THE PAST MEDICAL HISTORY
August 29 th , 2005 John Gazewood, MD, MSPH
Practice of Medicine-1
- To understand the structure and content of the past medical history, and its relation to the history of present illness.
- To understand appropriate use of communication skills in obtaining the past medical history.
- To observe an interview, and to see the resulting write-up of the interview.
At the conclusion of this lecture, you should be able to:
- Describe the content of the "other active problems" portion of a patient's history.
- Describe the content and structure of the past medical history.
- Describe how to use communication techniques in obtaining the past medical history.
- Know that some portions of the past medical history are obtained in the history of present illness.
Content of the Medical Interview
- Chief Complaint
- History of Present Illness
- 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.
Other Active Problems
- Many patients have other chronic conditions that affect, or are affected by, the present illness. For example, a patient with AIDS presents with a pneumonia, but has several other chronic infections related to AIDS, and hyperlipidemia related to drug treatment.
- It is appropriate to ask about these at the end of the HPI.
- These problems can be very significant; are often more efficiently and effectively dealt with here than in later portions of interview.
- Has anything else been bothering you?
- Can you think of any other symptoms you have had recently?
- What medicines do you take?
Past Medical History
- Major illnesses, beginning in childhood
- Significant injuries
- 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, poliomyelitis, 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.
- Need to ascertain primary reason for admission
- Approximate dates fine ( "in the early 1970's," or "I was about 22 or 23." OK)
- 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.
- 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
- Have patient describe allergic reaction - oftentimes, patient has experienced a side effect, not a true allergy.
- For adults, this includes flu, pneumonia, tetanus, hepatitis B, chickenpox (if they did not have chicken pox in childhood). 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).
- 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?"
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.
Patient Profile (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
- 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).
- 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?"
- 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?"
- type of exercise, frequency, and duration.
- 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
- 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 - routinize or explain questions.
- 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?
Review of Systems (ROS)
- Uncover additional medical problems not already discovered
- Identify additional symptoms related to the chief complaint/history of present illness. Inquiring about pertinent negatives also necessary.
- The ROS should be brief, if the remainder of interview well done.
- For each organ system, can ask general questions, with follow-up of positive responses.
- e.g., "Have you had any problem with your breathing?" as an initial question about the pulmonary system.
- May need to direct patients with a "diffusely positive" ROS.
- Symptoms that arise from the ROS are much less likely to indicate an important health problem than the symptoms a patient spontaneously reports during the HPI or Other Active Problems. In one study, only 3% of positive responses on a ROS led to a new diagnosis.
- General constitutional systems : fever, chills, fatigability, night sweats, weight loss/gain
- Eyes: Change in vision, blurring, acuity, diploplia, photophobia, pain, redness, discharge, loss of vision.
- Ears, nose, mouth, sinuses: Allergy symptoms, congestion, pain, discharge, change in hearing, tinnitus, sense of smell, epistaxis, sore throat, hoarseness, teeth or gum problems, oral ulcers, change in taste.
- Chest/lungs: Dyspnea, cyanosis, wheezing, cough, sputum, hemoptysis, chest pain related to breathing, exposure to TB, last chest X-ray.
- Cardiovascular : Chest pain, palpitations, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema, claudication,
- Digestive: Appetite, digestion, food intolerance, dysphagia (trouble swallowing), nausea, vomiting, bowel habits, change in bowels, hemorrhoids, history of ulcer, polyps.
- Genitourinary: dysuria, frequency, urgency, nocturia, hematuria, hesitancy, incontinence, hernias, flank or suprapubic pain. History of sexually transmitted diseases. Abnormal penile or vaginal discharge. For men: change in libido; difficulty obtaining or maintaining erection, abnormal ejaculation, premature or delayed orgasm. Testicular pain or swelling. For women: Normal menstrual pattern, change in menses, pain with menstruation, fertility problems pain with intercourse, problems with libido, arousal, orgasm, age at menopause, last Pap smear.
- Breast (for women): Pain, tenderness, discharge, lumps, last mammogram, performance of self breast exams, previous breast biopsies.
- Musculoskeletal : Joint pain, stiffness, restriction of motion, redness, warmth, deformity.
- Endocrine: thyroid enlargement or pain, heat or cold intolerance, changes in facial or body hair, change in weight, increased hat or glove size.
- Hematologic: Anemia, easy bruising, easy bleeding, history of blood clots.
- Lymph nodes: Swelling, tenderness, drainage.
- Neurologic: loss of consiousness, seizures, weakness or paralysis, change in sensation or coordination or gait, falls, tremor, memory loss.
- Psychiatric: depression, anxiety, mood changes, sleep disturbance, difficulty concentrating, suicidality.
- Skin , hair, nails: rash, itching, pigment or texture change, change in moles, excessive sweating/dry skin, abnormal nails or hair growth or texture.
Obviously, you could spend a lot of time memorizing these questions, and torturing patients with them when you interview them. Please don't! Remember, if you are spending a lot of time in the review of systems, you probably are not interviewing effectively! Use open-ended, broad introductory questions, with follow-up as needed!
Putting it together
- Can be helpful to have a "cheat sheet" with prompts, and space for notes.
- Different people have different styles and different organizational strategies for interviewing - experiment, and find one that works for you.
- Use good communication skills, and don't interrogate the patient.
- Don't forget to ask about medications and allergies.
One author's suggestion for time allotment:
- Introduction - 1 minute
- Definition of chief complaint and present illness - 15 minutes
- Definition of other active medical problems - 5 minutes
- Major past medical and family history - 8 minutes
- Patient profile - 5 minutes
- ROS - 3 minutes (Author obviously not a medical student!)
Coulehan and Block, The Medical Interview: Mastering Skills for Clinical Practice, 4 th ed.
Cohen-Cole, The Medical Interview: The Three-function Approach.
Mosby's Guide to the Physical Examination.
Verdon, ME, Siemens, K. Yield of review of systems in a self-administered questionnaire. J Am Board Fam Prac 1997;10:20-27.
Platt, FW, McMath, JC. Clinical hypocompetence: the interview. Ann Intern Med 1979; 91:898-902