Patient History

By: Dr Marwa Kamal

 Data to be Obtained from a Medication
History Interview

1- DEMOGRAPHIC INFORMATION

• Age/date of birth
• Height and weight
• Race and/or ethnic origin
• Type of residence
• Education or Occupation
• Life style
 1- Demographic informations

• Demographic information includes the patient’s

age, height, weight, race or ethnic origin,
education, and lifestyle.
• Lifestyle information includes the patient’s
housing situation (e.g., boarding house, private
home, apartment, shelter, living on the street), the
people living with the patient (e.g., spouse, young
children, elderly relatives, extended family), and the
patient’s type of work and work schedule, if
applicable (i.e., day shift, night shift, rotating shift
schedule, part time, full time).
 1- Demographic informations
• All of these factors influence decisions regarding the
selection of prescription and nonprescription medication,
the dosage of the medication, and the therapeutic regimen.
• For example,
 patients who work with machinery may choose not to take
medications that make them drowsy, sluggish, or shaky.
 Patients with restricted work breaks may be reluctant
to take diuretic medications.
 Patients who live in shelters may not have access to
refrigeration.
 Patients hesitant to give themselves injections may be
unwilling to take these types of medications unless
someone is available to help them
2- Dietary Informations
• Dietary restrictions
• Dietary supplements
• Dietary stimulants
• Dietary suppressants
 2- Dietary Informations
• For example, patients with diabetes may
follow a reduced-carbohydrate diet; other
patients may be consuming recommended or
self-imposed low-fat, low-sodium, low-
calorie,low-fiber, or high-fiber diets.
 2- Dietary Informations

• Dietary information is an important

component of the medication history, because
some drug therapies may appear ineffective if
the patient is nonadherent to recommended
dietary restrictions (e.g., patients with
congestive heart failure may not comply
with salt-restricted diets).
 2- Dietary Informations

• Patients may self-medicate with nonprescription

dietary supplements, stimulants, or
suppressants that interact adversely with
prescribed medications and treatment
regimens.
 3- Social Habits

• Tobacco use
• Alcohol use
• Illicit drug use
 3- Social Habits

• Document the duration of use, amount of

each agent consumed and frequency of use.
• Determine the type, quantity, pattern, and
duration of alcohol use
Alcohol Use Categories (Adults)
Category Men Women
 3- Social Habits

• To assess tobacco use, note at what age the

patient first started smoking tobacco and
when the patient quit smoking (if
applicable). Because the effects of smoking on
drug metabolism may be clinically
important for weeks to months after the
patient has stopped smoking, not
approximately when the patient stopped
smoking
 3- Social Habits

• Tobacco smoking is quantified in terms of

packs per day (ppd) and expressed in pack-
years (pk-yr) (e.g., 2 ppd for 5 years; 10
pk-yr). One pack-year is equivalent to
smoking one pack of cigarettes daily for 1 year.
• A 10 pk-yr tobacco history is equivalent to
smoking 0.5 ppd for 20 years, 1 ppd for 10
years, or 2 ppd for 5 years.
 3- Social Habits
• Tobacco Smoking Quantification.
• A 1 pack-year tobacco smoking history is
equivalent to smoking one pack of cigarettes
daily for 1 year.
 Illicit drug use
 Illicit drug use may be difficult to ascertain. Obtain this
information in a professional, nonthreatening, nonjudgmental
manner.
 Do not try to guess which patients are more or less likely to
use these agents but probe for this information with every
patient.
 Surprisingly, patients may be more comfortable revealing
this type of information to pharmacists than to other
health care professionals, including physicians.
 Patients generally do not understand the term illicit. The
best approach is to ask about the use of so-called street
drugs and give an example or two, such as marijuana, crack
cocaine, and heroin.
 Document the amount of each agent consumed; the
frequency, pattern, and duration of use; and the reasons for
use of each agent.
 CURRENT PRESCRIPTION MEDICATIONS

