f

1. Introduction of patient
assessment and history
taking
Associate Prof
DR ALTAF ALKAMISH

2. Topics
 Introduction and history taking (2hrs)
 Cardiopulmonary Symptoms (2hrs)
 Vital Signs and general symptoms (2hrs)
 Local examination of respiratory system (2hrs)
 Practicing history taking (2hrs)
 Cases presentation in history and examination of
respiratory system (2hrs)
 Neurological assessment (2hrs)
 Clinical lab studies (2hrs)
 Old patient assessment (2hrs)
 Pulmonary function test basics (2hrs)

3. Topics
 Respiratory monitoring in critical care (2hrs)
 Sleep and breathing assessment (2hrs)
 Home care patient assessment (2hrs)
 Nutritional assessment (2hrs)
 Documentation (2hrs)
 General review (2hrs)

4. Contents
 Introduction about subject
 History of cardiopulmonary system
 Why history
 Principles of Communication
 Structure and Technique for
Interviewing
 Structure of history
 Reviewing the Patient’s Medical
Record
 Remember ,suggested activities

5. Subject
Patient Assessment

6. GOALS
me
in
institution
you
me

7. How to attain your goals
 Have time scheduled plan
 Have alternative plans
 Practice more and more
 Create your way of learning
 Ask , think and search

8. Teaching Methods
 lectures
 Brain storming
 Group discussion
 Plenary presentation by participants
 Mini-lecture by facilitators
 Manual and computer based hand on
exercises
 Seminars
 Cases and scenarios
 Activities

9. References
✓ STUDENT RESOURCE MATERIALS
 1. Internally prepared and produced Study Units 1, 2, 3, 4 and
5.
 2. Corresponding homework and reading assignments for
Study Units (1-5), inclusive.
✓ Textbook(s) and References*
 1. Wilkins, Krider & Sheldon. (2000). Clinical Assessment in
Respiratory Care. 4th Ed., Mosby-Year book, Inc. ISBN: 0-
323-00909-3
 2. Kacmarek, R. M. & Pierson, D. J. Foundations of
Respiratory Care. ISBN: 0-443-08509-9
 3. *. Wilkins, R. L., Stoller, J. K. and Scanlan, C. L. (2021)
Egan’s Fundamentals of Respiratory Care, 12th Ed., ISBN: 0-
323-01813-0
 Clinical guidelines ,clinical trials ,researches

10. Assessment methods
 Summative Assessment
 Progressive/continuous assessment (Quiz,
assignment seminars ,homework's ,case
presentations ,activities, Assessment on
given topics and reflection exercise (40%)
 End of Course objectively written exam
(60%)
 MCQs ,cases

11. History of
cardiopulmonary systems

12. History of
cardiopulmonary systems
 The history is the foundation of comprehensive
assessment
 It is a written picture of patient perception of his
or her past and present health status and how
health problems have affected 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.

13. Why history
 To establish a rapport between the clinician and
patient
 When skillfully obtained, the history often
contributes in a significant way to an accurate
diagnosis.
 The history guides the rest of the assessment
process: physical examination, x-ray and laboratory
studies, and special diagnostic procedures
 To help monitor changes in the patient’s symptoms
and response to therapy.

14. Why history
 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

15. Why history
 Because respiratory therapists (RTs) often
participate in clinical decision-making, they must
develop competent bedside assessment skills. To
do this effectively, the RT must assume
responsibility for gathering and interpreting relevant
bedside patient data.
 In emergency situations when a physician is
unavailable., nurses and RTs may evaluate the
patient to rapidly implement appropriate lifesaving
therapy (e.g., cardiopulmonary resuscitation {CPR})

16. Why history
 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.
 All healthcare practitioners must be familiar with
the medical history of the patients they are treating
regardless of the reason for contact

17. Principles of Communication
 Importance
 Communication is a process of imparting a meaningful
message. The principles and practices of effective
communication, help form the basis for a properly
conducted patient interview.
 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
 It requires adherence to basic techniques an acquiring
knowledge about the causes and characteristics of
cardiopulmonary symptoms.

18. Principles of Communication
 Factors affecting communication between the RT
and the patient include the following:
 Sensory and emotional factors
 Environmental factors
 Verbal and nonverbal components of the
communication process
 Cultural values, beliefs, feelings, habits, and
preoccupations of both the RT and the patient
 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

19. Structure and Technique
for Interviewing
 As it is generally best to review records or new
information and prepare equipment and charting
materials before entering the room
 Site:Introductions are done from a social space of 4
to 12 feet from the patient, begin the interview
from what is referred to as personal space (2 to 4
feet from the patient).
 Introduction and permission
 introduction and permission

20. Structure and Technique
for Interviewing
 project a sense of undivided interest

21. Structure and Technique
for Interviewing
 shows your respect for thepatient’s
beliefs, attitudes, and rights

22. Structure and Technique
for Interviewing
 A relaxed, conversational style

23. Structure and Technique
for Interviewing
 Questions and Statements Used
 Combines the types of questions and responses
 (open ,closed , Direct questions. Indirect questions,
Neutral questions,reflecting question)
 Neutral questions and statements are preferred for
all interactions with the patient
 leading questions such as “You didn’t cough up
blood, did you?”should be avoided.
 Alternative Sources for a Patient History
 Variations in Health Histories
 Vary( experience,, the patient’s age, the reason for
obtaining the history, and the circumstance
surrounding the visit or admission

