The Medical History
and Interview
Chapter 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