• Name (proprietary and nonproprietary)

and/or description
• Dose
• Dose schedule (prescribed and actual)
• Reason for taking the medication
• Start date
• Outcome of therapy
 CURRENT PRESCRIPTION MEDICATIONS
• Obtain the prescribed dosing schedule (e.g., four
times a day, two times a day, once a day)
and note the routine times the patient takes
each dose.
• e.g., the patient is supposed to take the
medication four times a day but takes it two
times a day).
• Patients sometimes change dosing schedules to
fit their work schedules and lifestyles or to
conserve medication to reduce the expenses of
long-term medications
 CURRENT PRESCRIPTION MEDICATIONS

• Determine when the patient started taking

the prescription medication and the reason
the patient gives for taking the medication.
• Exact dates are important in determining
whether an adverse or allergic reaction is a
result of a specific medication and whether
the prescribed medication is effectively
treating or controlling a specific condition.
 CURRENT PRESCRIPTION MEDICATIONS

• For example, a patient with elevated blood

pressure may claim to adhere to his or her blood
pressure medication regimen yet still have
elevated blood pressure.
• The decision to continue or discontinue the
medication depends on when the patient started
the current regimen.
• The regimen would continue unchanged if the
patient had just started the medication the previous
week but would need to be changed if the patient
had been taking the medication for 2 months.
 CURRENT PRESCRIPTION MEDICATIONS

• Patients are unlikely to remember all these

details for past medications. Document the
details the patient can remember; avoid
excessive “grilling” of the patient.
 PAST PRESCRIPTION MEDICATIONS

• Name (proprietary and nonproprietary) and/or

description
• Dose
• Dose schedule (prescribed and actual)
• Reason for taking the medication
• Start date
• Stop date
• Reason for stopping
• Outcome of therapy
 CURRENT NONPRESCRIPTION MEDICATIONS
• Name (proprietary and nonproprietary) and/or
description
• Dose
• Dose schedule (recommended and actual)
• Reason for taking
• Start date
• Outcome of therapy
• Knowledge of current nonprescription medications
allows the pharmacist to determine whether drug
interactions may occur between prescribed and
self-administered medications, whether the
patient is self-medicating to relieve an adverse
drug reaction from a prescribed medication or in
an attempt to obtain better relief from symptoms
than that provided by the prescribed regimen, and
whether a nonprescription medication is the cause
of a patient’s complaint or is exacerbating a
concurrent medical condition.
 PAST NONPRESCRIPTION MEDICATIONS

• Name (proprietary and nonproprietary) and/or

description
• Dose
• Dose schedule (recommended and actual)
• Reason for taking
• Start date
• Stop date
• Reason for stopping
• Outcome of therapy
• Knowledge of past nonprescription regimens
gives the pharmacist insight regarding past
medical problems or attempts to treat
current medical problems.
 CURRENT COMPLEMENTARY AND
ALTERNATIVE MEDICINES

• Name (proprietary and nonproprietary)

and/or description
• Dose
• Dose schedule
• Reason for taking
• Start date
• Outcome of therapy
 CURRENT COMPLEMENTARY AND
ALTERNATIVE MEDICINES
e.g: herbal remedies, multivitamins, folk
remedies).However, the majority of people do
not discuss these therapies with their
physicians.
• Many of these medicines interact with
traditional medicines. Some have significant
side effects.
• Therefore, it is important to document the use
of these medicines.
 CURRENT COMPLEMENTARY AND
ALTERNATIVE MEDICINES
For example, if a patient states that he or
she is taking an alternative medicine to boost
the immune system, ask the patient whether
anyone has ever told the patient that he or
she has a weakened immune system and
whether the patient gets more infections
than most people.
 PAST COMPLEMENTARY AND ALTERNATIVE
MEDICINES
• Name (proprietary and nonproprietary) and/or
description
• Dose
• Dose schedule
• Reason for taking
• Start date
• Stop date
• Reason for stopping
• Outcome of therapy
ALLERGIES
• Drug name and description
• Dose
• Date of reaction
• Description of reaction
• Treatment for the reaction
• The term allergy indicates hypersensitivity to
specific substances.
• Drug-induced allergic reactions include
anaphylaxis, contact dermatitis, and serum
sickness.
• Ask patients if they have ever experienced
rashes or breathing problems after taking any
medications.
ADVERSE DRUG REACTIONS
• Drug name and description
• Dose
• Date of reaction
• Description of reaction
• Treatment of the reaction
 ADVERSE DRUG REACTIONS
• Adverse drug reactions are unwanted
pharmacologic effects associated with medications.
• Examples of adverse drug reactions include
drowsiness from first-generation antihistamines,
constipation from codeine-containing medications,
nausea from theophylline, and diarrhea from
ampicillin.
• Ask patients whether they have ever taken a
medication they would rather not take again.
This question often elicits specific descriptions of
adverse reactions the patient has experienced.
IMMUNIZATIONS
• Vaccines
• Date each vaccine was administered

