Medical History

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Chief Complaint

Often the chief complaint is directly related to the patient's nutrition, which may affect treatment and prognosis. The most commonly voiced nutritional concerns are ''loss of appetite,'' ''weight loss,'' and ''weakness.'' Changes in dietary intake and in weight are among the earliest signs of medical problems. These complaints should prompt a detailed inquiry about diet and related symptoms in the history of present illness.

History of Present Illness

After asking the patient to describe the symptoms or medical problem that caused him or her to seek medical attention, begin to explore any diet-disease relationship that may exist. The following self-directed questions should guide your inquiry:

• Does nutrition contribute to the cause, severity, or treatment of the illness? For example, type 2 diabetes is most often seen among obese patients and is diet responsive. Inquiry should be made into the patient's body weight history and diet, including calorie content, pattern and types of foods eaten, and relationship to blood glucose levels.

How has the illness affected the patient's diet and nutritional status? For example, a patient with dysphagia from esophageal cancer typically experiences increasing difficulty swallowing solid foods, occasional vomiting, weight loss, and reduced muscle strength.

Does the patient see a relationship between diet and disease? For example, is a patient with hypercholesterolemia aware that consumption of dietary saturated fats, trans-fatty acids, and cholesterol raises blood cholesterol, whereas intake of dietary fiber lowers blood cholesterol?

Was the patient ever advised to follow a special diet or use other nutritional therapy, such as defined formula supplements, tube feedings, or intravenous (parenteral) nutrition? What were the particular aspects of this therapy? What was the patient's understanding of how the treatment works? What was the patient's understanding of its potential efficacy? For example, a patient with celiac disease must learn to follow a strict gluten-free diet to control the disease. The patient must become knowledgeable of sources of gluten in the diet, how to read food labels, and how to make dietary substitutions. This requires guidance from a registered dietitian.

Body Weight History

Body weight is a global indicator for overall health. Any weight loss is a good general indication of the severity or systemic nature of the presenting symptoms, whether they are acute or chronic. Both low body weight and unintentional weight loss have been shown to be predictive of increased morbidity and mortality. Although the cause of weight loss is often linked to the presenting medical problem, often no identifiable physical cause is apparent. In all cases, the underlying reasons for the weight change should be explored and the amount of weight loss clearly defined. Information-yielding questions include the following:

''Has your weight changed, either up or down, over the past several weeks or months?'' If so, "In what way?''

"How much weight did you lose or gain?'' ''What was your weight before the symptoms started?'' ''Over what period of time did you experience the weight loss or gain?'' How was your appetite over this time?''

''Do you know what may have contributed to your change in weight?''

Rapid weight gain is often an indicator of fluid retention and may be accompanied by edema or ascites. Common diseases associated with rapid weight gain include congestive heart failure, liver disease, and renal disease. In contrast, rapid weight loss usually signifies loss of body tissue, unless the patient has been undergoing therapeutic diuresis (in which case the patient would report markedly increased urination) or is experiencing dehydration (in which case the patient would report decreased fluid ingestion, dry mouth, weakness, and dizziness). If the patient has experienced weight loss, it is useful to think in terms of the percentage of weight lost over a specific time frame. To convert absolute pounds into percentage lost, the following simple equation is used:

% weight change = [(usual weight — current weight)/usual weight] x 100

Significant involuntary weight loss is generally defined as more than 5% of usual weight during the preceding 6 months or 10% or more within the year. When a patient has experienced weight loss, it is useful to direct your questions toward the underlying causes. There are four physiologic categories for weight loss: (1) decreased caloric intake, (2) malabsorption or maldigestion, (3) impaired metabolism or increased requirements, and (4) increased losses or excretion (Table 5-1).

Past Medical History

As patients list their past illnesses, the health-care provider should consider the role of nutrition or diet in the cause or treatment. Common diet-related diseases include cardiovascular disease (coronary artery disease, peripheral vascular disease, cerebrovascular disease), hypertension, diabetes, hyperlipidemia, some forms of cancer, and gastrointestinal (GI) diseases. In addition to asking how the illness was diagnosed and what treatment was rendered, ask the patient whether he or she received dietary counseling or altered his or her diet in response to the diagnosis. Try to ascertain the patient's understanding of the role that diet plays in the condition.

Past Surgical History

All surgical procedures should be recorded in this section, along with serious surgical complications such as draining fistulas, abscesses, open wounds, and chronic blood loss. These complications often lead to malnutrition and the need for specialized nutritional support, including enteral and parenteral feedings. If the patient is currently in the postoperative period, you should consider the role of nutritional support in the recovery process and how the particular surgery has altered the patient's dietary habits and requirements. For example, a patient with a total gastrectomy needs to alter his or her diet to reduce simple sugars, eat multiple small meals each day, and receive supplemental vitamin B12 and iron to maintain good nutritional health.

