Past Medical History

The past medical history consists of the overall assessment of the patient's health before the present illness. It includes all of the following:

General state of health Past illnesses • Injuries

Hospitalizations

Surgery

Allergies

Immunizations

Substance abuse

Diet

Sleep patterns Current medications

Complementary and alternative therapies

As an introduction to the past medical history, the interviewer may ask, ''How has your health been in the past?'' If the patient does not elaborate about specific illnesses but says only ''Excellent'' or ''Fair,'' for example, the interviewer might ask, ''What does 'excellent' mean to

SIMPLE DESCRIPTIVE PAIN INTENSITY SCALE1

No Mild Moderate Severe Very Worst pain pain pain pain severe possible pain pain

0-10 NUMERIC PAIN INTENSITY SCALE1

01 23456789 10

No Moderate Worst pain pain possible pain

1If used as a graphic rating scale, a 10 cm baseline is recommended. 2A 10 cm baseline is recommended for VAS scales.

Figure 1-1 Examples of pain scales. A, Simple Descriptive Pain Intensity Scale. B, 0-10 Numeric Pain Intensity Scale. C, Visual Analog Scale. D, Face Scale.

you?'' Direct questioning is appropriate and allows the interviewer to focus on pertinent points that need elaboration.

The record of past illnesses should include a statement of childhood and adult problems. Recording childhood illnesses is obviously more important for pediatric and young adult interviewees. All patients should nevertheless be asked about measles, mumps, whooping cough, rheumatic fever, chickenpox, polio, and scarlet fever. Older patients may respond, ''I really don't remember.'' It is important to remember that a diagnosis given to the interviewer by a patient should never be considered absolute. Even if the patient was evaluated by a competent clinician in a reputable medical center, the patient may have misunderstood the information given.

The patient should be asked about any prior injuries or accidents: ''Have you ever been involved in a serious accident?'' The type of injury and the date are important to record.

All hospitalizations must be indicated, if not already described. These include admissions for medical, surgical, and psychiatric illnesses. The interviewer should not be embarrassed to ask specifically about psychiatric illness, which is a medical problem. Interviewer embarrassment inevitably leads to patient embarrassment and reinforces the ''shame'' associated with psychiatric illness. Student interviewers should learn to ask direct questions in a sensitive manner. The interviewer might ask, ''Have you ever been in therapy or counseling?'' or ''What nervous or emotional problems have you had?''

All surgical procedures should be specified. The type of procedure, date, hospital, and surgeon's name should be documented, if possible.

All allergies should be described. These include environmental, ingestible, and drug-related reactions. The interviewer should seek specificity and verification of the patient's allergic response. ''How do you know you're allergic?'' ''What kind of problem did you have when you took ...?'' The symptoms of an allergy (e.g., rashes, itching, anaphylaxis) should be clearly indicated.

It is important to determine the immunization history of all patients. Tetanus and diphtheria immunity is present in fewer than 25% of adults, and fewer than 25% of targeted groups receive influenza vaccines yearly. Tetanus and diphtheria are preventable, and the current recommendation is to use the combined toxoid whenever either immunization is considered. Any patient who has never received this toxoid receives an initial injection and follow-up doses at 1 month and 6 to 12 months. A booster dose is required every 10 years.

All patients with chronic cardiovascular, pulmonary, metabolic, renal, or hematologic disorders and patients with immunosuppression should be vaccinated yearly against influenza. Patients older than 65 years should also receive the vaccine.

Indications for the pneumococcal polysaccharide vaccine are similar to those for the influenza vaccine. In addition, patients with multiple myeloma, lymphoma, alcoholism, cirrhosis, and functional or anatomic asplenia should receive the vaccine. This vaccine usually provides lifelong immunity. Revaccination every 6 years is necessary only in asplenic patients, because they are at high risk for pneumococcal infection.

Hepatitis A is one of the most common vaccine-preventable infections acquired during travel. Hepatitis A is a liver disease caused by the hepatitis A virus. Hepatitis A can affect anyone and is transmitted by the fecal-oral route. In the United States, hepatitis A can occur in situations ranging from isolated cases of disease to widespread epidemics. Good personal hygiene and proper sanitation can help prevent hepatitis A. Vaccines are also available for long-term prevention of hepatitis A virus infection in persons 12 months of age and older. The first dose of hepatitis A vaccine should be administered as soon as travel to countries with high or intermediate endemicity is considered. One month after receiving the first dose of monovalent hepatitis A vaccine, 94% to 100% of adults and children have protective concentrations of antibody. The final dose in the hepatitis A vaccine series is necessary to promote long-term protection. Immune globulin is available for short-term prevention of hepatitis A virus infection in individuals of all ages.