Patients, especially those with chronic

diseases, may have lifetime vaccination
administration records.
  ASSESMENT OF ADHERENCE
• Clues about adherence may be obtained through
patient descriptions of how they take their
prescribed medications.
• Knowledge regarding patient adherence is useful
in evaluating the effectiveness of prescribed or
recommended medication regimens.
• Medications may be ineffective if the patient does
not comply with the prescribed or recommended
regimen.
• Nonadherence may result in additional diagnostic
evaluations, procedures, hospitalizations, and
unnecessary combination medication regimens
  ASSESMENT OF ADHERENCE

• Example: The patient is nonadherent. She admits

that she picks and chooses which medication to
take and that she takes the medications the way
she wants to, not as prescribed.
• Example: The patient is adherent. He knows the
names and descriptions of all of his medications
and is able to describe his usual routine for taking
the medications. He says his wife helps him
remember to take the medications.
 THE DIFFICULT INTERVIEW

 Patients may be difficult to interview

• Recalcitrant patients
• verbose patients
• confused patients
• patients whose command of the English
language is limited
• patients with hearing impairments
• patients with aphasia
• impatient patients
• patients hospitalized in isolation rooms
 THE DIFFICULT INTERVIEW
 Interventions of the difficult interview
• The best approach for recalcitrant or verbose patients is to exert
firm control of the interview and ask directed questions to draw
information from the recalcitrant patient and redirect the verbose
patient.
• The confused or aphasic patient may be unable to provide any
specific information. In this situation, interview family members
and friends of the patient.
• Interpreters are available for many foreign languages in most
institutions; take advantage of these resources.
• Enhance communication with patients with hearing
impairments by ensuring that the patient’s hearing aid (if any) is
turned on, by speaking clearly and distinctly, and by sharing
written information with the patient.
• Remind the impatient patient of the usefulness of an accurate
medication history and try to obtain the history efficiently and in a
reasonable amount of time.
  DOCUMENTATION OF THE MEDICATION
HISTORY

