Medical Interpreters: Guidelines

Medical Interpreters

• Patient understanding, safety, trust, and health outcomes improve when using the patient's preferred language
• Miscommunication can result in misdiagnosis, incorrect treatment, and medication errors
• Language barriers can lead to higher hospital readmissions and worse health outcomes
• Using professional interpreters lowers the risk of adverse events, compared to untrained staff
• Under Title VI of the Civil Rights Act, healthcare facilities with federal funding must provide language assistance to LEP patients
• The American Medical Association (AMA) and Joint Commission emphasize clear, patient-centered communication
• Miscommunication leading to harm can result in malpractice lawsuits
• Qualified interpreters and translated materials are essential for quality patient care

INTERPRET: Guidelines for working with interpreters

• Introductions: Introduce all individuals in the room and their roles
• Note Goals: Determine the goals of the interview; for example, what is the diagnosis? What will the course of treatment entail? Will there be any follow-up needed?
• Transparency: The patient must understand that everything said will be interpreted.
• Ethics: Engage qualified interpreters; not family members or children because qualified interpreters allow patients to maintain autonomy and make informed decisions about their care
• Respect Beliefs: Patients with limited English proficiency (LEP) might have cultural beliefs to consider, and interpreters may serve as cultural brokers to explain them.
• Patient Focus: Providers should interact with the patient rather than the interpreter to make sure that the patient remains the emphasis. Make sure to address the patient's questions before concluding the encounter, because the patient may not be able to call in with questions if there are no trained interpreters available on staff.
• Retain Control: Providers should stay in control of the encounter rather than allowing the patient or interpreter to take the lead.
• Explain: When utilizing an interpreter, use simple language and brief sentences to guarantee that comparable words can be found and that all information is conveyed clearly.
• Thanks: Note on the chart that the patient requires an interpreter and who served this time, give thanks to the interpreter and patient for their time.

Interviewing techniques

• Techniques include: active listening, guided questioning, empathetic responses, summarization, transitions, partnering, validation, empowering the patient, reassurance, and nonverbal communication

Adult Health History Components

• The components are: Identifying Patient Information, Source/Reliability, Chief Complaint(s), History of Present Illness, Past Medical History, Family History, Personal and Social History, and Review of Systems

Subjective Data: PQRST

• Provocation/Palliation: "What were you doing when the symptoms started?" "What makes it better or worse?"
• Quality: "Can you describe what the pain or sensation feels like?" (e.g., sharp, dull, burning, throbbing)
• Region/Radiation: "Where is the symptom located?" "Does it spread anywhere else?"
• Severity: "On a scale of 0 to 10, how bad is the pain?" "Is it affecting your daily activities?"
• Timing: "When did it start?" "Is it constant or does it come and go?" "Does it happen at a specific time of day?"
• Understanding (Patient's Perception): "What do you think is causing this?" "How is this affecting your life?”

Physical Examination Techniques

• Inspection: Close observation of appearance, behavior, and movement such as facial expression and mood
• Palpation: Tactile pressure from the palmar fingers or finger pads to assess areas of skin elevation, depression, warmth, or tenderness.
• Percussion: Use of the striking or plexor finger to deliver a rapid tap against the distal pleximeter finger to evoke a sound wave.
• Auscultation: Use of the diaphragm and bell of the stethoscope to detect the characteristics of heart, lung, and bowel sounds

Patient Positioning

• During examination, the patient can be in different positions such as sitting, lying supine, standing and more.

Assessing Overall Health Status

• Components of general survey include: physical appearance, body structure and posture, mobility, and behavior

Physical appearance

• Includes the following parameters:
  • Level of consciousness (LOC): Alert, drowsy, confused, lethargic, or unresponsive.
  • Facial expression: Relaxed, anxious, distressed, or grimacing
  • Skin color: Pallor, cyanosis, jaundice, erythema, or normal.
  • Signs of acute or chronic illness: Cachexia, frailty, or well-nourished appearance.
  • Personal cleanliness, odor, and clothing appropriate for weather.

