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
• It is often helpful to observe the patient prior
to this.
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
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
Referring Physician
• Communicated in notes or script
• Typically directed
– Iron deficiency anemia
– Diarrhea
– Abdominal Pain
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
Patient
• Look at affect
• Body language
• Important to ask about concerns during the
history as well as at the conclusion of the
process
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
Medical Evaluation
• Doctors/impressions – ‘never trust the nursing
home doctor’ (House of God)
• Labs
• Radiologic studies
• Endoscopic studies
• Surgeries
• Old records
History
• Sources:
– Patient
– Medical records
– Family or friends
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
Quantifying the History
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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?
Review of Systems
• Questioning about different body systems
• Complete the medical history
• Systems
– GI
– Cardiac
– Renal
– Pulmonary
– Rheumatologic
– General
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.
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
Past Medical History
• Previous Medical Problems, e.g. Diabetes
– Heart
– Lungs
– Kidneys
– GI tract
– Mental Health
Past Surgical History
• Surgeries and Procedures
– Appendectomy
– Colonoscopy
– Account for scars!
Medications
• All medications
– Dose
– Frequency
– How long
• OTC medications may not be volunteered
Allergies
• Medications
• Foods, e.g. Iodine such as seafood
Family History
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Ideally map out patterns of illness
Cancers
Diabetes
Heart Disease
Social History
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Smoking
Alcohol
Drugs
Occupation
Family life
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
Allergies
• Medications
• Latex
• Foods – may give insight into drug allergies
Listen and watch
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Listen to your patient
What they say
How they say it
How they sit
How they interact with you and your staff
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
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
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
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