Past Medical History: Start by asking the patient if they have any medical problems. If you receive little/no response, the following questions can help uncover important past events: Have they ever received medical care? If so, what problems/issues were addressed? Was the care continuous (i.e. provided on a regular basis by a single person) or episodic? Have they ever undergone any procedures, X-Rays, CAT scans, MRIs or other special testing? Ever been hospitalized? If so, for what? It's quite amazing how many patients forget what would seem to be important medical events. You will all encounter the patient who reports little past history during your interview yet reveals a complex series of illnesses to your resident or attending! These patients are generally not purposefully concealing information. They simply need to be prompted by the right questions!
Past Surgical History: Were they ever operated on, even as a child? What year did this occur? Were there any complications? If they don't know the name of the operation, try to at least determine why it was performed. Encourage them to be as specific as possible.
Medications: Do they take any prescription medicines? If so, what is the dose and frequency? Do they know why they are being treated?* Medication non-compliance/confusion is a major clinical problem, particularly when regimens are complex, patients older, cognitively impaired or simply disinterested. It's important to ascertain if they are actually taking the medication as prescribed. This can provide critical information as frequently what appears to be a failure to respond to a particular therapy is actually non-compliance with a prescribed regimen. Identifying these situations requires some tact, as you'd like to encourage honesty without sounding accusatory. It helps to clearly explain that without this information your ability to assess treatment efficacy and make therapeutic adjustments becomes difficult/potentially dangerous. If patients are, in fact, missing doses or not taking medications altogether, ask them why this is happening. Perhaps there is an important side effect that they are experiencing, a reasonable fear that can be addressed, or a more acceptable substitute regimen which might be implemented. Don't forget to ask about over the counter or "non-traditional" medications. How much are they taking and what are they treating? Has it been effective? Are these medicines being prescribed by a practitioner? Self administered? www.med126.com
* You'll be surprised to learn how many patients don't know the answers to these questions. Encourage them to keep an up to date medication list and/or write one out for them. When all else fails, ask the patient to bring their meds with them when they return or, if they are in-patients, see if a family member/friend can do so for them.
Allergies/Reactions: Have they experienced any adverse reactions to medications? The exact nature of the reaction should be clearly identified as it can have important clinical implications. Anaphylaxis, for example, is a life threatening reaction and an absolute contraindication to re-exposure to the drug. A rash, however, does not raise the same level of concern, particularly if the agent in question is clearly the treatment of choice.
Smoking History: Have they ever smoked cigarettes? If so, how many packs per day and for how many years? If they quit, when did this occur? The packs per day multiplied by the number of years gives the pack-years, a widely accepted method for smoking quantification. Pipe, cigar and chewing tobacco use should also be noted.
Alcohol: Do they drink alcohol? If so, how much per day and what type of drink? Encourage them to be as specific as possible. One drink may mean a beer or a 12 oz glass of whiskey, each with different implications. If they don't drink on a daily basis, how much do they consume over a week or month?