Concerning weight gain thresholds

• Unintentional gain of >5% of body weight over 6-12 months

Weight loss threshold

• ≥ 5% of body weight lost in 6 months is concerning
• ≥ 10% of body weight lost in 6-12 months is a serious concern
• Unintentional weight loss with symptoms (fatigue, pain, night sweats, etc.) is a red flag
• Weight loss >2 lbs per week without clear cause is severe

Vital signs

• Temperature: 37 C/98.6F
• HR and pulse: 60 to 100bpm
• BP: <120/ <80
• SpO2: 95-100%
• RR: 12-20 breaths/min

Pain

• Pain can be acute or chronic
• Pain scales include: Visual Analogue Scale, Wong-Baker FACES and Numeric Rating Scale

Fever

• Abnormal body temperature elevation

Shaking Chills

• Extreme temperature swings

Rising temp

• Cold, goose bumps, chills

Falling temp

• Hot, sweating

Special BP Considerations

• White coat hypertension: BP ≥140/90 in medical settings, ambulatory <135/85
• Masked hypertension: office BP <140/90, elevated daytime BP of >135/85
• Measure BP in both arms; a difference of >15 mmHg is concerning, and >20 mmHg is a medical emergency

Head and Neck

• Key components of examination are hair and scalp, skull and skin and cervical lymph nodes
• Bilateral = cervical lymph nodes are swollen on both sides, generally soft, mobile, nontender, and less than 2cm in size
• Unilateral = Only one side has swollen lymph nodes

Thyroid

• Screen for thyroid dysfunction and thyroid cancer

Eyes examination

• Includes: Acuity (Snellen, Allen, Tumbling Es), Field (Finger wiggle test) and Color (plates test)
• Inspect eyebrows, eyelids and assesses lacrimal apparatus
• Inspects conjunctivae and sclerae
• Inspects the cornea, iris, and lens (opacity, anterior chamber depth)
• Inspect the pupils (size, shape, symmetry), near reaction and extraocular movements
• Performs fundoscopic exam

Ear examination

• Inspects the auricle and tissues. Moves the auricle and palpates.
• Examine ear canals and tympanic membranes with an otoscope.
• Test auditory acuity or gross hearing with the whispered voice test

Nose examination

• Inspects inside with an otoscope

Throat and Oral Cavity examination

• Inspect the lips, oral mucosa, gums and assesses gum margins
• Inspect the teeth, the roof of the mouth and the floor of the mouth.
• Test hypoglossal nerve, inspect tongue, palpate tongue, inspect the soft palate, anterior and posterior pillars, uvula, tonsils, and pharynx
• Test the vagus nerve

Neurological System

• SNS is responsible for releasing catecholamines like norepinephrine, especially during stress

Mental status

• Appearance and Behavior determine aspects

Glasgow Coma Scale

• Assesses the severity of brain injuries based on eye opening, and verbal and motor responses to stimuli
• Alertness: speak to the patient in a normal tone of voice
• Lethargy: speak to the patient in a loud voice
• Obtundation: apply tactile stimulus

Motor and Sensory

• Stupor: apply a painful stimulus
• Coma: apply repeated painful stimuli to the trunk and extremities

Cranial Nerves

• I. Olfactory - check nasal patency and sense of smell.
• II. Optic - Snellen Eye Chart
• III, IV, VI. Oculomotor, Trochlear, Abducens - cardinal direction of gaze
• V. Trigeminal - TMJ clenching, assess sensation
• VII. Facial - Smile, eyebrows, puff the cheek
• VIII. Acoustic - Whisper Test with auscultation
• IX, X. Glossopharyngeal and Vagus - Say ahhh and gag reflex
• XI. Spinal accessory - Shoulder shrug
• XII. Hypoglossal - Stick out tongue

Motor System

• Strength is rated from 0 to 5 and involves some resistance.

RASS

• Richmond Agitation Sedation scale

Coordination

• Rapid alternating movements

Gait

• Spastic hemiparesis, Steppage gait AKA foot drop, Cerebellar ataxia, Scissors gait, Parkinsonian gait and Sensory ataxia

Posture

• Decorticate which suggest cerebral hemisphere damage and Decerebrate indicates lower brainstem involvement

Sensory System

• Tests the various types of sensations along various tracts.

Brainstem reflexes

• Pupillary Reflex, Oculocephalic Reflex (Doll's Eyes Test), Oculovestibular Reflex (Cold Caloric Test), Corneal Reflex, Cough/Gag Reflex and Spontaneous Breathing (Apnea Test)

Meningeal signs

• Nuchal rigidity, Brudzinski's Sign and Kernig's Sign

Headache assessment

• Pulsatile/throbbing, unilateral, nausea/vomiting, disabling
• Subarachnoid hemorrhage and Meningitis & encephalitis are life threatening and requires immediate attention

Tension-related headache

• Muscle tension-related headache, often due to stress.
• Bilateral, band-like pressure (not throbbing).
• Trigeminal neuralgia = nerve irritation of the trigeminal nerve, causing facial pain

Understand the importance of medical interpreters for patient care. Miscommunication results in misdiagnosis and incorrect treatment. Follow guidelines for working with interpreters to ensure patient safety and improve health outcomes.