24. Structure and Technique
for Interviewing
 Although variations in recording styles do exist, all
histories contain the following same types of
information
 Background information
 Screening Information(analysis ,review of systems)
 Description of Present Health Status or Illness
 Chief Complaint
 History of Present Illness

25. Structure and Technique
for Interviewing
 Personal Hx
-Name
-Sex
-Age
-Residence
-Education level
-Occupation

26. Structure of history
 Personal Hx
 -Occupation
 Work profoundly influences health. Unemployment
is associated with increased morbidity and mortality
while some occupations are associated with
particular illnesses .
 Ask all patients about their occupation. Clarify what
the person does at work, especially about any
chemical or dust exposure. If the patient has
worked with harmful materials (such asbestos or
stone dust), a detailed employment record is
needed, including , timing and extent of exposure,
and any workplace protection offered.

27. Examples of occupational
disorders

28. Structure of history
 Personal Hx
-Personal habits of medical importance
Smoking,alcoholism,others
Smoking history is recorded in pack-years.

29. Cardiopulmonary History
 Chief Complaint
 It explains why the patient sought medical care
 Each symptom is recorded separately with its
duration or date of initial occurrence.
 Ideally, symptom descriptions are written in the
patient’s own words.
 They should not be diagnostic statements, someone
else’s opinion, or vague generalities
 Should express the patient’s, not the examiner’s,
priorities.

30. History of Present Illness
 chronologic picture
 Analysis of complaints
 Onset ,course ,duration
 Characteristics of specific symptoms should be
elicited, as follows.
 Cough
 Quality (for example, dry, hacking, loose,
productive
 Severity
 Timing (for example, at night, with exercise, in
cold air, inside or outside
 Aggravating/relieving factors

31. History of Present Illness
 Shortness of Breath
 Exercise tolerance (number of stairs client can
climb or distance client can walk)
 Shortness of breath at rest
 Inability to converse in phrases or complete
sentences
 Marked increase in respiratory effort, use of
accessory muscles or retraction
 Orthopnea (number of pillows used for sleeping)
 Association with paroxysmal nocturnal dyspnea
 (waking up out of sleep acutely short of breath;
attack resolves within 20 to 30 minutes of sitting or
standing up,timing, severity

32. History of Present Illness
 Chest Pain
 Onset (sudden or gradual)
 Location
 Radiation
 Referral pattern
 Quality
 Timing
 Severity
 Aggravating and relieving factors
 Associated symptoms

33. History of Present Illness
 Other symptoms of involved system
 Wheezing,ll oedema ,hemoptysis
 Other constitiunal associated Symptoms
 Fever
 Fatigue
 Anorexia
 Diaphoresis
 Weight loss

34. History of Present Illness
 Other parts may be included in history of present
illness
 Risk factors,preciptating events,preceeding events
 Acute sob ,susp PE
 DVT symptoms (leg pain ,swelling)
 Risk of
thromboemolism(immobilazation,travel,surgery,CT
diseases symptoms (arthritis,rashes,abortion in
female)
 Symptoms of other physiological DDX
 Symptoms of anatomical dx (pain,sweeling)
 Complications

35. History strucure
 Review of others systems
 Common symptoms of other systems

36. History strucure
 Review of others systems

37. History structure
 Past medical and surgical hx
 Similar attaks ,chronic diseases as dm ,htn ,hx of
old TB,rheumatological or renal disease
 Surgical hx (lobectomy),
 Medications
 Vaccinations

38. History structure
 Family History (Specific to Respiratory System)
 Others at home with similar symptoms
 Allergies, hypersensitivity
 Asthma, lung cancer, TB, cystic fibrosis
 Heart disease

39. History structure
 Social History (Specific to Respiratory System)
 Exposure to secondhand smoke
 Occupational or environmental exposure to
respiratory irritants (for example, mining, forestfire
fighting)
 Exposure to pets
 Crowded living conditions,ventilation
 Poor personal or environmental cleanliness
 Institutional living
 HIV risks
 Hobbies and recreation, Recent travel

40. Reviewing the Patient’s
Medical Record
 It is the RT’s responsibility to become familiar with
pertinent information recorded in the chart and
overall medical record.
 The RT should carefully review the admission notes
the cause of admission ,the overall clinical status
and the initial plan .
 The RT should carefully review all orders related to
the treatment and monitoring of cardiopulmonary
disorders and specifically review the orders
pertaining to respiratory care.
 The RT should carefully review the progress notes
 may record their findings and treatment plan in a
progress note, often using a SOAP format

41. Remember
 Review your goals and have a plan
and alternative plan
 The history often contributes in a
significant way to an accurate
diagnosis, assessment and overall
patient care
 Interviewing is an art that takes time
and experience to develop

42. Suggeted home activities
and further readings
 Have at least 3 written history in your
homework book
 Review other occupational lung
disorders