Medical History
CASE STUDY
You are working with Dr. Stephanie Lee at her family medicine clinic. Dr. Lee tells you, “The next patient, Mrs. Payne, is a 45-year-old cisgender female who is here for a health maintenance exam. It looks like she hasn’t had a visit for over five years. When you’re talking with Mrs. Payne, I’d like you to find out if she has any current concerns, update her past medical history, and do a brief review of systems. Then, come on out and tell me what you’ve discovered and we’ll both go in to do the physical exam together.”
You introduce yourself to Mrs. Payne and begin obtaining her history:
Medical History:
“Do you mind if I ask you a few questions to find out how you are doing?”
Mrs. Payne says, “That sounds fine.”
“What brought you in today?”
“I feel fine, but I know I should get checked out since it’s been a while and I need to have a Pap test and mammogram.”
“I would like to update your medical history. Do you have any chronic medical problems?”
“Well, I don’t really have any medical problems.”
“Have you had any operations?”
“I had my tubes tied shortly after the birth of my last child.”
“Are you on any medications, or are you allergic to any medications?”
“I take an occasional Tylenol or ibuprofen for pain or headache and a multivitamin. I’m not allergic to any medicine as far as I know.”
Social History:
“Have you ever smoked?”
“Yes, I’m afraid I do smoke a pack of cigarettes a week. I keep trying to quit, but I just never seem to be able to do it.”
“Do you drink alcohol?”
“No, I don’t drink any alcohol at all.”
“Have you ever used any recreational drugs?”
“I never tried any illegal drugs. My friends have smoked marijuana but I was always too afraid to try.”
“How much do you exercise?”
“I used to try to walk at lunchtime, but I don’t do that anymore. It just seems like I’ve been too busy to have time to exercise.”
“Have you been hit, kicked, punched, or otherwise hurt by someone in the past year? If so, by whom?”
“No, I feel safe.”
Family History:
“How is the health of your family members?”
“My father has high blood pressure and my mother has mild arthritis, but both are in good health. My two sisters are healthy.”
“What about your extended family?”
“I don’t know how my grandparents died, but I think one of them had diabetes. My mom’s sister has breast cancer but is doing well after surgery and chemotherapy.”
Mrs. Payne asks you, “Does having an aunt with breast cancer increase my risk of developing breast cancer? My aunt was diagnosed with breast cancer when she was about 70 years old.”
You were able to reassure Mrs. Payne that the risk is increased only if there is a history in a first-degree relative, such as a parent or sibling.
OB/GYN:
“How old were you when your periods began?”
