Sunday, September 18, 2011

What I Covered in a Patient's Medical History by Dr. Robin Motz

     I am continually surprised at the lack of depth and detail in many medical histories that I read that were in the charts of new patients. Of course I was trained at Columbia Presbyterian Medical Center in the late 1970's, and we were taught to allow at least a full hour for the complete history and physical of a new patient. I also have to mention that the last medical patient I admitted as an intern in June 1976 to ward 9W was a 19 year old female with new onset diabetes presenting as DKA secondary to an unknown infection. I examined her down in the ER, brought her up to the ward, and broke her DKA  20 minutes after I extracted a tampon I found on pelvic exam that  she had forgotten  she had inserted the previous month and was the source of her infection.

     We were also taught to come out and greet the patient in the waiting room and escort the patient back to our consulting room, rather than have the PA put the patient directly into the exam room.

     I would like to list here some of the questions that I find are often not asked of a patient on the initial exam by the new physician. This of course pertains to the office exam, and not to the ER exam. In the ER as I would tell my residents, the two main considerations are: (1) does this patient need a hospital admission, and (2) what disease or process can the patient have than can kill him/her before I come in to make my morning attending rounds  (and, in the case of females, ALWAYS do a pregnancy test). The following list is not exhaustive, but I believe that if the questions are not asked, the patient is not going to get the best possible medical treatment.

The order of the questions is usually unimportant, and their place on the list need not correspond to their importance.

1) Are you allergic to any prescription drugs? What was the reaction? (Important)

2) Are you allergic to any over-the-counter-drugs or vitamins or health foods?  What was the reaction?

3) Were you ever hospitalized for any allergic reaction and did you have to be intubated?

4) What prescription drugs do you take and what are their doses? What was the last one added?

5) Are you on birth control pills (many women do not think of this as a prescription)?

6) What daily vitamin and food supplements do you take?----dosage and frequency. ?Daily aspirin dose?

7) Have you ever donated blood? To the blood bank or prophylactally pre-surgery.

8) Have you ever received a blood transfusion? After an accident? or surgery? or childbirth?

9) Do you still have your gallbladder, appendix and tonsils? Any recovery problems or excessive bleeding?

10) Last TB skin test and AIDS test.

11) Last tetanus, pneumonia , and flu vaccine. .Vaccinated against hepatitis A,B; or HPV? MMR? one or two?

12) Have you ever had unprotected sex? More than once? What were the circumstances?

13) When you were a child, did an adult of either sex ever make inappropriate advances to you?

14) Any broken bones, or damages in a motor vehicle accident?

15) Any surgeries or transplants. If yes, any anesthesia reaction?

16) Date of last mammogram, pap smear, colonoscopy, chest x-ray, EKG, stress-test, bone density test.

17) Date of last eye exam. Can you read street signs at night? Are you fearful of night driving?

18) Where were you born, where did you live and go to elementary school, high school, and any college or further education. Any serious illnesses or fractures or sprains while growing up?

19) Have you ever been pregnant? How many times and how many births? Medical pregnancy problems---elevated sugar, elevated blood pressure, C-section. Current method of birth control.

20) How many siblings.

21) Illnesses that run in family. Causes of death and ages at death of parents and any first degree relatives.

22) Excessive bleeding after dental work or tooth extraction or minor surgical procedure.

23) Do you look forward to your S.O. coming home, or to coming home to your S.O.?

24) When was your last vacation?

25) Do you look forward to going to work?

26) Do you have ongoing problems with your parents or inlaws?

27) With your children?

28) If dog in the house, does dog get monthly protective  treatment against Lyme ticks? What other pets, and are they sick?

29) When was the last time you had sex with your S.O.,? Did you both enjoy it? When was the last time before that?

30) Do you have trouble falling asleep or staying asleep?

31) Have you ever consulted a psychiatrist or other mental health worker? Any prescriptions given?

32) Have you ever thought of committing suicide? If yes, have you ever actually made plans.?

33) If you have a health care proxy, who is the named person? If not your S.O., what is the difference of opinion that caused that?

34) Where do you see yourself 5 years from now? 10 years from now?

35) Is there anything you would like to tell me that I haven't covered, or ask me?

36) Have you ever traveled outside the continental U.S. If yes, did you get sick on your travels? If you traveled to a malarious area did you take the prescribed anti-malaria medicine and for how long?

37) Have you ever fainted or passed out? What tests were done if you did?

38) How many times a week do you exercise?

39) What was your weight at high school graduation? College graduation? Before first pregnancy?

40) Do you think you drink too much?

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