Transcript Interview and History

The Medical History and the
Interview
Sean Ragain MD
Patient Assessment
You will be doing this extremely frequently!
 The initial assessment of a new patient is the
most complete and takes the most time.
 After that, your assessments of that patient will
be much quicker.
 You will find yourselves assessing people in
public. Example: you’ll hear people cough in
public and judge whether it’s COPD or a cold or
whooping cough.
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Don’t forget
The patient will be assessing you as well.
 Even as a student, don’t forget that your
behavior and mannerisms will be
important. If you disrespect or are
inappropriate with a hospitalized patient
the hospital will think poorly about you.
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2 Major Assessment Sources
Patient Interview
 Physical Exam
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Before you Go Into the Room
During your clinical rotations, you will be seeing
patients with supervision, and sometimes
without.
 No matter what the reason is for visiting a
patient, be sure to take a good, long look at
their chart.
 If time permits, read as much of the info
included.
 Charts can be a pain in the butt to find. Don’t
be shy to ask people if they know where so and
so’s chart is. May be at nurse desk, outside the
room, with a physician who is using it etc.
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Before you Start the Visit
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Most Doctors will politely give the chart to you
when they are done. Some won’t do it quite as
politely.
For some of you, adjusting to the powerful
emotions and stresses of the hospital will be
difficult, but every one of you can do it!
Many health care workers project their stress
and emotion on other co-workers.
Learn to shrug it off.
But… you do not have to tolerate personal
attacks or fun at your expense.
What is the Purpose of the
Interview?
Well, if you didn’t have to interview the
patient to figure out what was wrong with
them, then hospitals would be run like an
automobile factory.
 You are there to gather medical,
psychological, social, family, allergies,
exposures to certain substances, and
other historical information
 These will guide your plan
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Make a Good First Impression
Know your role, and be confident in it!
 Know as much as possible before entering
the room
 Identify yourself by name and occupation
 Identify the patient
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Be Attentive
Look for signs of discomfort, pain,
dyspnea, or mental status changes.
 Look for cues from the patient about their
personal space.
 Be up front with them.
 To sit or not to sit?
 Be alert to nonverbal communication
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Patient Interview/History
This is much more important than you
may first appreciate
 What is included?
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 Well
– a lot!
 ID
 Chief
Complaint
 History of Present Illness
 Past Medical History including medications
 Review of Systems … continued>
Social History
 Family History
 Lab Results
 Vitals
 Exam
 Assessment and Plan
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Things you must have to make good
decisions for the patient
Location and radiation of pain
 Quality of pain
 Quantity of pain
 Duration
 Frequency
 Aggravating/alleviating factors
 Associated symptoms
 Effect of daily life
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Factors that May Affect the Interview
Bias and prejudice
 Attitudes and values projected on the
patient
 Cultural Differences
 Religious Beliefs
 Your Social Behaviors (do you listen well
or do you interrupt people normally?)
 Preoccupations, feelings, fear, stress
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Factors that May Affect the Interview

The illness itself
 Pain,
worry, money, helplessness
Sight, hearing, or speech problems
 Language Barrier (huge)
 Interruptions (also huge)
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Other factors that will influence the
interview
Lighting
 Noise
 Privacy
 Distance
 Temperature
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Interviewing Technique
Open Ended Questions
 Closed Questions
 Assisting the narrative
 Non-verbal Communication
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Open Ended Questions
These allow the patient to tell their story
 This gives you the patients subjective
experience
 If allowed to expound on things, patients
will often give interesting clues about their
concerns, attitudes and understanding of
their situation.
 Example: What brings you to see me
today?
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Closed Questions
Much more direct
 Usually “yes” or “no” with some variation
of extra information.
 The proper closed questions to ask will
often be determined while listening to
their open ended responses.
 Example: Does it hurt when you cough?
Is there blood in your mucous?
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Assisting the narrative
Take the statements that patients make
and get more info about them
 Example: So your chest hurts with this
cough, have you ever had this type of
sensation before?
 Or: What were you doing when you
started to feel this shortness of breath?
Etc.
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Non-Verbal Skills
This is huge!
 Make sure to give a person some personal
space. Some need more, some need less.
 Always face the patient
 Pay attention
 Smile when appropriate
 Show empathic body language
 Relax!
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The Structure of the Interview
This may take 10 minutes or an hour
depending on the situation. Be flexible
 Give your patient your best undivided
attention. If your pager is going off, you
will have to answer it, but do so at a
comfortable point in the interview.
 Be professional
 Use last name unless they ask you not to.
 Ask permission to move their stuff
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Structure of the Interview
Don’t forget HIPAA
 Be honest
 Do your best to quell your negative
judgements.
 Again, listen, relax, and don’t contradict a
patient about their story (unless it is
important in your treatment).
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What if the Patient is Unable to Talk?
This happens a lot too.
 Remember a lot of your patients will be
ventilated and sedated to one degree or
another.
 Don’t hesitate to attempt to talk with a
sedated patient.
 Often they are lucid enough to give decent
yes/no answers.
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What if the Patient Can’t Talk?
Parents, family members
 Friends
 Coworkers
 Other health care providers
 Medical records
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Finishing Up
Ask the patient if they have further concerns or
questions
 Explain what you will be up to next. What is the follow
up plan?
 Speak to MD and/or nurses
 Recommend and send lab tests
 Treatment Plan
 Make a note in the chart
 Make sure the patient understands the call button.
 Be cordial on your way out, no matter how sick they are
or how grave the situation
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