Medical History and Interview Techniques

Chapter 2: The Medical History and the Interview

• Medical history forms the basis of a complete assessment
• Respiratory Therapists (RTs) interview patients to evaluate treatment effects and pulmonary status
• RTs must review patient charts for key facts within the medical history
• Communication is crucial in patient interactions
• Many factors influence how patients interpret verbal and nonverbal cues
• A common mistake is health care providers not actively listening to patients

Learning Objectives

• Properly obtain and record a patient's history
• Describe interviewing techniques to structure the interview
• Summarize conversational interviewing techniques
• Identify alternative sources for patient history data
• Define the difference between objective and subjective data (signs and symptoms)
• Describe components of a complete health history and information within each section
• Evaluate patient charts: admission notes, physician orders, and progress notes
• Understand DNR orders and their implications for patient care

Introduction

• Patient's medical history is the foundation of a comprehensive assessment
• Historically, medical histories are performed by physicians
• RTs interview patients to assess treatment effects and identify pulmonary status changes
• RTs must be able to review the patient's chart to identify key facts within the medical history

Patient Interview

• Communication is a vital part of each patient interaction
• Many factors influence how a patient interprets verbal and nonverbal communication
• A common mistake made is health care providers not truly listening to their patients

Patient Interview (Cont.)

• Interview structuring is important
• Project undivided interest in the patient
• Introduce yourself professionally
• Respect patient beliefs and attitudes
• Conversational style with empathy and genuine concern

Patient Interview (Cont.)

• Your introduction should establish your role and your interest in the patient's care
• Professional conduct should demonstrate respect for patient beliefs and attitudes; this enhances professional rapport
• A relaxed conversational style with empathetic questions and statements encourages patients to express concerns

Patient Interview (Cont.)

• Questions and statements enable effective interviewing
• Open-ended questions are beneficial at times
• Closed questions assist with clarification
• Avoid leading questions; they can influence the patient's responses
• Repeating words used by the patient encourages more input
• Avoid overly mechanical or monotonous questioning styles, as these can be anxiety-provoking

Patient Interview (Cont.)

• Alternative sources for patient history data
• Sometimes, patients are unable to provide sufficient information themselves
• Family members, friends, previous caregivers, and previous medical records can be valuable sources of information
• Patients with long-term chronic illnesses may minimize or deny symptoms as a result of adaptation to their conditions

Cardiopulmonary and Comprehensive Health History

• Patients with lung disease often have related problems in other body systems
• Assessing patients with lung disease requires questions about other systems
• The length and focus of the interview vary based on individual patient needs

Outline of Complete Health History

• Demographic data (name, address, DOB, birthplace, nationality, marital status, religion, occupation, source of referral)
• Date and source of history, with estimate of historian's reliability
• Brief description of patient's condition and profile
• Chief complaint
• History of present illness
• Past medical history
• Family history
• Social and environmental history
• Review of systems
• Signature

Demographic Data

• Name
• Address
• Age and birth date
• Birthplace
• Nationality
• Marital status
• Religion
• Occupation
• Source of referral

Source of Data and Description

• Date and source of history
• Estimate of historian's reliability
• Brief description of patient's condition at the time of history
• Screening information, designed to uncover problem areas the patient forgot to mention or omitted during examination.

Review of Systems (ROS)

• Pertinent negatives: Negative responses to important questions
• Pertinent positives: Affirmative responses to important questions
• Objective data: what can be observed, felt, smelled, or heard during the physical exam
• Signs
• Subjective data: what the patient reports
• Symptoms

Chief Complaint (CC)

• Brief explanation for the patient's visit
• Common symptoms associated with lung disease (cough, dyspnea, chest pain, wheezing)
• Constitutional symptoms (chills, fever, excessive sweating, loss of appetite, nausea, vomiting, fatigue)

History of Present Illness (HPI)

• Narrative description of each symptom listed in the CC
• All caregivers should be familiar with the patient's HPI
• Each symptom should be detailed, focusing on onset, location, severity, quantity, quality, duration, course, aggravating factors, and alleviating factors

Describing Symptoms

• Onset: Date, time, and type
• Setting: Cause, circumstance, activity
• Location: Where on the body; does it radiate?
• Severity: How bad is it, affecting daily activities?
• Quantity: How much, large area, or many?
• Quality: Unique characteristics (color, texture, odor, composition, sharp, viselike, throbbing)

Describing Symptoms (Cont.)

• Frequency: How often it occurs
• Duration: How long it lasts (constant/intermittent)
• Course: Getting better/worse/staying same
• Associated symptoms: Symptomes from same or different body systems
• Aggravating factors: Things that worsen symptoms
• Alleviating factors: Things that improve symptoms

PQRST Mnemonic

• P: Provocative/Palliative (Cause/What makes it better/worse)
• Q: Quality/Quantity (How much, look, feel, sound)
• R: Region/Radiation (Where is it? Does it spread?)
• S: Severity (Scale of 1 to 10)
• T: Timing (When did it begin? How often? Sudden or gradual?)

Past Medical History

• Description of patient's past medical problems
• Includes childhood diseases, hospitalizations, surgeries, injuries, accidents, and major illnesses
• Includes allergies, medications, immunizations, and general health status; sources of previous health care

Disease and Procedure History

• List of past diseases and procedures, including, but not limited to Pneumonia, Pleurisy, Fungal diseases, Tuberculosis, Colds and sinus infections, Bronchiectasis, Asthma, Allergies, Pneumothorax, Bronchitis or emphysema

Pack-Year History

• Number of years a patient has smoked multiplied by the number of packs per day
• A way to measure cumulative smoking

Family History

• Includes familial disease history, family history, marital history, and family relationships
• Useful for understanding the health status of the patient's blood relatives
• Importance of asking about exposure to family members or friends with infections

Social and Environmental History

• Education, military experience, and occupational history
• Religious and social activities, living arrangements, hobbies, recreation, and travel; habits (smoking, vaping, alcohol, drug use)
• Exposure to illnesses in friends/family and situations affecting satisfaction/stress, finances, and relationships; recent travel or events

Social and Environmental History (Cont.)

• Occupational and environmental history: exposure to dusts, fumes, or gases in industrial settings
• Reactions to inhaled substances may take months or years to develop
• Work or residence near mines, farms, mills, shipyards, or foundries should be noted
• Important to review various places a patient has lived or visited

Electronic Medical Records

• Electronic medical records (EMRs)
• Records stored in computerized databases
• Include admitting information, history/assessment notes, laboratory tests, and imaging studies

Reviewing the Patient's Chart

• Admission note: Attending physician's summary of important admission facts
• Physician orders: List of treatments and therapies, monitoring techniques
• Progress notes: Daily notes from physicians and other providers, describing the patient's response to treatment

DNR Status

• Advance directive—a legal document that specifies medical actions in case of inability to make decisions
• "Do Not Attempt to Resuscitate" and "Do Not Resuscitate"
• Based on patient/family wishes and physician orders
• Variations and specific instructions should be noted

This quiz focuses on the essential aspects of gathering a complete medical history and effective patient interviewing techniques specifically designed for Respiratory Therapists. It covers how to properly record patient information, assess verbal and nonverbal communication, and utilize alternative sources for obtaining patient data. Mastering these skills is critical for successful patient interactions and effective healthcare delivery.