History of Present Illness and Debilitating Symptoms

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The history of the present illness refers to the recent changes in health that led the patient to seek medical attention at this time. It describes the information relevant to the chief complaint. It should answer the questions of what, when, how, where, which, who, and why.

Chronology is the most practical framework for organizing the history. It enables the interviewer to comprehend the sequential development of the underlying pathologic process. In this section, the interviewer gathers all the necessary information, starting with the first symptoms of the present illness and following its progression to the present day. To establish the beginning of the present illness, it is important to verify that the patient was entirely well before the earliest symptom. Patients often do not remember when a symptom developed. If the patient is uncertain about the presence of a symptom at a certain time, the interviewer may be able to relate it to an important or memorable event;for example: ''Did you have the pain during your summer vacation?'' In this part of the interview, mainly open-ended questions are asked because these afford the patient the greatest opportunity to describe the history.

In the patient-centered evaluation, the interviewer must determine whether any debilitating symptoms are also present and what impact they have on the patient. These symptoms include pain, constipation, weakness, nausea, shortness of breath, depression, and anxiety.

Pain is one of the most debilitating symptoms and has traditionally been underrecognized. Unrelieved pain is very common and is one of the most feared symptoms of illness. Surveys indicate that 20% to 30% of the U.S. population experiences acute or chronic pain, and it is the most common symptom experienced by hospitalized adults. More than 80% of patients with cancer and more than two thirds of patients dying of noncancer illnesses experience moderate to severe pain. There are approximately 75 million episodes of acute pain per year resulting from traumatic injuries and surgical procedures. Acute pain is caused by trauma or medical conditions, is usually brief, and abates with resolution of the injury. Chronic pain persists beyond the period of healing or is present for longer than 3 months.

The effect of pain on the quality of life is important to understand. Untreated or undertreated pain impairs physical and psychological health, functional status, and quality of life. In particular, pain may produce unnecessary suffering; decrease physical activity, sleep, and appetite, which further weakens the patient; may increase fear and anxiety that the end is near;may cause the patient to reject further treatment;may diminish the ability to work productively; may diminish concentration; may decrease sexual function; may alter appearance; and may diminish the enjoyment of recreation and social relationships. In addition, pain has been associated with increased medical complications, increased use of health-care resources, decreased patient satisfaction, and unnecessary suffering. In the United States, the economic costs of undertreated pain approach $80 billion per year in treatment, compensation, and lost wages.

Because of health-care providers' lack of knowledge about analgesics, negative attitudes toward the use of pain control, and lack of understanding about addiction, and because of drug regulations and the cost of effective pain management, patients often suffer unnecessarily from inadequate pain control. A study of medical inpatients and the use of narcotic analgesics revealed that 32% of patients were continuing to experience ''severe'' distress despite the analgesic regimen, and 41% were in ''moderate'' distress. Breitbart and colleagues (1996) also revealed that pain was dramatically undertreated in ambulatory patients with acquired immunodeficiency syndrome (AIDS). Of patients experiencing severe pain, only 7.3% received opioid analgesics at the recommended doses. Approximately 75% with severe pain received no opioid analgesics at all. The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT) (1995) indicated that 50% of conscious patients who died in a hospital suffered ''moderate-severe'' pain during their last week of life.

Cleeland and associates (1997) reported that members of ethnic minority groups are likely to receive inadequate treatment for pain. Their study showed that minority patients were three times more likely to be undertreated for pain. Sixty-five percent of minority patients did not receive guideline-recommended analgesic prescriptions. Latino patients reported less pain relief than did African-American patients. Morrison and colleagues (2000) investigated the availability of commonly prescribed opioid analgesics in pharmacies in New York City. They found that 50% of a random sample of pharmacies surveyed did not stock sufficient medications to treat patients with severe pain adequately. Pharmacies in predominantly nonwhite areas were less likely to stock opioid analgesics than were pharmacies in predominantly white neighborhoods.

Whatever the cause of pain, health-care providers must ask repeatedly about the presence of pain and the adequacy of its control:

' 'Are you having pain?'' Have you had pain in the past week?'' ''Tell me where your pain or pains are located.'' How has the pain affected your life?'' Are you satisfied with your pain control?'' ''Tell me a little more about your pain.''

It is often useful with geriatric patients to say, ''Many people have pain. Is there anything you want to tell me?'' In cognitively impaired patients, the interviewer should ask about the real-time assessment of pain: pain now, not pain in the past 3 days.

Patients must be able to assess pain with easily administered rating scales and should document the efficacy of pain relief at regular intervals after the initiation or modification of treatment. In addition, it is vital to teach patients and their families how to promote effective pain management at home. The interviewer should ask patients to quantify their pain and should try using some form of pain rating scale. There are four commonly used ones:

• Simple Descriptive Pain Intensity Scale

• 0-10 Numeric Pain Intensity Scale

• Visual Analog Scale

These scales are illustrated in Figure 1-1.

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