MEDICAL HISTORY

The basic approach to a complete medical history is outlined in Table 6-2. The history begins by asking patients to describe, in their own words, the reason for seeking medical care. Although patients may have many reasons for initiating a visit to the physician, they should be encouraged to select the single or two most important concerns they have. The patient should be reassured that the physician will not ignore other concerns but wants to understand what is most important to the patient. It is generally best to steer patients to describing a symptom or sign that prompted the visit rather than steering them to a diagnosis. For example, instead of accepting “I am here for my diabetes,” the physician might preferentially elicit that “I am here because my blood sugar has been a little high.”

TABLE 6-2   -- PATIENT'S MEDICAL HISTORY

Description of the patient    Age, gender, ethnic background, occupation    Chief reason for seeking medical care    State the purpose of the evaluation (usually in the patient's words)    Other physicians involved in the patient's care    Include the clinician that the patient identifies as his or her primary provider or the physician who referred the patient.    Record contact information for all physicians who should receive information about the visit    History of the reason for seeking medical care    In chronologic fashion, determine the evolution of the indication for the visit and then each major symptom. It is best to address the patient's reason for seeking care first rather than what the physician ultimately believes is most important    Be careful to avoid “premature closure,” in which a diagnosis is assumed before all the information is collected    Past medical and surgical history    List other illnesses and previous surgeries not related to the current problem    List all prescribed and over-the-counter medications with dose    Remember to ask about vitamin and herbal supplements    Allergies and adverse reactions    List allergic reactions to medications and food. Record the specific reaction (e.g., hives). Distinguish allergies from adverse reactions or intolerance to medication (e.g., dyspepsia from nonsteroidal anti-inflammatory agents)    Social and occupational history    Describe the patient's current family and a typical day for patient. The occupational history should focus on current and past employment as it might relate to the current problem. For veterans, inquire about their military history, including combat exposure, years of service, and areas of deployment    Risk factors    Include history of tobacco use, illegal drug use, and risk factors for sexually transmitted disease (including human immunodeficiency virus and hepatitis)    Family history    History of any diseases in first-degree relatives and a listing of family members with any conditions that could be risk factors for the patient (e.g., cardiovascular disease at a young age, malignancy, known genetic disorders, longevity)    Review of systems (see Table 6-3)

History of the Present IllnessInitially, patients should be asked open-ended questions to permit a description of their problems in their own words. This initial process can be followed by a series of specific questions to fill in any gaps or to clarify important points. These questions should be asked in an order dictated by the story the patient tells and targeted to suit the individual problem. When the patient is acutely ill, the physician should limit the amount of time spent in open-ended discussion and move promptly to the most important features that allow quick evaluation and management. In general, the history of the problem under consideration includes the following:

	•	Description of onset and chronology
	•	Location of symptoms
	•	Character (quality) of symptoms
	•	Intensity
	•	Precipitating, aggravating, and relieving factors
	•	Inquiry into whether the problem or similar problems occurred before and, if so, whether a diagnosis was established at that time