Hepatitis B vaccine should be given to all health-care providers, staff of institutions for developmentally disabled patients, intravenous drug abusers, patients with multiple sexual partners, hemodialysis patients, sexual partners of hepatitis B carriers, and patients with hemophilia. Complete immunization necessitates three injections: an initial one and follow-up doses at 1 month and at 6 to 12 months. Booster doses are not required. For best results, persons at high risk of exposure (especially medical, dental, and nursing students) should receive immunization before possible exposure.

Haemophilus influenzae type B vaccine is now used routinely in children to prevent invasive H. influenzae diseases. In 2005, H. influenzae type B (Hib) was estimated to have caused 3 million cases of serious disease, notably pneumonia and meningitis, and 450,000 deaths in young children. Meningitis and other serious infections caused by Hib disease can lead to brain damage or death. Hib disease is preventable by immunizing all children younger than 5 years with an approved Hib vaccine. Several Hib vaccines are available. The general recommendation is to immunize children with a first dose at 2 months of age and to follow with additional doses according to the schedule for the vaccine being used. Three to four doses are needed, depending on the brand of Hib vaccine used. Hib vaccine should never be given to a child younger than 6 weeks, because this might reduce his or her response to subsequent doses.

Between 1991 and 1992, there was a 75% decrease in the number of cases of measles, mumps, and rubella (MMR), presumably because of the use of the MMR vaccine. This vaccine is now typically given in childhood, but it should also be given to adult health-care providers who have not had the diseases. Because the vaccine contains a live virus, it should not be given to pregnant patients, those with generalized malignancies, those receiving steroid therapy, those with active tuberculosis, or those receiving antimetabolites.

The Advisory Committee on Immunization Practices (ACIP) annually reviews the recommended Adult Immunization Schedule to ensure that the schedule reflects the current recommendations for the licensed vaccines. It is advisable for the health-care worker to review these guidelines regularly. The current recommendations at the time of this publication may be found at www.cdc.gov/mmwr/pdf/wk/mm5641-Immunization.pdf.

A careful review of any substance abuse by the patient is included in the past medical history. Substance abuse includes cigarette smoking and the use of alcohol and recreational drugs. In the United States in 2007, an estimated 46 million people were smokers. About 23%

of men and 19% of women smoke. As many as 30% of all deaths related to coronary heart disease in the United States each year are attributable to cigarette smoking;the risk is strongly dose-related. Smoking also nearly doubles the risk of ischemic stroke. Smoking acts synergistically with other risk factors, substantially increasing the risk of coronary disease. Smokers are also at increased risk for peripheral vascular disease, cancer, chronic lung disease, and many other chronic diseases. Cigarette smoking is the single most alterable risk factor contributing to premature morbidity and mortality in the United States, accounting for approximately 430,000 deaths annually.

The interviewer should always ask whether the patient smokes and for how long: ''Do you use nicotine in any form: cigarettes, cigars, pipes, chewing tobacco?'' A pack-year is the number of years a patient has smoked cigarettes multiplied by the number of packs per day. A patient who has smoked two packs of cigarettes a day for the past 25 years has a smoking history of 50 pack-years. If the patient answers that he or she does not smoke now, the interviewer should inquire whether the patient ever smoked.

It has been estimated that the incidence of hazardous alcohol drinking in the United States ranges from 4% to 5% among women and 14% to 18% among men. In primary care settings, the prevalence rates range from 9% to 34% for hazardous drinking. Although studies have shown the beneficial effects of moderate alcohol consumption (one to two drinks daily), these effects are lost at higher doses. Heavy alcohol consumption is associated with many medical problems (e.g., hypertension, decreased cardiac function, arrhythmias, hemorrhagic stroke, ischemic stroke, liver disease, increased risk of breast cancer), as well as behavioral and psychiatric problems. According to the American Psychiatric Association and the National Institute on Alcohol Abuse and Alcoholism, ''moderate drinking'' for men is defined as less than two drinks per day;for women and persons older than 65 years, it is defined as less than one drink per day.

