September 1st, 2008



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THE PATIENT’S STORY:

HISTORY OF PAST MEDICAL PROBLEMS

September 1st, 2008


Seki Balogun, MD, FACP

Practice of Medicine-1

Objectives
At the conclusion of this lecture, students should be able to:


  • Describe the structure of the medical interview




  • Describe the content of aspects of the medical interview




  • Demonstrate eliciting the patient’s story, with focus on the past medical history , family history and social history



Content of the Medical Interview


 Other Active Problems
  • Past Medical History

  • Family History

  • Social History (Patient Profile)


 Review of Systems

The majority of the information needed to diagnose and manage a patient’s problem(s) is obtained during the history of present illness. The information obtained during the latter portions of the interview provides a complete database of the patient’s medical, personal and family history needed to provide optimal management of a patient’s problems. Frequently, information contained in the past history is asked about and reported in the history of present illness. For example, in interviewing a patient with chest pain that is suspicious for angina, a physician would query the patient about health habits (for example smoking), past history (hypertension, diabetes, hyperlipidemia), and family history (of early coronary artery disease) that would affect the patient’s probability of having coronary artery disease.

 Balance – The physician must often strike a balance between the need to obtain certain information, the health of the patient, and the time available and the setting. Portions of the past medical history are frequently not needed to address the problem at hand. Elements of the past history can also be obtained over time, or by using questionnaires.
 Transitions – It is important to prepare patients for changes in direction the interview may take as you move into the past medical history, a more “physician-centered” portion of the interview.
 Appropriately use communication skills – Even though many of the questions in the past medical history are directive, appropriate use of open-ended questions can be time efficient, especially when moving into a new area. For example, “Tell me about any major illnesses you have had in the past” may result in a concise rendition of a patient’s past medical history. Additionally, new issues may arise during the past history that require you to use more patient-centered techniques.


Past Medical History

Major illnesses, beginning in childhood

Hospitalizations

Surgeries

Significant injuries

Medications

Allergies

Immunizations

Transfusions

Gynecologic and obstetric (women)

Psychiatric history

 Transition into this portion of the interview.



  • Summary statement, explanation of change in interview

  • e.g., “I think I understand your current problem, now I’d like to find out more about your past medical history. Have you had any major illnesses?”

 Questions are often relatively directive

 Interviewer must be prepared to move to more open-ended and facilitative style if

important new information comes out.

Specific points relevant to each content item

Major illnesses


  • Illnesses causing significant disability or change in health state or lifestyle

  • Must sometimes seek primary data – for example, a person recalling an episode of severe abdominal pain as an “obstruction” may have had a bad bout of constipation – it can be important to know the difference!

  • Ask about symptoms, tests done, treatment. Sometimes old records needed.

  • Major childhood illnesses include measles, mumps, rubella, whooping cough, chicken pox, scarlet fever, smallpox (highly unlikely in any adult younger than age 50), poliomyelitis (unlikely in any adult from the US or Western Europe younger than age 50), acute rheumatic fever.

  • “Did you have any serious diseases when you were a child?”

  • Major adult illnesses include TB, hepatitis, diabetes, hypertension, coronary artery disease, HIV disease, any chronic pulmonary, renal, gastrointestinal, rheumatologic, vascular, or neurologic disease.

  • “Have you had any major or chronic diseases? Do you have diabetes or hypertension?” (Worth asking about these two directly, as they are common and sometimes “overlooked” by patients.

 Hospitalizations

 Surgeries

  • Including surgeries in addition to those mentioned in hospitalization section above.

 Significant injuries

- Injuries resulting in significant disability or altered activity.

- Fractures, significant soft tissue injuries, concussions, motor vehicle accidents.

 Medications

- Name, dosage and frequency of medicine, and reason for use, if not clear from

other history. Consider asking about medicines prescribed by other doctors.

For people on many medicines, good idea to ask them to bring medicines in.

- Ask about over the counter medicines.

- Ask about herbal medicines, vitamins, and nutritional supplements

Allergies

- Have patient describe allergic reaction – oftentimes, patient has experienced a

side effect, not a true allergy.