Medications

The medication history should include both prescription and over-the-counter medications. Because complementary and alternative therapies have become popular, many patients take vitamins, minerals, herbs (Table 5-2), and other dietary supplements that they may not mention without prompting. A thorough review of alternative therapy use should be a standard

Table 5—1 Physiologic Categories Associated with Weight Loss

Category

Symptoms

Diseases

Decreased caloric intake

Loss of appetite (anorexia) or early fullness (satiety) Change in taste, dry mouth, or sore mouth and tongue Difficulty chewing or swallowing Nausea or vomiting Inability to feed self or obtain food Self-imposed diet

Social isolation, depression Dysmotility

Gingivitis, poor dentition Gastroparesis Obstruction (esophageal, gastric, or intestinal) Anorexia nervosa Cancer

Maldigestion/malabsorption

Diarrhea

Fatty, malodorous stools Change in bowel habits Food particles in stool

Pancreatic insufficiency Radiation enteritis Crohn's disease Short bowel syndrome Lactose intolerance Celiac disease

Impaired metabolism/increased requirements

Fever

Increased or decreased appetite

Acquired immunodeficiency syndrome (AIDS) Pneumonia, sepsis Major surgery or trauma Hyperthyroidism Chronic hepatic, renal, or pulmonary disease Pregnancy and growth

Increased losses/excretion

Draining fistulas or open wounds Diarrhea

Increased urination Excessive vomiting

Burns

Occult gastrointestinal bleeding

(iron loss) Hemodialysis Diabetes (glucosuria)

Table 5—2 Commonly Used Herbs and Their Side Effects

Herb Common Use Side Effect and Interaction

Echinacea St. John's wort Gingko biloba Garlic

Saw palmetto Ginseng Goldenseal Aloe

Siberian ginseng Valerian

Treatment and prevention of upper respiratory infections, common cold

Treatment of mild to moderate depression

Treatment of dementia

Treatment of hypertension, hypercholesterolemia, atherosclerosis

Treatment of benign prostatic hyperplasia

General health promotion, energy

Treatment of upper respiratory infections, common cold

Topical application for dermatitis, herpes

Similar to those of ginseng Treatment of insomnia, anxiety

Rash, pruritus, dizziness

Gastrointestinal upset, photosensitivity

Mild gastrointestinal distress, headache; may have anticoagulant effects

Gastrointestinal upset, gas, reflux, nausea, allergic reaction, antiplatelet effects

Uncommon

High doses: diarrhea, hypertension, insomnia, nervousness

Diarrhea, hypertension, vasoconstriction

Possible delay in wound healing after topical application; diarrhea and hypokalemia with oral use

May alter digoxin levels

Fatigue, tremor, headache, paradoxical insomnia part of the patient medication and lifestyle history. When eliciting this information, be careful not to be judgmental or accusatory. Many patients do not disclose this information because of fear of being censured. Suggested questions are as follows:

''Are you taking any vitamins, minerals, herbs, or other dietary supplements, either prescription or over-the-counter?'' If so, ''What is the dosage?''

''What is the reason you are taking the supplement?''

''Have you experienced any side effects or benefits from the supplements?''

''Is anybody monitoring you, such as your doctor, nutritionist, or herbalist?''

' 'What is your consumption of grapefruit and grapefruit juice?''

Drugs and nutrients interact in many ways to affect both nutritional status and the effectiveness of drug therapy. Drugs may influence nutritional status by several physiologic mechanisms: altering food intake (through changes in appetite, nausea, altered taste sensations), producing malabsorption (through alterations in intestinal mucus, motility, or pH; competition with nutrients for absorption sites;binding of bile acids), or modifying excretion (through renal tubular reabsorption or secretion). Drug-induced nutrient deficiencies usually develop slowly and are more likely in patients who use drugs chronically, especially the elderly. Other risk factors include high drug dosages, multiple drug dosages, multiple drug regimens, poor diets, and marginal nutrient stores. Table 5-3 lists examples of drug interactions and nutrient metabolism.

