Past medical history

As you wrap up the HPI, explicitly transition to the past medical history so your patient understands the flow of the interview. A statement like “May I ask you some questions about your past health?” lets them know that you’re moving on from the current problem. For each section of the PMH, you can start by asking an open-ended question followed by more focused questions.

Here’s a good starting point for Immersion and Autumn quarter.

Example: Past medical problems

Our patient does not require too much prompting to share her medical problems and surgical history! You may need to ask more questions with a less talkative person.

Medication history

A complete and accurate medication list is a critical part of the history. Sixty percent of American adults take at least one daily medication, and fifteen percent take five or more.  Current medications must be reviewed to ensure a new therapy won’t interact with any of them, and many symptoms can be caused by a side effect. Medications are also a common source of confusion and error.

As with other parts of the history, start with an open question, like “What medications do you take?” and follow up with focused questions to learn the dose, frequency, and indications for each medication.

• Do you know what the dose is?
• How many times a day do you take it?
• What is that medication for?

Tip 1. Cross-reference the PMH and the medication list.

If the patient hasn’t mentioned a therapy for an ongoing issue, ask how they are treating it. Eventually, you’ll know what medications a patient should be taking to treat their diagnoses – you can ask specifically about these.

• Do you take anything for your high blood pressure?
• Are you on a statin for your cholesterol?

Tip 2. Ask specifically about over-the-counter medications.

People often assume these are safe since they are available without a prescription, but many have serious side effects and drug interactions.  Acetaminophen (Tylenol) can cause liver failure, ibuprofen can cause ulcers, and antihistamines can cause confusion and inability to urinate.

• Do you take any medications that you can buy without a prescription, like ibuprofen or allergy medicine?

Tip 3. Ask specifically about herbal medications and supplements.

Like prescribed medications, these can be effective in treating some conditions and can also be associated with drug interactions and side effects.

• Any supplements or herbal medications?
• Any other treatments that you use?

Finally, ask about any allergies to medications. For each, ask specifically about the reaction that your patient had – some are minor and some might not be allergies at all. This is especially important for antibiotics, which might be needed emergently.

Assessing adherence

Medication nonadherence is responsible for nearly one third of ER visits and at least 10% of hospital readmissions. Research shows that one out of every five new prescriptions is never even filled, and of those that are, only half are taken as prescribed. Medication adherence has important consequences. For example, in patients with chronic heart disease, adherence is associated with fewer hospital admissions, lower mortality, and lower healthcare costs. In diabetes, adherence to glucose lowering therapy is associated with fewer ED visits, hospitalizations, and acute complications of diabetes

Screen for nonadherence by asking “Have you missed any medication doses in the past week?” or “How many medication doses do you usually miss in a week?”

If doses are missed, start by thanking your patient for telling you. Then explore possible reasons in an open and nonjudgmental way. There’s no one size fits all solution to improving adherence so you need to understand the ‘why’ for your patient. Common reasons for medication nonadherence are the 3C’s: cost, complexity of the regimen, and concerns about specific side effects or about taking medications in general.

You might wonder if there are ways to improve adherence to medications. Research shows that patient-centered care using communication skills that focus on rapport building and the patient perspective improve medication adherence. Just another example of the impact of communication skills on health!  

Health behavior history

Health behaviors are actions that affect an individual’s health. They can improve it, like good nutrition and exercise, or increase the risk of disease, like smoking, risky sexual activity and overuse of alcohol. Health behaviors are responsible for about a third of the difference in longevity and quality of life in US communities.

You may think of health behaviors as an individual’s choice but remember that not everyone has equal access to the resources and supports needed to optimize health. Adverse childhood experiences are strongly linked to substance use and chronic illness later in life. Policies and programs at the local, state and federal level can help to address these inequities – many of you will advocate for the systemic changes that make healthy behavior easier for everyone.

As you care for individual patients, asking about these sensitive topics in an empathetic and nonjudgmental way can lead to counseling, change, and ultimately, better health. But asking about health behaviors can feel more challenging than taking a patient’s HPI – for a variety of reasons.

Transition

For now, ask a short list of screening questions. We will cover this important area in more detail this fall. The transition to the health behavior history should:

1. Normalize this section of the history
2. Establish the relevance to your patient’s health
3. Ask permission to proceed

Transition with a phrase like, “May I practice asking you some questions about personal habits that could affect your health?”

