A medical history must be dynamic. Every history is different. All patients are asked the standard questions, but each patient should be evaluated individually. There is no limit to the questions to be asked.
The written history is a permanent, legal document of the patient's health history. The information that is recorded must be accurate and objective. On the basis of all the information gleaned from the patient's history, the interviewer carefully summarizes all the data into a readable format. Anything that is written in a patient's record could be presented to a court of law. Only objective data should be included. Opinions or statements about previous care and therapy must be avoided.
By convention, when the review of systems is stated or written, all symptoms that the patient has experienced are indicated first. Symptoms never experienced are indicated afterward. The pertinent positive symptoms are symptoms that have possible relevance to the present illness. Pertinent negative symptoms are symptoms that are not present but are often related to the present illness.
If information in the review of systems has been described previously—in the history of present illness, for example—it is correct to indicate under the systems review of that symptom, ''see history of present illness.''
As you proceed with the interview, you may sense that it is not going well. Is the patient comfortable? Is there a language barrier? Did you say or do something to interfere with the rapport? Is the patient intimidated? Is the patient concerned about confidentiality? Is the patient reluctant to talk in the presence of family members? Is the patient able to express his or her feelings? These issues reflect just a few of the common reasons for lack of progression of an interview. If you can alleviate the problems, do so. Perhaps interviewing the patient on another day but using the same approach will be more successful.
The key to success in an interview is the ability to put the patient at ease. To do so, the interviewer must be relaxed. What techniques are available to the interviewer and patient to relax? One useful approach is the visualization of color; for example, if the interviewer were to say, ''Close your eyes and visualize the color blue,'' the patient would feel a definite response in body as well as in mind. If the patient were then to let that image dissolve, take a few breaths, close the eyes again, and visualize the color red, he or she would notice that the response to this color is quite different. Red creates a different state of mind than do blue, green, yellow, and so forth.
Whether this is entirely a result of psychological association is irrelevant to this discussion. The point is that because people respond strongly to color, interviewers can influence the state of mind of patients and themselves by suggesting an atmosphere of color that calms, warms, cheers, cools, and so forth, depending on what is called for in the situation. Because color can help a patient relax, it can have beneficial effects on blood pressure, heart rate, and other bodily functions.
The same is true of the visualization of environments that are pleasant, beautiful, and peaceful. Having the patient take a few moments, with eyes closed, to imagine himself or herself in a garden or a quiet pine forest can substantially lessen nervousness and tension. The connection between relaxation and health is becoming more widely understood and accepted. According to studies in behavioral medicine, the practice of meditation has a beneficial effect in the treatment of hypertension, some heart problems, depression, and anxiety, among other illnesses.
Many visualization techniques are far from new. In the Tibetan approach to medicine, a system that developed between the 4th and 12th centuries, there is a direct connection between the state of a person's mind and the state of his or her health.
In the next chapter, the patient's responses to the questions are investigated, and the influence of background and age on those responses is observed.
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