Medical History & Patient Interviewing 1

Medical History & Interview

• The interview process involves imparting meaningful messages.
• Patient comfort is crucial during the interview.
• Clinicians must recognize nonverbal signs of patient discomfort.
• Active listening involves responding with "yes" or "no", or head nods.

Interviewing the Patient

• Proper introduction is important.
• Address the patient by name.
• Check the patient's armband.
• Project undivided interest in the patient.
• Maintain professional conduct.
• Patient comments are confidential.
• If using patient data for a case study, protect the patient's name.
• Use alternative methods for obtaining history if needed (e.g., family, friends, doctors).

Questions and Statements

• Understand open-ended versus closed questions.
• Differentiate direct and indirect questions.
• Use neutral questions and statements.
• Employ reflecting techniques (echoing).
• Use facilitating phrases.

Cardiopulmonary History

• Systemic diseases often demonstrate respiratory symptoms.
• Respiratory problems can impact multiple body systems.
• Thorough assessment extends beyond the chest.
• Comprehensive patient evaluation is critical.

General Content of Health Histories

• Background information is essential.
• Screening information is required.
• Description of current illness is necessary.
• Review of body systems is important.

Chief Complaint (CC)

• The chief complaint is what brought the patient to the hospital.
• Record each symptom separately.
• Avoid diagnostic statements.
• Close the interview with a question like "Is there anything else troubling you?".
• Common symptoms are associated with cardiopulmonary systems.

History of Present Illness (HPI)

• Chronologically describe the major complaint.
• Details the impact on the patient's life.
• Obtaining HPI can be complex.
• Patients should express themselves freely during the process.
• Avoid yes/no questions.

To Help You Remember...

• (P)rovocative/Palliative: What causes it? What relieves or worsens it?
• (Q)uality/Quantity: Detail how much, look, feel and sound?
• (R)egion/Radiation: Location and spread?
• (S)everity/Scale: Impact on daily activities?
• (T)iming: When did it start? Frequency?

Past Medical History (PMI)

• Illness information since birth.
• Surgeries and hospitalizations.
• Injuries and accidents.
• Immunizations.
• Allergies.
• Medications.

Family History

• Identify hereditary diseases.
• Gather information from three generations.
• Look for common illnesses.
• Important for patients with cardiopulmonary complaints.
• Focus on relevant diseases for the individual.

Drug and Smoking History

• Essential smoking history documentation.
• Record pack years.
• Assess smoking intensity.
• Document smoking initiation.
• Note frequency of attempts to quit.
• Offer smoking cessation classes when appropriate.

Occupational and Environmental History

• Identify exposure to potential disease-causing substances.
• Note inhalation exposure (dusts, fumes, gases).
• Many environmental agents cause allergic occupational asthma.
• Reactions can manifest immediately or take years to develop.
• Common occupational diseases sometimes take decades to appear.

DNR (Do Not Resuscitate) Status

• Used to inform the care team.
• The order is in the patient's chart.
• Resuscitation should be avoided.
• Created through advanced directives or other authorized individuals.

DNI

• Do Not Intubate