• How would you describe your diet?
• Is exercise part of your routine?
• Do you smoke or use tobacco products?
• Do you drink alcohol?
• Do you use any recreational drugs?
• Any concerns about your sexual health?

Examples: Brief substance use & sexual history

Family history

A patient’s family history may identify genetically inherited diseases transmitted in an autosomal dominant, recessive or X-linked manner. You may also identify familial diseases that run in families but are multifactorial and strongly influenced by environmental factors. Mental health disorders and cardiovascular disease are common examples.

Occasionally you’ll identify current illnesses in the household that affect your differential diagnosis. If you learn that a family member has influenza or carbon monoxide poisoning, the likelihood that your patient has the same diagnosis rises. How much you ask depends on your patients presenting illness, and should be tailored to the situation. The family history may be shorter in the Emergency Department but longer in a Pediatrics or Oncology or Genetics Clinic.

Approach #1

You can ask if any illnesses are common in the family:

• “Are there any illnesses that run in your family?”
• “Has anyone in your family been seriously ill?”
• “Does anyone in your family have diabetes? Heart problems? Cancer?”
• “Has anyone in the family had a similar problem to yours?”

Approach #2

You can ask specifically what illnesses parents, grandparents, children, and siblings have or died from.

Age at death is useful, especially if unusually young or old. For example, coronary artery or heart attacks are not typically seen in 30-year-olds and may indicate an underlying genetic condition which predisposes your patient to increased risk.

Some of the screening criteria recommendations are based on illnesses in first-degree relatives e.g. colon cancer screening recommendations change if you have a first degree relative with colon cancer diagnosed.

Be aware that patients may not know what illnesses family members had or may not be in contact with family members – “unknown” is an acceptable answer.

Example: Family History

As our patient with headache shares her family history, she shares a diagnosis she’s worried about because it affected her aunt. This is useful in two ways. First, there ARE genetic causes of brain aneurysms. Second, even if an aneurysm is not the diagnosis, it’s helpful for the physician to know that is something the patient is concerned about, so she can address it specifically.

Review of systems

The review of systems is a list of closed ended questions intended to uncover any recent symptoms that haven’t already come up. In the clinic, patients often complete the ROS on paper or online before the visit, and the provider simply reviews it. For a new patient in the hospital, physicians typically ask at least one or two of the most important questions about each organ system, but they would rarely ask all the questions on the checklist below.

A complete review of systems is important when a patient’s presenting problem is unusual or their diagnosis is very unclear. Uncovering another symptom, which the patient might not recognize as important or related, can be very helpful in narrowing the differential diagnosis

As a beginning medical student, practicing the complete ROS can help you remember which other symptoms to ask about related to your patient’s chief concern. Once you identify the organ system or systems that may be causing your patient’s problem, you’d ask all of the questions in those sections of the ROS. The presence or absence of each of these symptoms is included in the HPI.

For other systems, practice asking at least a few questions from each organ system. We encourage you NOT to use the checklist to tick off every question as you interview your patient, though you can use it to double check that you’ve asked all the pertinent questions. You’ll need to remember both the lay language that you might use with patients and the medical terms you might use in communicating with other clinicians.

Example: Review of systems

ROS: Review of Systems

Download FCM ROS as a PDF

Use the middle column prior to your interview to make note of how you might ask about the particular system or symptom. In the “Notes” column, note the presence or absence of the symptom and any additional details.

Documenting the Immersion CMD

Your immersion interview will be documented using the standard structure of the complete medical database (below).  The goal in Immersion is to become familiar with this structure and document information in the appropriate place. An example Immersion writeup is at the end of this chapter.

Deeper dive: Identifying data and chief concern

The identifying data and chief concern (ID/CC) is the headline of your write-up or oral case presentation. It sets the stage for your patient’s story and frames your audience’s clinical thinking. If not chosen carefully, it could also promote assumptions or trigger implicit bias in your audience, or it could alienate your patient if they read or hear it.

Best practices for patient identifiers are evolving and you will encounter differences in various clinical settings and specialties. It would not be possible to generate guidelines that incorporate all of patients’ identities in the ID/CC and we acknowledge this reality and approach this task with humility.

