The Medical History and the Interview

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The Medical History and the Interview

Albert J. Heuer

The history is the foundation of comprehensive assessment. It is a written picture of the patient’s perception of his or her past and present health status and how health problems have affected both personal and family lifestyle. Properly recorded, it generally provides an organized, unbiased, detailed, and chronologic description of the development of symptoms that caused the patient to seek health care. The history guides the rest of the assessment process: physical examination, x-ray and laboratory studies, and special diagnostic procedures. When skillfully obtained, the history often contributes in a significant way to an accurate diagnosis. It is believed by many clinicians that an accurate diagnosis can often be made after the history has been obtained and before the physical examination begins.

Traditionally, the task of obtaining a patient’s complete history has belonged to the physician, and only sections of the history were taken by other members of the health care team. Today, however, complete health histories are taken by nurses and physician assistants. Physical therapists, social workers, dietitians, and respiratory therapists (RTs) obtain medical histories from patients with an emphasis on information pertaining to their specialty.

Regardless of whether a student or clinician is expected to obtain and write a comprehensive history, each must be able to locate and interpret historical information recorded in the patient’s medical record. The information is used with other assessment data and provides the foundation for interprofessional communication to enable many medical disciplines to collaboratively develop or alter a plan of care. In addition, identifying the patient’s symptoms and changes in those symptoms permits the patient care team to assess the effect of therapeutic interventions and overall progress.

This chapter highlights interviewing principles and describes the types of questions used in history taking and the content of the comprehensive health history, emphasizing specific information needed for assessment of the patient with cardiopulmonary complaints. Chapter 3 discusses the most common cardiopulmonary symptoms.

Patient Interview

Principles of Communication

Communication is a process of imparting a meaningful message. The principles and practices of effective communication, which are outlined in Chapter 1, help form the basis for a properly conducted patient interview. Multiple personal and environmental factors affect the way both patients and health care professionals communicate during an interview. As a result, attention to the effects each of these components may have on communication makes the difference between an effective and an ineffective interview.

Structuring the Interview

The ideal interview, whether a 5-minute assessment of therapy or a 50-minute history, is one in which the patient feels secure and free to talk about important personal things. Interviewing is an art that takes time and experience to develop. It is a skill as useful in daily patient care as it is to the person obtaining a comprehensive history. Your ability to project a sense of undivided interest in the patient is the key to a successful interview and patient rapport. As such, it is generally best to review records or new information and prepare equipment and charting materials before entering the room. When practical, the RT or other clinician should know all available details of the patient case before the interview is started.

1. Your introduction establishes your professional role, asks permission to be involved in the patient’s care, and conveys your interest in the patient.

• Dress and groom professionally.

• Enter with a smile and an unhurried manner.

• Make immediate eye contact, and if the patient is well enough, introduce yourself with a firm handshake or other appropriate greeting.

• State your role and the purpose of your visit, and define the patient’s involvement in the interaction.

• Call the patient by name. A person’s name is one of the most important things in the world to that person; use it to identify the patient and establish the fact that you are concerned with the patient as an individual. Address adult patients by title—Mr., Mrs., Miss, or Ms.—and their last name. Occasionally, patients will ask to be called by their first name or nickname, but that is the patient’s choice and not an assumption to be made by the health care professional. Keep in mind that by using the more formal terms of address, you alert the patient to the importance of the interaction.

2. Professional conduct shows your respect for the patient’s beliefs, attitudes, and rights and enhances patient rapport.

• Be sure the patient is appropriately covered.

• Position yourself so that eye contact is comfortable for the patient. Ideally, patients should be sitting up with their eye level with or slightly above yours, which suggests that their opinion is important, too. Avoid positions that require the patient to look directly into the light.

• Avoid standing at the foot of the bed or with your hand on the door while you talk with the patient. This may send the nonverbal message that you do not have time for the patient.

• Ask the patient’s permission before moving any personal items or making adjustments in the room (see Chapter 1).

• Remember, the patient’s dialogue with you and the patient’s medical record are confidential. The patient expects and the law demands that this information be shared only with other professionals directly involved in the patient’s care. When a case is discussed for teaching purposes, the patient’s identity should be protected.

