Interpretation of Patient Medical History PDF

Interpretation of Patient Medical History SARA ALHUSSINI. RRT,MSC SAKINAH ALMASHHED. RRT,MSC  Principles of Interviewing Outline: PatientMedical History Common Cardiopulmonary Symptoms Principles of Interviewing ► Interviewing is the process of gathering the...

Interpretation of Patient Medical History SARA ALHUSSINI. RRT,MSC SAKINAH ALMASHHED. RRT,MSC  Principles of Interviewing Outline: PatientMedical History Common Cardiopulmonary Symptoms Principles of Interviewing ► Interviewing is the process of gathering the medical history of a patient. ► Building rapport with a patient requires basic human skills of communicating concern, warmth, and empathy  Interview Structure Respect patient’s beliefs, Introduction of professional attitudes, and rights role Cover the patient appropriately Asks permission to be involved Ask for the patient’s permission in the patient’s care Never guess at an answer or Professionally Dress information you do not know Smile, and Make eye contact Never argue Call the patient by name Ask if there is anything else Factors affecting communication between the RT and the patient  Open-ended Questions and questions Direct “What prompted questions Statements Used you to come to “Why?” the hospital?” to Facilitate Neutral questions Conversational “Tell me more about...” Interviewing Indirect questions “If I understood Closed you correctly, it is questions harder for you to “When did your breathe now than it cough start?” was yesterday.”  Asking the patient, “Is your breathing better now?” leads the Avoid asking patient toward a desired response and may elicit false leading questions information. Rather ask the patient, “How is your breathing now?” Often this gets more accurate information PHI= Protected Health Information Patient Medical History ► Subjective data information that the patient reports feels, or experiences that cannot be perceived by an observer. ► The foundation of comprehensive assessment  Complete Health History Past medical Social and History of Family history Chief complaint history environmental present illness history Childhood Familial Education Reason for Onset illness disease history Religious and social seeking Location Hospitalization Family history activities health care Severity Surgeries Marital history Living arrangements (quantity) Injuries Family Hobbies Quality Accidents relationships Recreation (character) Major Illnesses Habits Aggravating/alle Allergies Smoking viating factors Medications Immunizations Activity  Medical History Chief Complaint History of Present Past Medical Family History Social and Illness History Environmental History  ► When did the symptoms start? Common ► How severe is it? (This can be rated on a scale of 1 to characteristics of 10.) symptoms can be identified by asking ► Where on the body is it? (This is especially important for chest pain.) the following questions during the ► What seems to make it better or worse? interview ► Has it occurred before? (If so, how long did it last?) ► Identifying characteristics of any new symptom may be helpful in determining the cause and selecting appropriate therapy  Smoking History Calculation Example (pack-years) The smoking history is recorded in pack-years There are 20 cigarettes per pack Smoking History Pack years = # number of packs smoked per day X number of years smoked Example 1: If a patient states that he or she has smoked a pack of cigarettes a day for 20 years, Pack years = # 1X 20 The patient has a 20 pack-year smoking history  Example 2: If a patient states he or she has smoked a pack and a half of cigarettes per day for 20 years, Smoking History 30 cigarettes /20 cigarettes per pack =1.5 packs Pack years = 1.5 packs × 20 years = 30 pack years smoking history Example 3: If the patient states that he or she has smoked 15 cigarettes per day for 20 years, 15 cigarettes /20 cigarettes per pack = 0.75 packs Pack years = 0.75 packs × 20 years = 15 pack years smoking history  The patient (or a legally authorized Advance Directive representative) has formalized his or her wishes for resuscitative efforts; this is typically referred to as the DNR status (“do not resuscitate”) or may be expressed as DNI (“do not intubate”).  Common Cardiopulmonary Signs and Symptoms Sputum Dyspnea Cough Hemoptysis Production Chest Pain Fever Pedal Edema  The RT should try to categorize each sensation according to a particular aspect of breathing: inspiration, expiration, respiratory drive, or lung volume “I feel that my breath stops,” reflects a problem Dyspnea with inspiration. “my breath does not go all the way out,” suggests a problem with expiration. “I can’t catch my breath,” suggest breathlessness.  The RT should ask what activities of daily living tend to trigger episodes of dyspnea. For example, is dyspnea triggered by walking on Assessing flat surfaces, by climbing stairs, by bathing, by dressing? The RT should ask how much exertion makes the patient to stop to Dyspnea in catch his or her breath with different activities. Does the patient need to stop after walking up one mile or 5 miles? Dyspnea provoked by less strenuous activities indicates more advanced disease the The RT should ask whether the quality or the sensation of breathing Interview discomfort varies with different activities. To gain a better understanding of the patient’s history, ask the patient to recall when dyspnea first began and how it has evolved over time. Has dyspnea progressed slowly or rapidly? How long has this progression taken place: over a period of months or years? Has there been a dramatic change in the intensity of dyspnea over the recent past?  