Chapter 2: The Medical History Interview and Charting

Question 1

communication key points (3)

Answer 1

1. important part of each patient interaction
2. many factors influence how pt may interpret your verbal and nonverbal communication skills
3. a common mistake made by health care providers is not listening to the patient

Question 2

structuring the interview (4)

Answer 2

• Project undivided interest in the patient
• Introduce yourself in a professional manner
• Respect the patient’s beliefs and attitudes
• Use a relaxed conversational style that communicates empathy and genuine concern

Question 3

Alternative sources for a patient history

Answer 3

• In some cases the patient may not be able to communicate

- Family members, friends, previous caregivers, previous medical records, etc. can provide important information

Question 4

cardiopulmonary and comprehensive health history

Answer 4

• 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

Question 5

CC

Answer 5

CC = chief compliant

• 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

Question 6

common symptoms associated with lung disease (4)

Answer 6

1. cough
2. dyspnea
3. chest pain
4. wheezing

Question 7

constitutional symptoms

Answer 7

Constitutional symptoms refers to a group of symptoms that can affect many different systems of the body. Examples include weight loss, fevers, headache, fevers of unknown origin, hyperhidrosis, generalized hyperhidrosis, chronic pain, fatigue, dyspnea, and malaise.

• chills, fever, excessive sweating, loss of appetite, nausea, vomiting, an fatigue

Question 8

HPI

Answer 8

HPI = 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

Question 9

PQRST mnemonic

Answer 9

P - provocative / palliative: cause, makes it better/worse
Q - quality/quantity - how much is involved, how does it feel, look, sound
R - radiation/ region - where is it, does it spread
S - severity scale - does it interfere with activities
T - timing - when did it being, how often, sudden or gradual

Question 10

past history

Answer 10

- A description of the patient’s past medical problems
Includes previous: Illnesses, 
Surgeries,
Accidents, 
Allergies, 
Medications, 
Habits (e.g., use of tobacco, drugs, and alcohol), 
Description of general health

Question 11

SAMPLE

Answer 11

S - symptoms 
A - allergies 
M - medications 
P - past history 
L - last meal 
E - events leading up to the problem

Question 12

Family History (3)

Answer 12

1. Useful to learn about the health status of the patient’s blood relatives
2. Cardiopulmonary diseases that may have a hereditary link include asthma, lung cancer, cystic fibrosis, emphysema, and sleep apnea
3. Interviewer should ask about exposure to family or friends with an infectious disease

Question 13

cardiopulmonary diseases that may have a hereditary link include:

Answer 13

• asthma
• lung cancer
• cystic fibrosis
• emphysema
• sleep apnea

Question 14

occupational and environmental history (3)

Answer 14

• 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

Question 15

components to pts chart (3)

Answer 15

1. admission note
2. physician orders
3. progress notes

Question 16

admission note

Answer 16

Written by the attending physician

Description of important facts related to the patient’s admission

Question 17

physician orders

Answer 17

Written by physicians
List of treatments and therapies
Monitoring techniques

Question 18

progress notes

Answer 18

Written by physician and other health care providers each day
Describe the patient’s response to treatment

Question 19

DNAR/ DNR status

Answer 19

• Found in the patient’s medical record
• Provides Advanced Directive
  Do Not Attempt to Resuscitate
  Do Not Resuscitate
• Instituted based on patient/family wishes and physician order
  Be aware of variations and specific instructions