches, overall weakness, or exhaustion are often relevant. A clinician may ask patients directly about "pertinent positives and negatives," such as the presence of bloody or tarry stools associated with changing bowel habits.