Studies by Bailey and associates (1998) revealed possible drug interactions involving grapefruit and grapefruit juice (fresh or frozen) with several common medications used to treat

Table 5—3 Drug Interactions and Nutrient Metabolism

Drug Class and Examples Nutrients Affected

Antacids Aluminum hydroxide Magnesium trisilicate

Antibiotics Tetracyclines Neomycin, kanamycin Sulfasalazine

Anticonvulsants

Phenobarbital, phenytoin

Hypolipidemics Cholestyramine, colestipol

Cytotoxic agents Methotrexate

Laxatives Mineral oil

Antituberculotics Isoniazid

Anticoagulants Warfarin

Analgesics

Aspirin, nonsteroidal anti-inflammatory drugs

Diuretics Thiazides, furosemide

Antineoplastic agents Cisplatin

Phosphorus Iron

Calcium, magnesium, iron, vitamin B12 Fat-soluble vitamins, vitamin B12 Folate

Calcium, vitamin D, folate Fat and fat-soluble vitamins Folate

Water, electrolytes, fat, and fat-soluble vitamins Pyridoxine (vitamin B6) Vitamin K Iron

Potassium, magnesium, calcium, zinc Potassium, magnesium high blood pressure, anxiety, depression, cancer, gastroesophageal reflux disease, erectile dysfunction, angina, convulsions, and human immunodeficiency virus infection/acquired immunodeficiency syndrome. In general, the grapefruit or its juice tends to increase the drug's effect. The advisory also cautioned that sour oranges and tangelos may also interfere with medication blood levels. Other citrus fruits were considered safe. The study stated that as little as one 8-oz (0.26-mg) glass of grapefruit juice could increase the blood drug level and the effects could last for 3 days or more.

Allergies and Food Intolerances

In addition to asking about allergies to medications and environmental allergens, the interviewer should inquire about allergies and intolerances to food. The most common allergenic foods among adults are peanuts, tree nuts, shellfish, fish, eggs, soy, wheat, and milk. The first four foods listed may cause life-threatening reactions. If the patient states that he or she has a food allergy, the interviewer should ask what happens when those foods are eaten. Allergic symptoms may affect the respiratory tract (rhinorrhea, sneezing, wheezing, chest tightness, laryngeal edema), skin (urticaria, angioedema, pruritus, erythematous macular rash), or GI tract (nausea, vomiting, diarrhea, abdominal cramping).

A food allergy needs to be differentiated from food intolerance. Symptoms of food intolerance are usually confined to the GI tract and may be acute or chronic. Upper GI tract symptoms of belching and bloating may be due to aerophagia (swallowing air during the ingestion of food or drink), which is commonly associated with smoking, eating rapidly or talking while eating, chewing gum and hard candy, or ingesting carbonated beverages. Chronic lower GI tract symptoms of bloating, cramping, flatulence, or diarrhea may result from the ingestion of sugar substitutes (sorbitol, xylitol) or fructose, high fiber intake, or lactase deficiency. Of these potential causes, lactose intolerance is the most common, affecting 25% of the population in the United States and up to 80% of African Americans. In lactose-intolerant individuals, symptoms occur after the consumption of products containing lactose, including milk, cheese, ice cream, yogurt, and some processed foods.

Social History

Multiple social factors affect the dietary and nutritional status of patients. For example, low socioeconomic status, low fixed income, homelessness, or lack of access to a variety of food choices may contribute to nutritional deficiencies. Chronic alcoholism and recreational drug use are two additional conditions that put people at high nutritional risk. The patient's attitudes about food and nutrition, as well as religious observances, also determine eating patterns and the selection or avoidance of specific foods. This information is important to note and document.

Lifestyle Habits

The lifestyle habits section of the medical history includes the dietary history, physical activity history, alcohol use, and smoking history. Questions related to alcohol use and smoking are discussed in Chapter 1, The Interviewer's Questions.

Dietary History

The dietary history provides information about the patient's food habits, diet, and any counseling he or she may have received. Depending on the patient's medical problems, the dietary history may be brief or comprehensive. It is often difficult to obtain accurate information about a patient's diet because of variability, general lack of focus on what is eaten, and for-getfulness. For this reason, the primary goal is to obtain a qualitative description of eating patterns and the foods and beverages that are habitually chosen, along with any dietary changes that occurred over the course of the illness. Three methods are commonly used: a 24-hour intake recall, a typical day, and food frequency.

A 24-hour intake recall is used extensively and may be broached as follows: ''Please tell me what you had to eat and drink for the entire day yesterday. Could you start with the first item you had to eat or drink and bring me through the entire day? I would also like to know the times you ate and the amounts.'' The advantage of this method is that patients can usually remember what they ate over the course of one recent day. The disadvantage is that one particular day may not adequately depict the patient's usual diet, especially if there has been a recent change.

The preferred method is to ask the patient to describe a typical day. A good opening is, ''I would like to know about your usual or typical diet. Can you bring me through a typical day, starting with the first item you eat or drink? I would also like to know the times you eat and the amounts.'' The advantage is that you are more likely to capture a picture of the patient's habitual diet. If the patient states that every day is different and there are no typical days, then ask him or her to describe one or two days as examples, such as one weekday and one weekend day.