In 2018, a workgroup of UWSOM students and faculty worked with the WWAMI community and local experts to establish guidelines for the use of patient identifiers in notes and case presentations. Based on this work, our recommendations for ID/CC are:

Always include:

Name

Ask your patient how they would like to be addressed and refer to them in that way. For FCM writeups, which will be submitted to Canvas rather than a highly secure electronic health record, do NOT include names and instead use made-up initials like “Mr. X” or “FX”.

Age

Always be included in the ID/CC since the prevalence of many diseases changes with age. The most likely causes of abdominal pain are very different in a 9 month old, a 9 year old and a 90 year old. Use an actual number rather than imprecise terms like elderly or middle aged, which are less accurate and might inadvertently offend your patient.

The chief concern

The symptom or problem that led to the hospitalization or the clinic visit today. Start with the reason for the visit as reported by your patient, in their words. To help narrow the list of possible causes of a new symptom, you can also include:

• descriptors of that symptom (like acute or chronic, mild or severe)
• other symptoms that seem to go along with it (like fever in patient with sore throat)
• known health issues that affect your clinical reasoning about the problem – we will work more on this next quarter.

In some cases include:

Gender and sex

Gender and sex are commonly included in the ID/CC but they are often not relevant to the clinical situation at hand. Gender refers to an internal sense of identity so should only be included in the ID/CC if it has been confirmed, for example on a clinic intake form completed by the patient or by asking about pronouns. Making assumptions risks mis-gendering patients and damaging the therapeutic relationship.

The words female and male refer to anatomic sex and are typically assigned to an infant at birth, based on appearance of external genitalia. In some clinical scenarios, your patient’s reproductive anatomy could influence medical decision making. In these cases, anatomic sex should be included in the ID/CC. Although some providers use ‘female’ or ‘male’ in most ID/CCs, this feels overly clinical or dehumanizing to some adults. We generally recommend against it at the bedside if anatomic sex is not relevant to the clinical concern. However, the plural “males” and “females” is used in research to designate populations.

Information regarding gender identity or assigned sex at birth (ASAB) can be included in the social history, and information regarding history of or plans for gender affirming care can be included in the past medical history.

In your block courses, you’ll see cases in which patients are identified by their chromosomal complement (i.e. ABC is a 23 year old 46, XX). This is appropriate for cases focused on patients’ genetics, but would not be appropriate for most clinical settings.

Do not include:

Practice is changing, and you will see others include information in the ID/CC that we would generally recommend against.

Race

Race is a sociopolitical construct that does not accurately reflect genetic ancestry. However, racism and the health disparities it causes clearly impact patient outcomes. Both resources and stress are disproportionately distributed across racial categories. At a population level, information about race and ethnicity can help us to understand and address health disparities so health systems collect it to identify the populations served. When collected it should be the patient who designates the race.

For an individual patient, race is rarely relevant enough to the presenting concern to belong in the ID/CC headline. Routinely including race in the ID/CC perpetuates the myth that people of different races are biologically different, a myth many physicians and educators are working hard to counteract.

If there is a clear linkage between ancestry and a disease on your differential diagnosis, you could consider including this information in the ID/CC.

If your patient shares experiences with racism, especially in healthcare, these can be included in the HPI if relevant to the presenting concern or in the past medical or social history. A patient’s self-reported racial or ethnic identity is often recorded in a demographic section of the EHR but can also be included in the social history.

Sexual orientation and practices

These should only be included in the ID/CC if they are directly related to the presenting medical concern. Otherwise these can be documented in the social and sexual history sections of the write-up, using the patient’s personally-articulated terms for their sexual orientation identity.

Disability status

Should only be included in the ID/CC if it pertains to medical decision making for the presenting concern. Otherwise it should be documented in the problem list and past medical history. Person first language is usually preferred, for example ‘Sam is a 36 year-old with spinal cord injury‘ rather than ‘Sam is a paraplegic‘. However, some people and disability communities prefer identity-first language, i.e. ‘Sam is Deaf‘ rather than ‘Sam has a hearing impairment‘. Observe the language your patient uses or ask them their preferred terminology.

Size

Body size should only be included in the ID/CC if it is clearly pertinent to the reason for the visit, as when the patient’s chief concern is weight or weight change is relevant to the differential diagnosis. Although the body mass index (BMI) is imperfect, it is preferred over subjective terms such as “obese”, “morbidly obese” and “thin” which can be interpreted as judgmental.

Language matters!