 Immunizations


  • For adults, this includes flu, pneumonia, tetanus (new vaccine -2006 onward -with and older vaccine without pertussis), hepatitis B, chickenpox (if they did not have chicken pox in childhood), shingles vaccine, meningococcal vaccine. Also includes history of TB skin testing (PPD), and immunizations related to travel, foreign residence, or occupation/avocation. (For example, spelunkers should receive rabies vaccine).

 Transfusions

 Gynecologic and obstetric history (females only)



  • Important to inquire about LMP (last menstrual period) in women of childbearing

age.

  • Age at menarche (when periods began); frequency of periods; duration of flow.

  • Use of birth control in reproductive age women.

  • Number of pregnancies, children, method of delivery (vaginal or cesarean section).

 Past psychiatric history

  • History of significant mental illness, such as depression or schizophrenia.

“Have you ever seen a counselor or taken medicine for mental health concerns?”

Family History

Systematic inquiry into possible presence of disease states in the family that might affect patient’s health. This would include information about:

 Hereditary diseases (Huntington’s chorea)

 Familial illnesses (diabetes, hypertension, certain cancers)

 Family traits

 Illnesses that would affect the patient’s family environment, and have potential for ongoing affect on patient (alcoholism)

 Current illnesses in family that could result from exposure to a common infectious agent (strep throat) or toxic exposure (carbon monoxide poisoning).

Helpful to ask about:


  • Current health/illnesses of parents, siblings and children, and age and cause of death, if deceased.

  • Specific questions about common familial, such as diabetes, hypertension, heart disease, cancer.

  • Specific question about family members with illnesses similar to patient’s illness

  • Be prepared to respond to emotional issues that might arise.



Social History
Details and knowledge of the patient – their work, relationships, hobbies, beliefs- often develop over time – the days of a hospital stay or the years of a relationship in the office. In the short term, need to answer three questions: How does the patient’s lifestyle or personal traits:

 Contribute to etiology of illness?

 Aggravate or limit the severity of illness?

 Interfere or help with getting well?

 Some if this information will be obtained during the initial portion of the interview when you are getting to know the patient, and as you find out how the current illness is affecting the patient.
Content:
Demographics/personal status


  • Age, marital status, ethnicity, insurance status (can be important for ability to adhere to treatment plans).

Occupational history

  • Including description of work

  • Possible exposures (chemicals, sound, overuse injury, stress)

  • Past work

 Military service

  • Including geographic areas where patient stationed. (For example, malaria possible in person previously stationed in Southeast Asia).

  • PTSD in those with combat history

Education
  • Highest level completed


Travel

  • Particularly interested in overseas travel.

  • Long bus or plane rides can be risk factor for deep venous thrombosis.

Health Habits/Lifestyle

  • “The usual day”

  • A good indicator of patient’s functional state – what they can do.

  • “.What is a usual day like for you? Tell me about your usual day. How has that been changed any by this illness?”

- Diet

  • 24 hour recall reasonably accurate way of finding out what patients eat.

  • “Tell me what you ate yesterday, beginning with breakfast.”

  • “Was that a typical day for you? How was it different?”

- Exercise

- Tobacco use

  • Type, age at onset of use, frequency, intensity, if quit, when.

  • For example, smoked 1 ppd (pack-per-day) for 30 years, quit 5 years ago.

- Alcohol use – (Another session on this later).

  • Frequency, duration, amount, history of alcohol related problems.

- Illegal drug use

- Type of drug, frequency and duration of use, how it is used (smoked, injected, etc.), associated problems


Relationships

  • Support system

  • Who resides in home? Who can help care for patient if necessary?

  • Marital and other significant relationships/family composition

  • Consider asking about quality of relationship.

  • e.g. How are things going with your husband? Children?

  • Domestic violence (Another session on this later)

 Sexual history (Another session on this later)


  • Introductory statement – explain questions or make questions routine.

  • Tailor question to person – a 70 year-old married woman may not respond to the same question that a 20 year-old single person would.

Spirituality (Another session on this later)



  • What spiritual/religious beliefs are important to this patient?

  • Where do they find meaning? How do they cope with illness?

References
Coulehan and Block, The Medical Interview: Mastering Skills for Clinical Practice, 5th ed.
Cohen-Cole, The Medical Interview: The Three-function Approach.

Mosby’s Guide to the Physical Examination.



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