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Medical History

Medical History. Howard M. Hack, M.D. Adjunct Clinical Asst Prof of Medicine Stanford University. Introduction. The history is a critical piece of information which allows the physician to solve problems The interaction may start in the exam room

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Medical History

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  1. Medical History Howard M. Hack, M.D. Adjunct Clinical Asst Prof of Medicine Stanford University

  2. Introduction • The history is a critical piece of information which allows the physician to solve problems • The interaction may start in the exam room • It is often helpful to observe the patient prior to this.

  3. Chief Complaint • Why is the patient here or why are you seeing them? • 1st level: the referring physician • 2nd level: the patient or their family • Typically documented concisely, e.g. patient reports diarrhea for 3 weeks

  4. How to Start • What can I do for you today? • I see Dr Smith wanted you to be seen for anemia, is that correct? Is this your understanding of why you are here? • What brought you in today? • My cousin Lenny • The taxi

  5. Referring Physician • Communicated in notes or script • Typically directed • Iron deficiency anemia • Diarrhea • Abdominal Pain

  6. Patients Concerns • They are coming to you with specific goals • If we cannot identify and meet these, the patient will likely feel disappointed • This may be communicated directly • May come out during the interview • Read body language

  7. Patient • Look at affect • Body language • Important to ask about concerns during the history as well as at the conclusion of the process

  8. History as a Story • Patients may present the history in a variety of ways • Organized/Disorganized • Historical timeframe/Jump around • Consistent/Inconsistent • Medical pigeon hole • Repeat the story in an abridged version

  9. Medical Evaluation • Doctors/impressions – ‘never trust the nursing home doctor’ (House of God) • Labs • Radiologic studies • Endoscopic studies • Surgeries • Old records

  10. History • Sources: • Patient • Medical records • Family or friends

  11. Mars and Venus • Men typically are less expressive about medical history • Screening colon with Crohn’s • Frequently helpful to hear from spouse or other family members • Some women may want to chat. • Many patients may present for companionship

  12. Quantifying the History • Describe the nature of the problem • When did this start? • How long does it last? • If pain, does it radiate anywhere? • Any modifying factors? • Does this wake you up from sleep? • Does it interfere with your activities?

  13. Review of Systems • Questioning about different body systems • Complete the medical history • Systems • GI • Cardiac • Renal • Pulmonary • Rheumatologic • General

  14. Putting Together the Story • Doctors reading the history should be able to get the same picture you do • You are the editor. We organized the order of facts and put the information together in a readable and understandable format. • Try not to edit out information, unless it is duplicative.

  15. Review • It is helpful to present back the informational story to the patient before the end of the history. • They may be able to correct errors or remember additional important information

  16. Past Medical History • Previous Medical Problems, e.g. Diabetes • Heart • Lungs • Kidneys • GI tract • Mental Health

  17. Past Surgical History • Surgeries and Procedures • Appendectomy • Colonoscopy • Account for scars!

  18. Medications • All medications • Dose • Frequency • How long • OTC medications may not be volunteered

  19. Allergies • Medications • Foods, e.g. Iodine such as seafood

  20. Family History • Ideally map out patterns of illness • Cancers • Diabetes • Heart Disease

  21. Social History • Smoking • Alcohol • Drugs • Occupation • Family life

  22. Social History • Insight into illness and coping mechanisms • Makes our patients into people rather than subjects • Allows us to remember our patients • Improves the doctor-patient relationship

  23. Allergies • Medications • Latex • Foods – may give insight into drug allergies

  24. Listen and watch • Listen to your patient • What they say • How they say it • How they sit • How they interact with you and your staff

  25. Pitfalls • The US consumes 99% of opioids • Addicts will do anything to get the love of their lives • We have the responsibility to provide adequate pain relief • We are responsible for supervising the medications we prescribe

  26. Long Lists • Nightly calls for medication refills when I was a young and naïve intern at Cleveland Clinic • Patients would call with long lists of meds • At the end or buried in the middle was the candy • Patients will feign symptoms or diagnoses to get candy

  27. Medicine is Local • The post-test probability is dependent on the pre-test probability • There are locales with huge numbers of opioid-seekers • Las Vegas • Kingman, AZ

  28. Tracking • Statewide lists of opioid prescriptions • ED physicians get to know frequent fliers • Be wary of patients who ask for opioids with paucity of medical records

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