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Note how the patient relates to the staff, takes off a jacket, and sits in the examination room. How does the patient begin to describe the problem and what does he or she seem to want from the visit? Who accompanies the patient to the office and who seems to do the talking?
Be sure to use “tell me about” open-ended questions. The inexperienced clinician moves early to closed-ended “Yes” or “No” questions, but the veteran Dx10 clinician has learned that using narrow questions too early can lead to misleading conclusions, which, at least in the long run, are wasteful of time and, at worst, dangerous. An example would be inappropriately attributing chest pain to gastroesophageal reflux disease because the patient has a past history of esophageal reflux and responds affirmatively to questions about current heartburn and intolerance to spicy foods.
Watch the facial reaction to issues discussed. Tune in to hesitation and evasive answers, and be willing to follow these diagnostic paths, which may lead to the otherwise hidden problems such as drug abuse or domestic violence. In the case of Joan S., does she answer questions readily, or does she seem evasive when addressing some topics, such as family concerns or her home life?
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
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