The history of alcohol consumption and dependency should be integrated into the general history immediately after the interviewer inquires about less threatening subjects such as smoking. It is easy to miss alcohol dependency unless specific direct questions are asked. It is acceptable to broach the topic of alcoholism by asking, ''Please tell me about your drinking of alcohol.'' The interviewer should focus not on the quantity of alcohol consumed but rather on the adverse effects of drinking. By asking, ''How much do you drink?'' the interviewer may put the patient on the defensive. This type of question may also create an unnecessary power struggle between patient and interviewer. Ask instead, ''How much can you drink?'' which puts the patient and interviewer in a position of alliance. Most individuals who drink heavily also underestimate the quantities they consume. The interviewer can often learn more about the quantity of alcohol consumed by asking about the patient's feelings and interpersonal relationships than by asking directly about the amount. The interviewer should determine whether the patient drives while intoxicated, has suffered amnesia of events that occurred during drinking, neglects or abuses his or her family, and has missed work as a result of alcohol consumption.

Ewing and Rouse (1970) developed the CAGE questionnaire as a formal screening instrument to help identify patients in primary care with alcohol problems. The acronym CAGE helps the interviewer remember the four clinical interview questions that focus on the social and behavioral aspects of alcohol problems. Once it is established that a patient drinks alcohol, the following questions should be asked:

''Have you ever felt you should Cut down on your drinking?'' ''Have people Annoyed you by criticizing your drinking?'' ''Have you ever felt bad or Guilty about your drinking?''

''Have you ever taken a drink first thing in the morning (Eye-opener) to steady your nerves or get rid of a hangover?''

Since its introduction, the CAGE questionnaire has been shown to be one of the most efficient and effective screening devices for detecting alcoholism. In a primary care setting, CAGE scores of 2 (two positive responses) have a sensitivity of 77% to 94% and a specificity of 79% to 97% for a current diagnosis of alcohol abuse. One positive CAGE response has a sensitivity of 21% to 71% and a specificity of 84% to 95%. The history of alcohol consumption and dependency can be further assessed by using the sets of questions referred to by the acronyms HALT, BUMP, and FATAL DT.

The HALT questions are as follows:

' 'Do you usually drink to get High?'' ''Do you drink Alone?''

''Do you ever find yourself Looking forward to drinking?'' ''Have you noticed whether you seem to be becoming Tolerant of alcohol?''

The BUMP questions are as follows:

''Have you ever had Blackouts?'' ''Have you ever used alcohol in an Unplanned* way?'' ''Do you ever drink alcohol for Medicinal{ reasons?'' ' 'Do you find yourself Protecting{ your supply of alcohol?''

The final acronym reminds the interviewer about other major associations with alcoholism. The FATAL DT questions are as follows:

' 'Is there a Family history of alcoholic problems?''

' 'Have you ever been a member of Alcoholics Anonymous?''

''Do you Think you are an alcoholic?''

''Have you ever Attempted or had thoughts of suicide?''

''Have you ever had any Legal problems related to alcohol consumption?''

''Do you ever Drive while intoxicated?''

''Do you ever use Tranquilizers to steady your nerves?''

These questions provide the interviewer with a useful, thoughtful, and organized approach to the interview strategy designed to identify patients with a drinking problem.

In the late stages of alcoholism, a person may suffer delirium tremens (DTs). DTs are completely different from the hallucinations that occur in the earlier stages of alcoholism. During hallucinations, the patient may see or hear ''things.'' DTs occur 24 to 96 hours after withdrawal from alcohol; occasional patients hallucinate or have convulsions, but all patients tremble. DTs are the most severe form of withdrawal and are fatal in one of every four cases.

The interviewer must ask all patients about the use of other drugs. People who use recreational drugs often engender negative feelings or anger in the interviewer. These feelings are almost unavoidable. The interviewer must not allow these feelings to interfere with empathetic interviewing. A useful way of approaching the topic of recreational drugs is to ask,

Have you ever used drugs other than those required for medical reasons?'' ' 'Do you use drugs other than those prescribed by a physician?'' Have you abused prescription drugs?''

If the answer to any of these questions is affirmative, the interviewer should determine the types of drugs used, the routes of administration, and the frequency of use. In contrast to alcohol abusers, drug abusers are more likely to magnify their use. The interviewer must ask all patients with a history of drug abuse the following questions:

''What type of drugs do you use?'' ''At what age did you start using drugs?''

*Drink more than you intended or have an additional drink after you decided you had had enough. {As a cure for anxiety, depression, or the ''shakes.'' {Buying enough alcohol just in case ''company'' arrives.

''What was your period of heaviest use?''

