Interview Basics III & IV Flashcards
Past Medical History
-PMH
• Illnesses the patient has had/has now
– May not have been diagnosed by a doctor
– May be ongoing (“other active problems”)
• Controlled – Meds?
– Lifestylechanges? • Uncontrolled
Past Surgical History
-PSH
- Counts: Tonsillectomy and/or appendectomy in childhood, Cesarean Section
– Doesn’t count: Most dental surgeries (unless in a hospital), sutures for minor injuries
Current Medications
Ask about (Required) 1) Rx (Prescriptions) 2) OTC (Over-The-counter) 3) Supp (Supplements) – Herbals, supplements, etc. -Must record Dose, timing Positive or negative
Allergies
Ask about (Required) 1) Medications 2) Environmental 3) Food -Must record Reaction Positive or negative
Family History
-FH
-First degree relatives
– Mom, Dad, Siblings, Kids
Things that run in the family
– Cancers (ie. breast and colon)
– Mental health issues (suicide, depression, addiction)
– Cardiac – when? Dad had MI at age 30 vs 92
FEDTACOS
- Food – Nutrition and diet
- Exercise – Daily activities and exercise
- Drugs – Recreational drug use
- Tobacco – Smoking and smokeless
- Alcohol –
- Caffeine –
- Occupation – Demographics and occupational history
- Spirituality and Sexual Relationships, Safety (at home, in car, with leisure activities, etc.)
CDC recommendations on exercise
- CDC recommends adults get 150 minutes per week of moderate activity (brisk walking) and strength training 2 days of the week that focuses on all major muscle groups.
- CDC children and adolescents 6 years and older can achieve important health benefits by getting 1 hour (60 minutes) or more of daily physical activity.
Recreational Drug Use
• Type: Street versus prescription
• Quantity (How much?)
• Frequency (How often?)
• Route of Administration (PO, inhaled, IV, etc.)
• May be tolerant of and/or addicted to prescription pain/anxiety
meds
• Establishing confidentiality is important
Tobacco Use
• Quantity
• Duration
• Pack years (ppd X years=pack-years)
– Increased pack years associated with increased risk of smoking-related illness
– You should know this to present to your attending, but don’t document just pack years.
Alcohol Use
AUDIT (Alcohol Use Disorders Identification Test)
Better Sensitivity than CAGE
More questions for physicians remember, somewhat difficult to score.
CAGE Questionnaire
Useful to screen for patients who drink more than one drink daily OR who drink a lot on the weekends. Can open door to conversation about getting help.
If pt is a daily drinker, cannot say “just quit” – could go through DTs – need medical support
Lots of false positives
CAGE Questions
- Has anyone ever suggested you CUT BACK?
- Are you ever ANNOYED when people talk about your drinking?
- Do you ever feel GUILTY about your drinking?
- Do you ever need a drink in the morning to steady your nerves (an EYE OPENER?)
Audit -C Questions
- How often do you have a drink contains alcohol?
- How many drinks containing alcohol do you have on a typical day when you are drinking?
- How often do you have six or more drinks on one occasion?
Safe Drinking Limits - NIAAA
- National Institute of Alcohol Abuse and Alcoholism
- For women and those over age 65, low-risk drinking is defined as no more than 3 drinks on any single day and no more than 7 drinks per week.
- For men, it is defined as no more than 4 drinks on any single day and no more than 14 drinks per week.
- NIAAA research shows that only about 2 in 100 people who drink within these limits have AUD.
Standard Drinks
- beer = 12 ounces
- wine = 5 ounces
- liquor = 1 ounce
Caffeine Use
Caffeine –
• How much?
• How often?
What form – coffee, tea, soda, energy drinks, pills, etc.