As you document information about your patients, be thoughtful about the words that you choose. Electronic health record (EHR) notes can be copied forward and follow patients for years, and as more people access their own EHR, chart notes have more potential to offend. A poor choice of words can seed mistrust in the physician-patient relationship and in the healthcare system as a whole.

Your notes should not:

Make the patient their disease. Person-first language is preferred in most cases, for example “a person with diabetes” rather than “a diabetic” or “has a substance use disorder” rather than “substance abuser”.

Cast doubt on your patient’s experience. You will often hear words like ‘claims or ‘denies’ or ‘believes that’ in the HPI. Although a clinician may use these words neutrally, others can hear them as doubtful. Instead, use simple statements like ‘has severe pain’ or ‘did not have nausea’ or ‘attributes the rash to soap’.

Imply that your patient is culpable for their medical condition. Most health problems have multiple contributors, and unhealthy behavior is often driven by social, structural, and mental health issues. Blaming the victim can decrease empathy and decrease our patients’ trust in us.

Include unnecessary descriptors or details that could bias other providers. Everyone carries implicit biases that have the potential to affect the quality of care that they provide. Reading that a patient is ‘non-compliant’ or ‘an ex-convict’ may change the way another provider thinks of them.

Imply or reinforce a stereotype that is racist, sexist, homophobic, transphobic or culturally unaware.

Stigma & Language

Stigma can arise from any attribute or behavior that may be socially discrediting, and stigmatizing language can perpetuate bias and healthcare disparities. People with stigmatizing conditions like substance use disorder, chronic pain, and obesity are particularly affected by the language their providers use.

In one study, highly trained clinicians attending a mental health conference were presented with two different versions of the same vignette. One used the term ‘substance abuser’ and the other ‘has a substance use disorder’.  Those who read ‘substance abuser’ saw the patient as more personally culpable for their condition than those who read ‘has a substance use disorder’.

This video is from “Addiction Treatment: Clinical Skills for Healthcare Providers,” a Yale/Coursera course. Many of you have already seen physicians use stigmatizing or biased language. This is an area of culture change within medicine – if you hear it from us, your mentors and teachers, we would appreciate your feedback. And as you continue your training, maintain this awareness and resist adopting language that does not support your patients.

Less stigmatizing language for specific content areas

Adapted from Raney J, Pal R, Lee T, et al. 

Sample Immersion CMD

Identifying Information/Chief Concern: Carol is a 64-year-old with coronary artery disease, with an acute myocardial infarction and coronary artery bypass surgery six years ago. She was admitted yesterday evening with 3 hours of chest pain.

History of the Present Illness: Carol was first diagnosed with heart disease six years ago, when she presented with acute chest tightness, dizziness, nausea, and shortness of breath. She was diagnosed with an acute myocardial infarction and had urgent coronary bypass surgery. She then had no chest pain until eighteen months ago, when she experienced 20 minutes of tightness and “congestion” and was told by her doctor that she had had another ‘minor’ heart attack. Over the past six months, she has frequently had a dull ache across her chest in the evenings after dinner which resolves with one sublingual nitroglycerin. Carol’s problems with her heart have changed her life in many ways; she is much more careful about taking good care of herself but doesn’t like the feeling that something could go wrong at any point.

On the evening of admission, Carol was watching TV after dinner when she developed a dull, heavy, 5/10 pain across the front of the chest radiating down the left arm, similar to the pain she’s had over the past six months. She took one nitroglycerin tablet, but the pain seemed to worsen to a 7/10 and she began to feel short of breath. The patient took a second nitroglycerin 15 minutes after the first, again with no improvement in symptoms. Five minutes later, she took a third tablet at which point she was also feeling sweaty and slightly nauseated. In addition to the pain, which was now about 9/10, she had worsening shortness of breath. Carol called her daughter Helen and she called 911. In the emergency room, she was started on some IV medications, which resolved the symptoms, and admitted.

Carol has a history of hypertension, diagnosed after her heart attack and now well controlled on metoprolol and Lisinopril. She quit smoking one year to the day after heart surgery. She has been on atorvastatin to lower her cholesterol for the past two years, and her medication adherence has been good. She also has a history of heartburn which causes burning chest pain a few times a month, unlike the pain that led to admission.

