The Patient Interview, Cardiopulmonary Symptoms, and Medical Record Review

Vocabulary practice cards covering effective patient interviewing techniques, cardiopulmonary symptoms, symptom quantification scales, and reviewing the clinical medical record.

Plain Language Approach

A verbal or written communication method designed to ensure patients quickly and fully understand health information by avoiding verbose, convoluted wording, jargon, and inflated vocabulary.

Open-Ended Questions

Questions used to begin an interview, introduce a new line of questioning, or gather narrative information whenever a patient introduces a new topic.

Closed Questions

Direct questions used after a patient's narrative to gather specific details, eliciting short one- or two-word responses, yes/no answers, or forced choices.

Patient Frame of Reference Responses

Examiner responses—including facilitation, silence, reflection, empathy, and clarification—that focus on and react to the facts or feelings communicated from the patient's perspective.

Examiner Frame of Reference Responses

Interview techniques—including confrontation, interpretation, explanation, and summary-making—where the perspective shifts to the clinician's own thoughts, feelings, or conclusions.

Symptom

A subjective clinical finding perceived and reported by the patient during or shortly after the initial medical interview.

Dyspnea

A general clinical term describing the subjective sensation of breathing discomfort, representing the single most critical factor limiting daily activity.

Modified Borg Scale

A graded scale numbered from $0$ to $10$ used alone or alongside standardized exercise maneuvers to quantify the subjective severity of dyspnea.

Breathlessness

An unpleasant urge to breathe that can be triggered by acute hypercapnia, acidosis, or hypoxemia, whose intensity is frequently amplified by emotional distress.

Orthopnea

Dyspnea triggered when assuming a reclining or supine position, commonly seen in congestive heart failure, mitral valve disease, bilateral diaphragm paralysis, and superior vena cava syndrome.

Platypnea

Dyspnea triggered by assuming an upright position, which may develop following pneumonectomy, during hypovolemia, or after lower cervical spinal cord injury.

Trepopnea

Dyspnea that occurs when a patient with unilateral lung disease lies with the affected lung in the dependent (downward) position.

Psychogenic Hyperventilation Syndrome

Breathing at a rate and depth exceeding metabolic demands, frequently associated with panic disorders and accompanied by chest pain, anxiety, palpitations, and paresthesia.

Cough

The most common yet nonspecific respiratory symptom; a protective reflex triggered by stimulation of irritant receptors within the airways, lung parenchyma, and visceral pleura.

Inspiratory Phase of a Cough

The initial cough phase involving reflex opening of the glottis and deep inspiration, leading to increased bronchial diameter, length, and lung volume.

Compression Phase of a Cough

The second cough phase marked by glottic closure and diaphragm relaxation against contracting expiratory muscles, building extremely high intrathoracic pressure.

Expiratory Phase of a Cough

The final cough phase marked by opening of the glottis and an explosive outflow of trapped intrathoracic air, vibrating mucosal walls to shake loose secretions.

Chronic Cough

A cough lasting $8\,\text{weeks}$ or longer, commonly caused by chronic lung diseases, upper airway cough syndrome, asthma, gastroesophageal reflux disease ($\text{GERD}$), or medications.

Phlegm

Mucus produced directly from the tracheobronchial tree that is completely uncontaminated by oral secretions.

Sputum

Mucus originating from the respiratory tract that is expectorated out through the mouth.

Purulent Sputum

Thick, colored, and sticky sputum that contains pus cells, characteristic of bacterial infections.

Fetid Sputum

Sputum that gives off a distinctly foul, offensive odor.

Mucoid Sputum

Clear, thick, and viscous sputum typically associated with asthma.

Hemoptysis

The coughing up of blood or blood-streaked sputum from the respiratory tract.

Frank Hemoptysis

Expectorant consisting primarily of pure blood rather than mucus streaked with blood.

Massive Hemoptysis

A life-threatening medical emergency defined by coughing up more than $300\,\text{mL}$ of blood within a $24\,\text{hour}$ period.

Pleuritic Chest Pain

Sharp, abrupt inspiratory chest pain localized laterally to one side that worsens with coughing, sneezing, or deep breathing, typical of pleural inflammation.

Nonpleuritic Chest Pain

A dull ache or pressure located centrally in the anterior chest that is unaffected by breathing and may radiate to the shoulder, neck, or back.

Angina

A frequent cause of nonpleuritic anterior chest pain brought on by physical exertion or emotional stress and associated with coronary artery occlusion.

Pedal Edema

Swelling in the feet and lower extremities that serves as a common clinical sign and symptom of heart failure.

Pitting Edema

Swelling in an extremity where finger pressure leaves a lingering indentation mark in the skin.

Weeping Edema

Severe peripheral edema in which applied pressure causes small droplets of fluid to leak directly through the skin surface.

Chief Complaint

The patient's primary reason for seeking medical attention, stated in their own words; it guides the history of present illness and is not a formal diagnostic statement.

History of Present Illness (HPI)

A systematic, detailed narrative documenting the onset, course, and characteristics of the patient's current major complaints.

PQRSTU

A diagnostic mnemonic used to explore symptom history: Provocative/Palliative, Quality/Quantity, Region/Radiation, Severity, Timing/Treatment, and Understanding.

Past Medical History (PMH)

A comprehensive review in the medical record covering major illnesses, injuries, surgeries, hospitalizations, allergies, home medications, and health-related habits.

Pack-Years

A standardized measure of cumulative tobacco smoke exposure calculated by: $\text{Packs smoked per day} \times \text{Number of years smoked}$.

Advance Directive

A legal document specifying what healthcare decisions should be enacted if a person becomes unable to speak or decide for themselves, such as a living will or healthcare proxy.