• Be honest. Never guess at an answer or information you do not know. Remember, too, that you have no right to provide information beyond your scope of practice. Providing new information to the patient is the privilege and responsibility of the attending physician.

• Make no moral judgments about the patient. Set your values for patient care according to the patient’s values, beliefs, and priorities. Belittling or laughing at a patient for any reason is unprofessional and unacceptable.

• Be mindful and respectful of cultural, ethnic, religious, and other forms of diversity (see Chapter 1).

• Expect a patient to have an emotional response to illness and the health care environment and accept that response. Listen, then clarify and teach, but never argue. If you are not prepared to explore the issues with the patient, contact someone who is.

• Adjust the time, length, and content of the interaction to your patient’s needs. If the patient is in distress, obtain only the information necessary to clarify immediate needs. It may be necessary to repeat some questions later, to schedule several short interviews, or to obtain the information from other sources.

3. A relaxed, conversational style on the part of the health care professional with questions and statements that communicate empathy encourages patients to express their concerns.

Questions and Statements Used to Facilitate Conversational Interviewing

An interview made up of one direct question followed by an answer and another direct question is mechanical, monotonous, and anxiety producing. Frankly, such an approach can make patients feel as though they are being interrogated. In addition, this type of interview usually takes longer and acquires less pertinent information than a more casual, conversational interview. A rambling discussion is also inefficient and frustrating. Therefore, a conversational style that combines the types of questions and responses as described in the following list encourages open and honest descriptions by the patient, family member, or other historian while giving enough direction to clarify, quantify, and qualify details.

1. Open-ended questions encourage patients to describe events and priorities as they see them and thereby help bring out concerns and attitudes and promote understanding. Questions such as “What prompted you to come to the hospital?” or “What happened next?” encourage conversational flow and rapport while giving patients enough direction to know where to start.

2. Closed questions such as “When did your cough start?” or “How long did the pain last?” focus on specific information and provide clarification.

3. Direct questions can be either open-ended or closed questions and always end in a question mark. Although they are used to obtain specific information, a series of direct questions or frequent use of “Why?” can sound intimidating.

4. Indirect questions are less threatening because they sound like statements: “I gather your doctor told you to monitor your peak expiratory flow rates every day.” Inquiries of this type also work well to confront discrepancies in the patient’s statements: “If I understood you correctly, it is harder for you to breathe now than it was yesterday.”

5. Neutral questions and statements are preferred for all interactions with the patient. “What happened next?” and “Tell me more about . . .” are neutral open-ended questions. A neutral closed question might give a patient a choice of responses while focusing on the type of information desired: “Would you say there was a teaspoon, a tablespoon, or a half-cup?” By contrast, leading questions such as “You didn’t cough up blood, did you?” should be avoided because they imply a desired response.

6. Reflecting (echoing) is repeating words, thoughts, or feelings the patient has just stated and is a successful way to clarify and stimulate the patient to elaborate on a particular point. For example, saying to the patient that “So you just said that you could not breathe well and your cough was getting worse for about a week,” might encourage the patient to elaborate on these and other symptoms. However, overuse of reflecting can make the interviewer sound like a parrot.

7. Facilitating phrases, such as “yes” or “umm” or “I see,” used while establishing eye contact and perhaps nodding your head, show interest and encourage patients to continue their story, but this type of phrase should not be overused.

8. Communicating empathy (support) with statements like “That must have been very hard for you” shows your concern for the patient as a human being. Showing the patient that you really care about how life situations have caused stress, hurt, or unhappiness tells the patient it is safe to risk being honest about real concerns. Other techniques for showing empathy are described in Chapter 1.

Alternative Sources for a Patient History

Various factors affect the patient’s ability or willingness to provide an accurate history. Age, alterations in level of consciousness, language and cultural barriers, emotional state, medications, inability to breathe comfortably, and the acuteness of the disease process may alter a patient’s ability to communicate. For instance, the patient suffering an acute asthma attack or someone just admitted to an intensive care unit may be unable to give even a brief history. Patients with long-standing chronic disease may have become so accustomed to the accompanying symptoms, or their lives may have changed so gradually, that they may minimize and even deny symptoms. In addition, some aspects of the history may be embarrassing to the patient, such as smoking history or alcohol use. In such cases, family members, friends, work associates, previous physicians, and past medical records often can provide a more accurate picture of the history and progression of symptoms. Keeping these possibilities in mind, most hospital histories begin with a one- or two-sentence description of the current state of the patient, the source of the history, and a statement of the estimated reliability of the historian.