The third method is food frequency. This refers to how often the patient consumes specific food groups or nutrients and about other dietary practices. Examples of questions are ''How often do you eat fruits and vegetables: daily, every few days, weekly, or rarely?'' and ''When you do eat them, how many servings do you choose?'' The same qualitative questions can be extended to the consumption of dairy products, whole-grain breads and cereals, red meats, visible fats, and so forth. Examples of other informative questions for taking a dietary history are as follows:

''What are your favorite foods and snacks?''

''Are you following any special diet (diabetic, low sodium, low fat, kosher, vegetarian, low protein, commercial)?'' If so, ''What does this diet entail?''

''How often are meals home cooked? Who prepares the meals?''

''What sort of fats or oils (if any) do you use in cooking?''

''How often do you eat out or order food in?'' (Meals prepared outside the home are generally higher in calories, fat, and sodium.)

''How is food usually prepared (baked, broiled, fried, boiled, steamed, poached)?''

Targeted disease-focused questions should be asked, depending on the patient's medical history. For example, if the patient has osteoporosis, you would probe for the consumption of calcium-containing foods, such as milk, cheese, sardines, and greens. For a patient with hyper-cholesterolemia or coronary artery disease, you would ask about the intake of saturated fats, whole dairy products, egg yolks, fried foods, tropical oils, and fiber sources. For a patient with diabetes mellitus, you would ask whether meals and snacks are timed to correspond with insulin injections, whether the patient follows the American Diabetes Association food group exchange system and counts carbohydrate grams, and whether the patient knows symptoms of hypo-glycemia and how to treat it.

Patients should be asked whether they read nutrition labels and, if they do not, instructed how to read them. Since May 1994, nutritional labeling has been required for almost all foods. There are now uniform definitions for the terms ''free,'' ''low,'' ''light,'' ''reduced,'' ''high,'' ''lean,'' ''extra lean,'' and so forth. The current food label, known as Nutrition Facts, allows individuals to choose healthier foods more easily. Nutrition labeling provides the ''% Daily Value,'' which shows how a food fits into the overall daily diet. This value is based on a 2000-calorie diet and informs the individual whether the food is high or low in the specific nutrient. These labels must include serving size, total calories, calories from fat, total fat, saturated fat, cholesterol, sodium, total carbohydrate, dietary fiber, sugars, and protein. The % Daily Value of four key vitamins and minerals (vitamin A, vitamin C, calcium, and iron) is also mandatory on these labels. Information about other vitamins and minerals is optional. Information about thiamine, riboflavin, and niacin is no longer necessary because deficiencies of these vitamins are rare in the United States. The % Daily Value is only a guide;if a patient eats more than 2000 calories a day, the food would contribute a lower % Daily Value to the diet.

The Institute of Medicine of the National Academies recommends that the following guidelines be used daily for achieving a healthful diet:

Carbohydrates: 45% to 65% of calories

Trans fat: no more than 1% total body calories

Protein: 10% to 35% of calories

Cholesterol: no more than 300 mg each day

Fiber: women need 21 to 25 g/day;men need 30 to 38 g/day

Most individuals on a balanced diet consume foods that contain all the vitamins and minerals they need. Some individuals, however, might benefit from vitamin supplementation. These individuals include habitual dieters, ill patients (especially those with loss of appetite or impaired absorption), pregnant or lactating women, infants consuming formula, some vegetarians, elderly patients, and patients with anorexia nervosa.

Physical Activity

Both nutrition and regular physical activity play an important role in the overall health of the individual. It is recommended that all adults perform at least 30 minutes of moderately intense physical activity 5 days a week. There are many benefits to regular physical activity: increasing physical fitness; building and maintaining healthy bones, muscles, and joints; improving endurance and muscle strength;lowering the risk of certain diseases (e.g., diabetes, cardiovascular disease, colon cancer); controlling blood pressure; promoting and improving a sense of well-being; reducing feelings of anxiety and depression; and managing weight problems.

Always ask patients about their current level of physical activity and functioning. Some helpful questions include the following:

' 'What is the most physically active thing you do in the course of the day?'' How do you spend your working day and leisure time?'' ' 'What types of physical activity do you enjoy? How often do you do them?'' ''Do you exercise regularly?'' If so, ' 'What exercises do you do regularly? How often?'' ''What gets in the way of you consistently doing physical activity?'' ''How many hours of TV do you watch every day?'' How many hours are you at a computer or desk every day?'' ''Do you belong to (and attend) a health club or exercise classes?''

Review of Systems

The review of systems section is a reexamination of the patient's history by organ system. This section should include a general statement about the patient's body weight history and appetite if such a statement is not included in the history of present illness or the past medical history.

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