The Medical History and InterviewChapter 2

Introduction

• Patient’s medical history is the foundation of a comprehensive assessment• 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

Patient Interview

• Communication• Important part of each patient interaction• Many factors influence how patient may

interpret your verbal and nonverbal communication skills• cultural heritage• religious beliefs• level of education

• Communication occurs only if both parties speak clearly and listen carefully• A common mistake made by health care

providers is not listening to the patient

Patient Interview (cont’d)

• Structuring the interview• Project undivided interest in the patient• VERY important

• Introduce yourself in a professional manner• Respect the patient’s beliefs and

attitudes• Use a relaxed conversational style that

communicates empathy and genuine concern

Patient Interview (cont’d)

• Questions and statements facilitate interviewing• Use open-ended questions at times• Closed questions provide clarification• Neutral questions encourage the patient to

respond with sentences and honest answers• Avoid using leading questions• Repeating certain words the patient just

used can stimulate further input from the patient

Patient Interview (cont’d)

• 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

Cardiopulmonary History 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

General Content of Health Histories

Chief Complaint

• 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

History of Present Illness

• 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

History of Present Illness (cont’d)

Past History

• A description of the patient’s past medical problems• Includes previous illnesses, surgeries,

accidents, allergies, medications, habits (e.g., use of tobacco and alcohol), and description of general health

Calculating Pack Years

• Pack-years is the standard way to document a patient’s smoking history. • This is determined by multiplying the

number of packs smoked times the number of years smoked.

Family History

• Useful to learn about the health status of the patient’s blood relatives• Cardiopulmonary diseases that may have a

hereditary link include asthma, lung cancer, cystic fibrosis, emphysema, and sleep apnea, alpha1-antitrypsin deficiency• Interviewer should ask about exposure to

family or friends with an infectious disease

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

Reviewing the Patient’s Chart

• Admission note: written by the attending physician; a description of important facts related to the patient’s admission• Physician orders: list of treatments and

monitoring techniques• Progress notes: written by physician and

other health care providers each day to describe the patient’s response to treatment