There are perplexing situations in which a patient with normal cardiopulmonary function complains of dyspnea or suffocation. This is Psychogenic known as psychogenic hyperventilation syndrome and is associated with panic Dyspnea: Panic disorders. Disorders and Hyperventilation may coincide with other Hyperventilation symptoms such as chest pain, anxiety, palpitations, and paresthesia (the sensation of tingling and numbness in the extremities  The RT always must approach any situation involving hyperventilation or dyspnea as if it had a pathogenic basis The first priority is to measure the vital signs, including SaO2, and perhaps a 12-lead Hyperventilation electrocardiogram and arterial blood gases A psychogenic source is considered only after a pathogenic source for hyperventilation or dyspnea has been ruled out.  The effectiveness of a cough depends on (1) the ability of the individual to take a deep breath (2) lung elastic recoil (3) expiratory muscle strength (4) level of airway resistance Cough Often, expiratory flow is limited by factors such as bronchospasm (e.g., asthma), reduced lung elastic recoil (as in emphysema) and muscle weakness. Patients with an inadequate ability to cough often have problems with atelectasis, retained secretions, and therefore are more prone to developing pneumonia and/or hypoxemia.  A dry, nonproductive cough is typical for restrictive lung diseases such as CHF or pulmonary fibrosis. A loose, productive cough is more often Cough Types associated with inflammatory obstructive diseases such as bronchitis and asthma. The most common cause of an acute, self-limited cough is a viral infection of the upper airway.  Ineffective (non-productive) coughing is common in patients with cardiopulmonary, neurologic, or neuromuscular diseases, as well as in the early Sputum postoperative period after thoracic and upper abdominal surgery or trauma. Ineffective coughing Production places patients at increased risk of developing Atelectasis Retained secretions Pneumonia Hypoxemia  Coughing up blood or blood-streaked sputum from the lungs is common in patients with pulmonary disease Massive hemoptysis is when more than 300 ml of blood is expectorated over 24 hours and represents a medical emergency Hemoptysis Bronchiectasis Lung abscess Acute or chronic tuberculosis Non-massive hemoptysis is observed in many conditions such as airway infections Pneumonia Lung cancer Tuberculosis Blunt or penetrating chest trauma Pulmonary embolism  Pleuritic Chest pain Non pleuritic Chest pain Location Laterally or posteriorly and In the center of the anterior chest and may radiate to the shoulder, neck, or back Description Sharp, stabbing type of pain Dull ache or pressure type of pain Chest Pain Effect of breathing Worsens when taking a deep breath It is not affected by breathing Common It manifests primarily in chest Angina (a pressure sensation causes diseases that cause the pleural with exertion or stress that lining of the lung to become results from coronary artery inflamed (such as pneumonia, occlusion) empyema, pleural effusion) Gastroesophageal reflux Pulmonary embolism Esophageal spasm Gallbladder disease  Fever is an elevated body temperature greater than 38.3°C (101°F) The most common sources being a bacterial, viral, or fungal infection Non-infectious causes of fever: Fever Drug reaction (e.g., sulfa drugs) Malignancies (e.g., lymphomas metastatic cancer), Head trauma (e.g., damage to the hypothalamus), Burns Thromboembolic disorders (e.g., pulmonary embolism) Non- infectious inflammatory diseases (e.g., rheumatoid arthritis, systemic lupus erythematosus)  Swelling of the lower extremities and often most occurs with heart failure. Increased hydrostatic pressure from blood pooling in the gravity-dependent lower extremities causes fluid to leak into the interstitial spaces Pedal Edema The degree of pedal edema depends on the severity of heart failure. Patients with chronic hypoxemic lung disease are especially prone to right-sided heart failure (cor pulmonale) that also causes pedal edema Chronic hypoxia causes severe pulmonary vasoconstriction and pulmonary hypertension. This places a heavy demand on the thin-walled right ventricle, which can eventually fail, resulting in venous congestion Pedal Edema  Pitting edema is when finger pressure applied on a swollen extremity leaves an indentation mark on the skin The height at which pitting edema occurs can indicate the severity of heart failure. Pitting/ Weeping Pitting edema that extends to the knee signifies a more significant problem than edema limited to the Edema ankles. A standard scale may be used to quantify the severity of pitting edema, with “1” equating to a trace with rapid refill and “4” meaning severe pitting with refill time over 2 minutes Weeping edema occurs when the applied finger pressure causes a small fluid leak  Thank you Any Questions?