Cardiopulmonary History and Comprehensive Health History

Abnormalities of the respiratory system frequently are manifestations of other systemic disease processes. In addition, alterations in pulmonary function may affect other body systems. Therefore, cardiopulmonary assessment cannot be limited to the chest; a comprehensive evaluation of the patient’s entire health status is essential. A detailed discussion of all aspects of obtaining and recording such a health history is beyond the scope of this text but has been well covered by other authors (see the Bibliography). This section provides an overview of the content of complete health histories and discusses specifically (in their classic order) chief complaint, history of present illness, past history, family history, and occupational and environmental history.

Variations in Health Histories

Health (medical) histories vary in length, organization, and content, depending on the preparation and experience of the interviewer, the patient’s age, the reason for obtaining the history, and the circumstances surrounding the visit or admission. A history taken for a 60-year-old person complaining of chronic and debilitating symptoms is much more detailed and complex than that obtained for a summer camp application or a school physical examination. Histories recorded in emergency situations are usually limited to describing events surrounding the patient’s immediate condition. In such situations, it is often difficult to get a thorough history, unless the patient is accompanied by someone who can speak on their behalf. Nursing histories emphasize the effect of the symptoms on activities of daily living and the identification of the unique care, teaching, and emotional support needs of the patient and family. Histories performed by physicians often focus on making a diagnosis. Since diagnosis and initial treatment may be done before there is time to dictate or record the history, the experienced physician may record data obtained from a combination of the history, physical examination, laboratory tests, and x-ray films rather than the more traditional history outlined in Box 2-1.

Box 2-1   Outline of a Complete Health History

1. Demographic data (usually found on first page of chart): name, address, age, birth date, birthplace, race, nationality, marital status, religion, occupation, source of referral

2. Date and source of history, estimate of historian’s reliability (“the patient seems to be a good/fair/poor historian”)

3. Brief description of patient’s condition at time of history or patient profile

4. Chief complaint: reason for seeking health care

5. History of present illness (chronologic description of each symptom)

6. Past history or past medical history

7. Family history

8. Social and environmental history

9. Review of systems (see Fig. 2-1)

10. Signature

General Content of Health Histories

Although variations in recording styles do exist, all histories contain the following same types of information:

Background Information

Background information tells the interviewer who the patient is and what types of diseases are likely to develop. It also provides a basic understanding of the patient’s previous experiences with illness and health care and the patient’s current life situation, including the effect of culture, attitudes, relationships, and finances on health. Knowing the level of education, patterns of health-related learning, past health care practices, and reasons for compliance or noncompliance with past courses of therapy gives insight into patients’ ability to comprehend their current health status. This may predict their willingness or ability to participate in learning and therapy. From the free discussion used to obtain background information, the interviewer may also get clues about patients’ reliability and possible psychosocial implications of their disease.

Review of Systems

Review of systems (ROS) is a recording of past and present information that may be relevant to the present problem but might otherwise have been overlooked. It is grouped by body or physiologic systems to guarantee completeness and to assist the examiner in arriving at a diagnosis. Figure 2-1 is an example of an ROS checklist that may be completed by a patient before an interview or by an examiner. It provides for recording both positive and negative responses so that when the documentation is later reviewed, there is no doubt as to which questions were asked. Negative responses to important questions asked at any time during the interview are termed pertinent negatives; affirmative responses are termed pertinent positives. For example, if a patient complains of acute coughing but denies any fever, the fever would represent a pertinent negative, whereas the cough is a pertinent positive.

Experienced examiners usually elicit the ROS information in conjunction with the system-by-system physical examination; however, the two must not be confused. The physical examination provides objective data, or that which can be seen, felt, smelled, or heard by the examiner, commonly referred to as signs. On the other hand, the ROS provides subjective data, or that which is evident only to the patient and cannot be perceived by an observer or is no longer present for the observer to see and therefore can only be described by the patient. Subjective manifestations of disease are termed symptoms