1 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Chapter 2 The Medical History and the Interview

2 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Learning Objectives After reading this chapter you will be able to:  Recognize the importance of properly obtaining and recording a patient history  Identify factors that can influence communication between the patient and clinician during the interview  Identify at least three examples of nonverbal communication techniques  Describe how to structure the interview

3 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Learning Objectives (cont’d)  Describe techniques to facilitate conversational interviewing  Identify alternative sources of patient history  Differentiate between objective and subjective data and signs and symptoms  Describe the components of a complete health history and the type of information found in each section of the history

4 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Learning Objectives (cont’d)  Describe the value in reviewing the following parts of the patient’s chart:  Admission notes  Physician orders  Progress notes  Recognize what is indicated by a “DNR” label on the patient’s chart

5 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Introduction  Patient’s medical history is the foundation of a comprehensive assessment  RTs interview the patient to assess effects of treatment and identify changes in pulmonary status  RT must be able to review the patient’s chart to identify key facts in the medical history

6 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Patient Interview  Communication  Important part of each patient interaction  Many factors influence how patient may interpret your verbal and nonverbal communication skills  A common mistake made by health care providers is not listening to the patient

7 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Patient Interview (cont’d)  Structuring the interview  Project undivided interest in the patient  Introduce yourself in a professional manner  Respect the patient’s beliefs and attitudes  Use a relaxed conversational style that communicates empathy and genuine concern

8 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Patient Interview (cont’d)  Questions and statements facilitate interviewing  Use open-ended questions at times  Closed questions provide clarification  Avoid using leading questions  Repeating certain words the patient just used can stimulate further input from the patient

9 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Patient Interview (cont’d)  Alternative sources for a patient history  In some cases the patient may not be able to communicate  Family members, friends, previous caregivers, previous medical records etc. can provide important information

10 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Cardiopulmonary History and Comprehensive Health History  Patients with lung disease often have medical problems in other body systems  Interviewing the patient with lung disease must include questions about other body systems  The length and focus of the history vary with the needs of the patient

11 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. General Content of Health Histories

12 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Chief Complaint  A brief notation explaining why the patient is seeking medical care  Common symptoms associated with lung disease include cough, dyspnea, chest pain, and wheezing  Constitutional symptoms include chills, fever, excessive sweating, loss of appetite, nausea, vomiting, and fatigue

13 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. History of Present Illness  HPI is a narrative description in detail of each symptom listed in the CC  All caregivers should be familiar with the patient’s HPI  Each symptom is reviewed in the HPI for its onset, location on the body, severity, quantity, quality, duration, course, aggravating factors and alleviating factors

14 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. History of Present Illness (cont’d)

15 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Past History  A description of the patient’s past medical problems  Includes previous illnesses, surgeries, accidents, allergies, medications, habits (e.g., use of tobacco and alcohol), and description of general health

16 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Family History  Useful to learn about the health status of the patient’s blood relatives  Cardiopulmonary diseases that may have a hereditary link include asthma, lung cancer, cystic fibrosis, emphysema, and sleep apnea  Interviewer should ask about exposure to family or friends with an infectious disease

17 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Occupational and Environmental History  Most occupational pulmonary diseases are the result of workers inhaling dusts, fumes, or gases in the industrial setting  Reaction to inhaled substances can occur within minutes or may take months or years to develop  Work or residence near mines, farms, mills, shipyards or foundries is noted

18 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Reviewing the Patient’s Chart  Admission note: written by the attending physician; a description of important facts related to the patient’s admission  Physician orders: list of treatments and monitoring techniques  Progress notes: written by physician and other health care providers each day to describe the patient’s response to treatment