• The details of the medication history are

documented in writing and communicated to
the health care team.
• Many standardized patient profile forms have
specific areas for the documentation of this
information.
• Documenting that the patient is not currently
taking any prescription drugs is as important as
documenting that the patient is currently taking a
long list of prescription drugs
  DOCUMENTATION OF THE MEDICATION
HISTORY
• Document both the nonproprietary drug name (the
name intended for unrestricted public use;
sometimes referred to as the generic drug name) and
the proprietary drug name (the legally trademarked
name) when the patient refers to a medication by the
proprietary name.
• Document just the nonproprietary drug name if the
patient refers to the drug by the nonproprietary
name. For example, if the patient says she takes
Avandia document the proprietary name Avandia and
the nonproprietary name rosiglitazone. If the patient
says he takes pseudoephedrine, document the
nonproprietary name pseudoephedrine.
 Sample Interview Questions
• GENERAL QUESTIONS
• Do you take any prescription medications?
• What prescription medications are you taking?
• Do you take any nonprescription medications
• (medications that you can buy without a
prescription)?
• If so, what nonprescription medications are you
taking?
• Do you take any complementary and alternative
medicines (for example, herbal supplements)? If so,
• what complementary and alternative medicines are you
• taking?
• Are you allergic to any medication?
• Have you ever had trouble breathing or had a rash after
taking a medication?
• Have you ever had any bad reactions to a medication? If
so, can you describe what happened?
• Can you describe your routine for taking your
medications?
 Case History (1)
• Brian Flannery is a 50 year old 163 hight (DOB
11-2-60) with a history of HTN since 2002. He
has been taking Cozaar (losartan) 50 mg daily
and hydrochlorothiazide 25 mg daily to treat his
HTN since 2005 and says his blood pressure is
well controlled.
• He used to take other medications for his HTN
but doesn’t remember their names, dosages, or
dates of medications he took.
• BF is not currently taking any nonprescription
medications but takes Tylenol (acetaminophen)
325-650 mg every 4-6 hours on demand for
headache/pain 40 years. He takes 3-4 doses per
month and says it is relieves the HA/pain very
well.
• Per the patient’s medical record, BF’s past
prescription antihypertensive medications include
hydrochlorothiazide 25 mg daily (started in 2002
and stopped in 2004) and Vasotec (enalapril) 5 mg
daily (started in 2004 and stopped in 2005).
• The last several charted blood pressures were in the
140’s/90’s range.
• BF takes Garlique 400 mg daily to lower his
cholesterol; started in 2008 and says his cholesterol
is good. He says he has never taken any other
complementary or alternative medications. His last
influenza vaccine was in 2009 and his last
tetanus/diphtheria vaccine was in 2003.
• BF is allergic to penicillin. He says that penicillin
caused an itchy rash when he took it for the first time
when he was 25 years old. He stopped taking the
penicillin and the rash went away without any other
treatment.
• BF doesn’t take codeine because it caused
nausea and vomiting after he took it when his
wisdom teeth were removed when he was 20
years old. BF is a lawyer. He lives in his own
home with his wife.
• He smokes tobacco 1ppd 32 years, drinks 1-2
glasses of wine with dinner 3-4 nights per
week 20 years and denies ever using illicit
drugs. He has been following a low-fat diet (20
grams of fat per day) for five years.
He says he doesn’t take dietary supplements,
stimulants or suppressants. BF admits to
skipping his blood pressure medications several
times a month.
 Patient History
DEMOGRAPHIC INFORMATION
Name: Brian Flannery
Age: 50 y/o
Height: 163
DOB:11-2-60
Weight:
Occupation: lawyer; lives in own home with wife
with a history of HTN diagnosed in 2002.
Social History:
Tobacco (1ppd 32 years; 32 pk-yrs)
Alcohol (1-2 glasses of wine with dinner 3-4
nights per week 20 years); moderate drinker
Denies use of illicit drugs.
Dietary informations (restrictions,
supplements, stimulants and suppressants):
Restrictions: Low-fat diet (20 grams of fat per
day) for five years.
Supplements: None
Stimulants: None
Suppressants: None
Allergies: Penicillin; caused an itchy rash when
he took penicillin for the first time when he
was 25 years old. The rash went away when
he stopped taking it.
Adverse Drug Reactions: Codeine; caused
nausea and vomiting when it took it after his
wisdom teeth were removed when he was 20
years old.
 Current Prescription Medications:
• cozaar (losartan 50 mg daily; started in 2005 for HTN;
