The Medical History & the Interview

Vocabulary terms and definitions based on Wilkins' Clinical Assessment in Respiratory Care 9th edition, covering medical history and interviewing techniques.

Subjective Data

Information that the patient reports, feels, or experiences that cannot be perceived by an observer.

Communication

A process of imparting a meaningful message, affected by personal and environmental factors.

Reflecting (or Echoing)

The act of repeating certain words the patient just used to stimulate further input from the patient.

Review of Systems (ROS)

A recording of past and present information grouped by body or physiologic systems to guarantee completeness and assist the examiner in arriving at a diagnosis.

Pertinent Negative

Negative responses to important questions asked at any time during the interview.

Pertinent Positives

Affirmative responses to important questions asked at any time during the interview.

Signs

Objective data which can be seen, felt, smelled, or heard by the examiner during an examination.

Symptoms

Subjective manifestations of disease that are evident only to the patient and cannot be perceived by an observer.

Chief Complaint (CC)

A brief notation explaining why the patient sought health care, including duration or the date of initial occurrence.

History of Present Illness (HPI)

The narrative portion of the history that describes chronologically and in detail each symptom listed in the CC and its effect on the patient’s life.

Onset

The description of a symptom's start, categorized by date, time, and type ($\text{sudden}$ or $\text{gradual}$).

Severity

A measure of how bad a symptom is and how it affects the patient's activities of daily living.

Quality

The character or unique properties of a symptom, such as color, texture, odor, composition, or sensations like sharp, viselike, or throbbing.

Course

The progression of a symptom, determining if it is getting better, worse, or staying the same.

Associated Symptoms

Symptoms from the same or other body systems that occur before, with, or following the primary problem.

Aggravating Factors

Factors that make a symptom worse, such as position, weather, temperature, anxiety, or exercise.

Alleviating Factors

Factors that make a symptom better, such as change in position, hot, cold, or rest.

Pack-years

A calculation of cigarette consumption determined by multiplying the number of years the patient has smoked by the number of packs smoked each day (e.g., $10 \text{ years} \times 3 \text{ packs/day} = 30 \text{ pack-years}$).

Admission Note

A narrative description by the admitting physician of important facts related to the patient’s hospitalization, baseline status, and treatment plan.

Physician Orders

A list of the treatment plan and monitoring techniques needed to best care for the patient.

Progress Notes

Daily documentation in the patient's chart by physicians and other health professionals identifying progress and response to treatment.

Do Not Resuscitate (DNR)

A label indicating a physician’s order that resuscitation should not be attempted if the patient experiences respiratory or cardiac arrest.

Advance Directive

A legal document in which individuals specify what actions should be taken for their health if they are no longer able to make decisions for themselves.

Do Not Intubate (DNI)

A variation of DNR orders that prohibits intubation but allows the administration of certain CPR medications such as epinephrine or atropine.