Chapter 2. The Medical History and the Interview (1).pdf

THE MEDICAL HISTORY AND THE INTERVIEW Chapter 2  Patient Interview PRINCIPLES OF COMMUNICATION 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 n...

THE MEDICAL HISTORY AND THE INTERVIEW Chapter 2  Patient Interview PRINCIPLES OF COMMUNICATION 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.  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