''What is your recent pattern of use?''

''Are larger doses necessary to get the same effect now?''

''What do you feel when you take the drug?''

''Have you ever tried to quit? What happened?''

''Have you ever had any convulsions after taking the drug?''

''Do you use drugs on a continuous basis?''

''Have you been in trouble at work because of drug use?''

''Have you ever had withdrawal symptoms as a result of your use of drugs?''

It is important to use simple words and expressions when inquiring about recreational drugs. It may also be more appropriate to use slang than to use more formal terms. For example, ''Do you ever shoot up or snort coke?'' may be better understood than ''Have you ever taken cocaine intravenously or by insufflation?'' With experience, the interviewer acquires relevant knowledge about recreational drugs. Knowing the local street names for drugs can be as important as knowing the pharmacologic effects and may provide a means of better communication. It should be recognized that these street names are often different from place to place and change from time to time. Appendix A (Commonly Abused Drugs) lists their street names and the major symptoms and signs associated with each of them.

It should also be recognized that any medication can be abused. Drugs such as propranolol and metoprolol (beta blockers used in the treatment of hypertension) are not usually considered recreational drugs. They are, however, frequently abused by the acting community to relieve performance anxiety, or stage fright.

In questioning a patient about diet, it is useful to ask the patient to describe what he or she ate the day before, including all three meals plus any snacks. How many fish meals does he or she have each week? What is the proportion of red meat in the diet in comparison with fish or poultry? How much saturated fat is there in the diet? Does the patient add salt when he or she cooks, and does he or she add salt at the table? Has his or her diet changed recently? What kinds of foods does the patient like or dislike, and why? Are there any food intolerances? Does the patient eat foods with a high fiber content, such as whole-grain breads and cereals, bran, fresh fruits, and vegetables? Does the patient eat high-fiber snack foods (which include sesame bread sticks, date-nut bread, oatmeal cookies, fig bars, granola bars, and corn chips)? What is the consumption of sodium? Pickled foods, cured meats, snack foods, and prepared soups have a high sodium content. The consumption of caffeine-containing products such as coffee, tea, cola sodas, and chocolate is important to determine. Caffeine ingestion may produce a variety of symptoms, including heart palpitations, fatigue, lightheadedness, headaches, irritability, and many gastrointestinal symptoms (see Chapter 5, Assessment of Nutritional Status, for a detailed description). The interviewer should also ascertain the amount of exercise the patient gets.

It is important to know a patient's sleep patterns because this may provide information about the patient's psychological problems. Sleep-related complaints such as insomnia and excessive daytime somnolence impair the lives of 20% to 50% of Americans. More than 60% of patients with psychiatric problems complain of disturbed sleep patterns. Eighty percent of patients with depression complain of disturbed sleep. The most common problem in patients with post-traumatic stress disorder is disturbed sleep;more than 50% of patients with chronic pain experience sleep problems. An estimated 200,000 automobile accidents a year are caused by excessive sleepiness on the part of drivers; 20% of drivers report that they have fallen asleep behind the wheel. The following questions should be asked:

Do you have trouble falling asleep?''

' 'Do you stay asleep the whole night, or do you awaken in the middle of the night, unable to go back to sleep?''

Do you go to bed only when sleepy?'' Do you adhere to a regular waking time?''

All current medications should be noted. The following questions should be asked:

Do you use any prescription medications?'' Do you use any over-the-counter medications?'' Do you use any herbal medications or vitamins?'' Do you use any recreational drugs?''

If possible, the patient should show the interviewer the bottles and demonstrate how the medications are taken. The interviewer should note whether the patient is taking them according to the directions on the bottle. Frequently, patients consider over-the-counter medications such as vitamins, laxatives, antacids, or cold remedies not worth mentioning; the interviewer should ask specifically about each of these types of drugs. The interviewer should determine the type of contraception used, if any, and whether a woman has used or uses birth control pills.

The use of alternative therapies is extremely common, as discussed in Chapter 4, Understanding Complementary and Alternative Medicine. The patient and the health-care provider must be comfortable with how questions about these therapies are asked. Avoid using the terms other therapies, unorthodox therapy, or unconventional medicine. These labels may be perceived as judgmental and could inhibit free discussion. You might start by saying, ''Many patients frequently use other kinds of therapy when they have the symptoms you described. Have you used or thought about using massage, herbs, chiropractic, acupuncture, vitamin, or other different therapies for your problem or for any other reasons?''

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