Medical History and Interview PDF

THE MEDICAL HISTORY AND THE INTERVIEW ===================================== Chapter 2 - Process of imparting a meaningful message. - Patient's level of comfort plays a very important role in the interview process. - Clinicians should learn to recognize non-verbal signs of patient d...

THE MEDICAL HISTORY AND THE INTERVIEW ===================================== Chapter 2 - Process of imparting a meaningful message. - Patient's level of comfort plays a very important role in the interview process. - Clinicians should learn to recognize non-verbal signs of patient discomfort. - Actively listen to patient by responding with a yes or no or shaking head yes or no. nonverb1 nonverb2  Interviewing the Patient ======================== STRUCTURING THE INTERVIEW - Points to keep in mind: - Proper introduction - **Address the patient by name.** - **Check the patient's armband.** - Project a sense of undivided interest in the patient. - Professional conduct. Interviewing the Patient ------------------------ - Patient's comments are confidential! - If using this patient for a case study the name of the patient should be protected. - Alternate methods of obtaining history may be from family, friends, doctors if the health of the patient prevents extensive questioning. Interviewing the Patient ======================== QUESTIONS AND STATEMENTS - Open-ended Questions vs. Closed Questions - Direct Questions vs. Indirect Questions - Neutral Questions and Statements - Reflecting (echoing) - Facilitating Phrases - Communicating Empathy. Cardiopulmonary History ======================= - Systemic diseases frequently have respiratory symptoms - Respiratory problems may affect all body systems - Assessment should not be limited to the chest - Comprehensive evaluation of the patient is essential - Variations in health history - Diagnosis and Treatment General Content of Health Histories =================================== - Background Information - Screening Information - Description of the Patient's Current Illness - Review of Systems Chief Complaint (CC) -------------------- - What brought the patient into the hospital - Each symptom recorded separately - Should not be diagnostic statements - Close the interview with "Is there anything else bothering you at this time?" - Symptoms most commonly associated with the cardiopulmonary system (pg. 21) ### History of Present Illness (HPI) - Describes chronologically and in detail the CC. - It describes effects on patient's life. - Usually the most difficult part of history to obtain. - Patient should be able to express freely. - Avoid yes or no questions. To Help You Remember... ----------------------- - P: Provocative/palliative: What is the cause? What makes it better? What makes it worse? - Q: Quality/quantity: How much is involved? How does it look, feel, sound? - R: Region/radiation: Where is it? Does it spread? - S: Severity/scale: Does it interfere with activities? - T: Timing: When did it begin? How often does it occur? Is it sudden or gradual? Past Medical History (PMI) -------------------------- - Information includes: - Illnesses and development since birth - Surgeries and hospitalizations - Injuries and accidents - Immunizations - Allergies - Medications - Habits, including diet, sleep, exercise, use of alcohol, coffee, tobacco (pack-year history), illicit drugs Family History -------------- - Search for hereditary diseases - Information on three generations - Presence or absence of most frequently reviewed diseases - In patients with cardiopulmonary complaints certain diseases are asked about specifically ### Drug and Smoking History - Important to ascertain smoking history - Document pack years - Measures smoking intensity - Record age the patient began to smoke - How often attempted to stop smoking - When the time is ideal offer smoking cessation classes ### Occupational and Environmental History - Exposure to potential disease-producing substances - Inhalation of particles, dusts, fumes, or gases - More than 200 agents are known to cause allergic occupational asthma - Reactions may take minutes to years to appear - Most common chronic pneumoconiosis take [\>]20 years to become symptomatic - Some fungal infections have a special geographic distribution, e.g. Histoplasmosis and Blastomycosis DNR (Do Not Resuscitate) Status ------------------------------- - This is used to alert the care team that there is a physician's order in the patient's chart - When present, resuscitation should not be attempted - May be instituted from an advance directive or from someone who is entitled to make decisions on behalf of the patient - DNI