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

2. 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. 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. 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. 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. 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. 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. 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. 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. 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. 11 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. General Content of Health Histories

12. 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. 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. 14 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. History of Present Illness (cont’d)

15. 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. 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. 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. 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