Carol has had no palpitations, syncope, orthopnea, PND or lower extremity edema. She’s had no fever, cough, chest trauma, hemoptysis, or recent travel.
Hospital course: Since the patient was admitted to the hospital last night, she has had no pain or other symptoms, but is very worried about her condition because multiple family members have died suddenly from a heart attack, and she has not yet been told whether she actually had another heart attack.

Past Medical History:

• Hypertension: High blood pressure for 10 years; well controlled with metoprolol and Lisinopril
• Coronary artery disease: Diagnosed in 2014 after having a heart attack. Angiogram showed several blocked arteries. Underwent coronary artery bypass graft (CABG) surgery Nov 2014. Treated with atorvastatin, aspirin, metoprolol and Lisinopril.
• Hyperlipidemia: LDL was 195 before treatment with atorvastatin. LDL now 100.
• Pre-diabetes: HgA1c 5.9%. Diet controlled.
• Former tobacco user: 20 pack-year history. Quit Nov 2014.
• GERD (Gastroesophageal reflux disease-reflux): Intermittent heart burn a few times per month. Uses as needed tums or famotidine. Never had upper endoscopy.
• Macular degeneration: Taking “eye vitamin” Sees ophthalmology every 6 months
• Low back pain: Intermittent. X-rays 2010 showed osteoarthritis. Seen by physical therapy in the past. Back pain flairs every 4-6 months. Usually triggered by heavy lifting or increased activity. Does PT exercises at home for treatment and uses acetaminophen as needed.
• History of gallstones: Reported recurrent gallstone attacks. No symptoms since cholecystectomy at age 50
• Seasonal allergies: Uses over the counter loratidine (Claritin) as needed.

Past Surgical History

• Coronary artery bypass graft (CABG) surgery Nov 2014
• Appendectomy, age 18
• Cholecystectomy, age 50 for recurrent gall stone attacks
• Tonsillectomy as a child

Allergies to medications: Sulfa drugs caused a full body very itchy rash

Medications:

• Lisinopril 20mg per day
• Metoprolol ER 25 mg daily
• Aspirin 81 mg daily
• Atorvastatin 80 mg at bedtime
• Famotidine (Pepcid) 20 mg up to twice a day as needed for heartburn, a few times/week.
• Over the counter anti-acids (Tums) 1-2 tablets every 6 hrs as needed for indigestion.
• Acetaminophen (Tylenol) 325 mg 1-2 tablets every 6 hrs as needed for pain
• Omega 3 1000 mg daily.
• AREDS2 vitamin one daily
• Loratidine (Claritin) 10 mg daily as needed for seasonal allergies
• Nitroglycerin 0.4 mg tabs. Take one tab under the tongue every 5 minutes as needed for chest pain. Max doses 3 within 15 minutes

Health related behavior:

• Tobacco: 20 pack-year history of smoking. Quit in Nov 2014
• Alcohol: a beer or 2 every once in a while, (2x per month)
• Recreational Drugs: None.
• Exercise: Tried to get outside on the weekends to do a little yard work but nothing too strenuous. Otherwise no regular exercise.
• Diet: Since the patient’s first heart attack, she has focused on eating a healthier diet. Lots of fruits and vegetables and only eats red meat once per week. Otherwise fish and chicken. Tries to avoid sweets because of the pre-diabetes
• Sexual history: Not sexually active since the death of her husband.

Family History:

• Mother had a ‘silent heart attack’ a couple years ago. She also had hypertension and diabetes. She is in her late 80s now.
• Father deceased, motor vehicle accident twenty years ago.
• Brother with heart disease, heart attack in his early 50s.
• Otherwise NO family medical problems.

Social History: Sedentary office work. Works as a tax accountant. Job is super stressful around tax time but the rest of the year it is not too bad. Has lived in the area entire life. Widowed, 2 adult kids. Good support system. Good insurance, and no significant financial stressors. Enjoys watching TV at night. Does not consider herself religious.

Knowledge Check

References & resources

Driever EM, Brand PLP. Education makes people take their medication: myth or maxim? Breathe (Sheff). 2020 Mar;16(1):190338. doi: 10.1183/20734735.0338-2019. PMID: 32194770; PMCID: PMC7078734. 

Free interactive module. Medication Adherence: Improve Patient Outcomes and Decrease Cost

Raney J, Pal R, Lee T, et al. Words matter: an antibias workshop for health care professionals to reduce stigmatizing language. MedEdPORTAL.2021;17:11115.