Chapter 2: The Medical History and the Interview PDF

Chapter 2 The Medical History and the Interview  Learning Objectives After reading this chapter, you will be able to: 1. Recognize the importance of properly obtaining and recording a patient history. 2. Describe the techniques for structu...

Chapter 2 The Medical History and the Interview  Learning Objectives After reading this chapter, you will be able to: 1. Recognize the importance of properly obtaining and recording a patient history. 2. Describe the techniques for structuring the interview. 3. Summarize the techniques used to facilitate conversational interviewing. 4. Identify alternative sources available for the patient history. Copyright © 2018, Elsevier Inc. All Rights Reserved. 2  Learning Objectives (Cont.) 5. Define the difference between objective and subjective data and the difference between signs and symptoms. 6. Describe the components of a complete health history and the type of information found in each section of the history. 7. Describe the value in reviewing the following parts of a patient’s chart: admission notes, physician orders, and progress notes. 8. Summarize what is indicated by a DNR order and label on the patient’s chart. Copyright © 2018, Elsevier Inc. All Rights Reserved. 3  Introduction Patient’s medical history is the foundation of a comprehensive assessment Traditionally done by the physician 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 Copyright © 2018, Elsevier Inc. All Rights Reserved. 4  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 Copyright © 2018, Elsevier Inc. All Rights Reserved. 5  Patient Interview (Cont.) 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 Copyright © 2018, Elsevier Inc. All Rights Reserved. 6  Patient Interview (Cont.) Structuring the interview Your introduction establishes your professional role, asks permission to be involved in the patient’s care, and conveys your interest in the patient Professional conduct shows your respect for the patient’s beliefs, attitudes, and rights and enhances patient rapport A relaxed, conversational style on the part of the health care professional with questions and statements that communicate empathy encourages patients to express their concerns Copyright © 2018, Elsevier Inc. All Rights Reserved. 7  Patient Interview (Cont.) 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 An interview made up of one direct question followed by an answer and another direct question is mechanical, monotonous, and anxiety producing Can make patients feel they are being interrogated Copyright © 2018, Elsevier Inc. All Rights Reserved. 8  Patient Interview (Cont.) 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 Patients with long-standing chronic disease may have become accustomed to the accompanying symptoms They may minimize and even deny symptoms Copyright © 2018, Elsevier Inc. All Rights Reserved. 9 Cardiopulmonary 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 Copyright © 2018, Elsevier Inc. All Rights Reserved. 1 0  Outline of Complete Health History Demographic data Date and source of history, estimate of historian’s reliability Brief description of patient’s condition at time of history or patient profile Chief complaint History of present illness Past history or past medical history Family history Social and environmental history Review of systems Signature Copyright © 2018, Elsevier Inc. All Rights Reserved. 11  Demographic Data Name Address Age and birth date Birthplace Race Nationality Marital status Religion Occupation Source of referral Copyright © 2018, Elsevier Inc. All Rights Reserved. 1 2  Source of Data and Description Date and source of history Estimate of historian’s reliability “The patient seems to be a good/fair/poor historian” Brief description of patient’s condition at time of history or patient profile Screening information Designed to uncover problem areas the patient forgot to mention or omitted Obtained during the head-to-toe exam Copyright © 2018, Elsevier Inc. All Rights Reserved. 13  Review of Systems (ROS) Pertinent negatives Negative responses to important questions Pertinent positives Affirmative responses to important questions Objective data: provided during physical exam That which can be seen, felt, smelled, or heard Signs Subjective data: provided during the ROS That which is evident only to the patient Symptoms Copyright © 2018, Elsevier Inc. All Rights Reserved. 1 4  Chief Complaint (CC) 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 Copyright © 2018, Elsevier Inc. All Rights Reserved. 1 5  History of Present Illness (HPI) 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 Copyright © 2018, Elsevier Inc. All Rights Reserved. 1 6  Describing Symptoms Description of onset: date, time, and type Setting: cause, circumstance, or activity surrounding onset Location: where on the body the problem is located and whether it radiates Severity: how bad it is and how it affects activities of daily living Quantity: how much, how large an area, or how many Quality: what it is like and character or unique properties, such as color, texture, odor, composition, sharp, viselike, or throbbing Copyright © 2018, Elsevier Inc. All Rights Reserved. 1 7  Describing Symptoms (Cont.) Frequency: how often it occurs Duration: how long it lasts and whether it is constant or intermittent Course: is it getting better, worse, or staying the same? Associated symptoms: symptoms from the same body system or other systems that occur before, with, or following the problem Aggravating factors: things that make it worse Alleviating factors: things that make it better Copyright © 2018, Elsevier Inc. All Rights Reserved. 1 8 Copyright © 2018, Elsevier Inc. All Rights Reserved. 19  Past Medical History A description of the patient’s past medical problems Includes: Childhood diseases and development Hospitalizations, surgeries, injuries, accidents, and major illnesses Allergies Medications Immunizations General health and sources of previous health care Copyright © 2018, Elsevier Inc. All Rights Reserved. 2 0  Disease and Procedure History Pneumonia Pleurisy Fungal diseases Tuberculosis Colds and sinus infections Bronchiectasis Asthma Allergies Pneumothorax Bronchitis or emphysema Copyright © 2018, Elsevier Inc. All Rights Reserved. 2 1  Pack-Year History The term pack-years is the number of years the patient has smoked multiplied by the number of packs per day If a patient smoked 3 packs a day for 10 years Recorded as a 30 pack-year smoking history Copyright © 2018, Elsevier Inc. All Rights Reserved. 2 2  Family History Includes: Familial disease history Family history Marital history Family relationships Useful to learn about the health status of the patient’s blood relatives Cardiopulmonary diseases that may have a hereditary link Interviewer should ask about exposure to family or friends with an infectious disease Copyright © 2018, Elsevier Inc. All Rights Reserved. 2 3  Social and Environmental History Education Military experience Occupational history Religious and social activities Living arrangements Hobbies, recreation, and travel Habits, including smoking and vaping Alcohol or drug use Exposure to friends or family who are ill Satisfaction/stress with life situation, finances, and relationships Recent travel or other event that might affect health Copyright © 2018, Elsevier Inc. All Rights Reserved. 2 4  Social and Environmental History (Cont.) 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 Important to review the various places a patient has lived or visited for any period of time Copyright © 2018, Elsevier Inc. All Rights Reserved. 2 5  Electronic Medical Records Electronic medical records (EMRs) Records are stored in computerized databases Including: Admitting information History and assessment notes Laboratory tests Imaging studies Copyright © 2018, Elsevier Inc. All Rights Reserved. 2 6  Reviewing the Patient’s Chart Admission note: Written by the attending physician Description of important facts related to the patient’s admission Physician orders: Written by physicians List of treatments and therapies Monitoring techniques Progress notes: Written by physician and other health care providers each day Describe the patient’s response to treatment Copyright © 2018, Elsevier Inc. All Rights Reserved. 2 7  DNR Status Advance directive A legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity Do Not Attempt to Resuscitate Do Not Resuscitate Instituted based on patient/family wishes and physician order Be aware of variations and specific instructions Copyright © 2018, Elsevier Inc. All Rights Reserved. 2 8