Finally, it is often helpful to ask patients to express what they believe is the cause of the problem or what concerns them the most. This approach often uncovers other pertinent factors and helps establish that the physician is trying to meet the patient's needs.Past Medical and Surgical HistoryMuch of the past medical and surgical history is obtained when the patient relates the history of the problem in question. An astute clinician should not rely on patients to divulge all their prior problems, however, because they may forget, may assume that previous events are unrelated to their current problem, or simply may not want to discuss past events. An open-ended statement such as “Tell me about other medical illnesses you have had that we did not discuss” and “Tell me about any operations you have had” prompts the patient to consider other items. During the physical examination, the physician should ask the patient about unexplained surgical or traumatic scars.A list of current medications should include prescriptions, over-the-counter medications, vitamins, and herbal preparations. When a patient is uncertain about the names of medications, the patient or family member should be asked to bring all medication bottles to the next visit. Patients may not consider topical medications (e.g., skin preparations or eye drops) as important, so they may need prompting.Information about allergies (Chapter 275) is particularly important to collect but also challenging. Patients may attribute adverse reactions or intolerances to allergies, but many supposed allergic reactions are not truly drug allergies. Less than 20% of patients who claim a penicillin allergy are allergic on skin testing. Eliciting the patient's actual response to medications facilitates a determination of whether the response was a true allergic reaction.Social and Occupational History and Risk FactorsThe social history not only reveals important information but also improves understanding of the patient's unique values, support systems, and social situation. The social history should be tailored to the individual patient and allow for physician-centered questioning and patient-centered expression of values and concerns.Data that may influence risk factors for disease should be gathered, including a nonjudgmental assessment of substance abuse. The tobacco history should include the use of snuff, chewing tobacco, and cigar and cigarette smoking (Chapter 30). Alcohol use should be determined quantitatively and by the effect that it has had on the patient's life (Chapter 31). Past or present use of illicit substances, prescription pain medications or sedatives, and intravenous drugs should be assessed (Chapter 32). The sexual history should include current sexual activity, including the number of partners and past history. The employment history should include the current and past employment history, military experience, and any significant hobbies. Information should be elicited from military veterans regarding their combat history, years of service, and areas of deployment.The physician should also obtain information on socioeconomic status, insurance, the ability to afford or obtain medications, and past or current barriers to health care because of their impact on care of the patient (Chapter 5). Marital status and the living situation (i.e., whom the patient lives with, significant stressors for that patient) are important as risk factors for disease and to determine how best to care for the patient. A patient's culture (Chapter 4) and values should be known, including any prior advance directives or desire to overrule them (Chapter 3). The physician should explicitly elicit and record information regarding the next of kin; surrogate decision makers; emergency contacts; social support systems; and financial, emotional, and physical support available to the patient.The social history should be tailored to the individual patient and to the physician-patient encounter. An understanding of a patient's habits and social situation furthers understanding of risk factors, is crucial to developing an appropriate patient-physician relationship, and allows planning of optimal care.Family HistoryThe patient's family history is of increasing importance given the rapid expansion of knowledge about genetics in medicine. The family history is never diagnostic, but it allows risk stratification, which affects the pretest probability for an increasing number of disorders (e.g., heart disease, breast cancer, or Alzheimer's disease). For common diseases such as heart disease, additional inquiry into the age of onset in first-degree relatives and death attributed to the disease should be obtained (Chapter 49). When a patient reports that a first-degree relative had a myocardial infarction, the LR is 19 that the patient has a family history of myocardial infarction. Patients may lack appropriate information about the absence of disease, however, so a reported lack of a family history of myocardial infarction reduces the likelihood only by a third. In general, the specificity of the reported family history far exceeds its sensitivity; for example, only two thirds of patients with essential tremor (Chapter 434) report a family history, but 95% of such patients have first-degree relatives with tremor. The expansion of knowledge about genetic diseases (Chapter 37) requires clinicians not only to improve their skills in eliciting the family history but also to develop methods for confirming the information. For example, patients who report that a first-degree relative had carcinoma of the colon (LR 25), breast (LR 14), ovaries (LR 34), or prostate (LR 12) are usually providing accurate information.Review of SystemsThe review of systems, which is the structural assessment of each of the major organ systems, elicits symptoms or signs not covered, or overlooked, in the history of the present illness. In practice, the review of systems may be accomplished by direct questioning (Table 6-3) or by having the patient fill out a previsit questionnaire that constrains the answers to a specific time frame. When directly obtained, the best approach is not to use open-ended questions but rather to proceed efficiently and effectively by asking direct questions. The physician may ask the patient, “Has there been any recent change in your vision” or “Have you recently had shortness of breath, wheezing, or coughing?” The relative value of these approaches has not been investigated fully, but restricting the symptoms to a narrower time frame prevents a complete retelling of the history. One estimate is that the review of systems yields a new important diagnosis about 10% of the time. Nevertheless, the review of systems is an efficient mechanism for detecting issues and for obtaining a complete understanding of the patient's overall status.

TABLE 6-3   -- REVIEW OF SYSTEMS^[*]

FOCUS all questions on a specific time frame (e.g., within the past “month” or “now”) and on items not already addressed during the clinical examination    Change in weight or appetite    Change in vision    Change in hearing    New or changing skin lesions    Chest discomfort or sensation of skipped beats    Shortness of breath, dyspnea on exertion    Abdominal discomfort, constipation, melena, hematochezia, diarrhea    Difficulty with urination    Change in menses    Joint or muscle discomfort not already mentioned    Problems with sleep    Difficulty with sexual function    Exposure to “street” drugs or medications not already mentioned    Depression (feeling “down, depressed, or hopeless”; loss of interest or pleasure in doing things)    A sensation of unsteadiness when walking, standing, or getting up from a chair

*

Clinicians may start with this basic list and adapt the items to their specific patient population by considering factors such as age, gender, medications, and the problems identified during the examination. The process is facilitated by developing a routine personal approach to these questions, typically going through the systems from “head to toe.”