says BP well controlled
• Hydrochlorothiazide 25 mg daily; started in 2005 for
HTN; says BP well controlled
 Past Prescription Medications:
• Per the patient’s chart:
• Hydrochlorothiazide 25 mg daily for HTN (2002-2004)
• Vasotec (enalapril) 5 mg daily for HTN (2004-2005)
Current Nonprescription Medications:
• None
Past Nonprescription Medications
• Tylenol (acetaminophen) 325-650 mg every 4-
6 hours PRTN Headache/pain 40 years; takes
3-4 doses per month. Effective.
 Current Complementary and Alternative
Medicines:
• Garlique 400 mg daily to lower his cholesterol;
started in 2008; thinks it is working
 Past Complementary and Alternative Medicines:
• None.
 Immunizations (vaccine, date given):
• Influenza 2009; tetanus/diphtheria 2003
Compliance:
(Assessment of Patient Compliance)
• BF says he skips his blood pressure
medications several times a month( non
adherent).
 Case History (2)
• Luke Miller (LM) is a Hispanic male (date of birth,
December 4, 1954) who works as a financial
advisor and lives in a house in the suburbs. He is
165 hight and weighs 183 kg.
• LM has drunk one to two beers per week for the
last 30 years and has smoked two to three packs
of cigarettes per day for the past 25 years. He
snorted crack cocaine in college two or three
times per week for 3 years but has not used an
illicit substance since.
• LM is currently trying to quit smoking and has
been taking the prescription medication
varenicline (Chantix) 1 mg twice daily for the
past 12 weeks. Before starting varenicline, he
took bupropion (Zyban) 150 mg twice daily for
7 weeks but was unable to to quit smoking.
• LM says he is allergic to amoxicillin because
his mother told him he developed a rash
while taking it as a baby. He had an adverse
reaction to diphenhydramine (Benadryl) (very
dry mouth and eyes) when he used it
once or twice in his thirties to help him
sleep. He hasn’t taken diphenhydramine since.
• LM is currently taking Nicorette (nicotine
polacrilex gum) 2 mg mint for breakthrough
nicotine cravings. He currently chews two or
three pieces of gum per day and has been using it
for the past 12 weeks.
• LM takes the complementary and alternative
medicine red yeast rice 600 mg capsules two
capsules twice daily with breakfast and dinner to
help control his cholesterol. He started taking the
red yeast rice 7 years ago. He took three to four
cups of coffee per day for the past 5 years
• LM has no dietary restrictions and takes no
dietary supplements or suppressants. His only
dietary stimulant is three to four cups of
coffee per day for the past 5 years.
• LM is determined to quit smoking. He
understands how and when to take the
Chantix and when to use the Nicorette gum.
 DEMOGRAPHIC INFORMATION
• Name: Luke Miller (LM)
• Age: 63 y/o
• Race: Hispanic
• Gender : Male
• Height: 165
• DOB: December 4, 1954
• Weight: 183 kg
• Occupation: works as a financial advisor and lives
in a house in the suburbs.
Social History:
Tobacco (2-3 ppd 25 years; 50-75pk-yrs)
Alcohol (drunk one to two beers per week for
the last 30 years); light drinker
 Illicit drugs (snorted crack cocaine in college
two or three times per week for 3 years ) but
has not used an illicit substance since
Dietary informations (restrictions,
supplements, stimulants and suppressants):
• Restrictions: None.
Supplements: None
Stimulants: three to four cups of coffee per
day for the past 5 years
Suppressants: None
Allergies: he is allergic to amoxicillin because
his mother told him he developed a rash
while taking it as a baby.
Adverse Drug Reactions: He had an adverse
reaction to diphenhydramine (Benadryl) (very
dry mouth and eyes) when he used it
once or twice in his thirties to help him
sleep. He hasn’t taken diphenhydramine since.
Current Prescription Medications:
• varenicline (Chantix) 1 mg twice daily for the
past 12 weeks
Past Prescription Medications:
• bupropion (Zyban) 150 mg twice daily for 7
weeks but was unable to to quit smoking.
Current Nonprescription Medications:
• Nicorette (nicotine polacrilex gum) 2 mg mint
for breakthrough nicotine cravings. He
currently chews two or three pieces of gum
per day and has been using it for the past 12
weeks.
Past Nonprescription Medications
None
 Current Complementary and Alternative
Medicines:
red yeast rice 600 mg capsules two capsules twice
daily with breakfast and dinner to help control his
cholesterol. He started taking the red yeast rice 7
years ago
 Past Complementary and Alternative Medicines:
• None.
 Immunizations (vaccine, date given):
• None
OVERALL PATIENT ADHERENCE
• LM is very adherent to his medication regimen
because he is determined to quit smoking. He
understands how and when to take the
Chantix and when to use the Nicorette gum.