Screening for General Medical Conditions
Screening Questions
Mnemonic: MIDAS
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Do you take any Medications now?
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Do you have any medical Illnesses?
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Do you have a primary care Doctor?
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Have you ever had Allergies, reactions, or side effects from any medications?
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Have you ever had any Surgery?
Medical review of systems.
Recommended time: 3 minutes
There are two major reasons for asking about the medical history in psychiatric patients:
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To screen for medical illnesses. Many psychiatric patients, particularly patients with chronic schizophrenia in public care systems, have very poor medical follow up, both because they are indigent and because their psychiatric disorder leads to poor compliance with appointments (Hall et al. 1980). Thus, they may have a high prevalence of undiagnosed medical conditions. Whether these conditions affect their psychiatric status or not, you will do them a large service by screening for medical conditions for which they may not be receiving treatment.
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To uncover general medical causes of psychiatric illness. A number of medical illnesses and medications can cause psychiatric syndromes and aggravate preexisting ones (Lishman 1987). This is a convenient section of the interview for asking about such illnesses.
MIDAS
If you can develop the MIDAS touch, you’ll never forget to ask about the medical history:
Medications
Obtain a list of all medications, including those for general medical conditions. Ascertain whether the patient has been taking them as prescribed.
History of Medical Illnesses
You can begin with a screening question such as
Do you have any medical problems?
Have you ever had a medical illness?
However, a common problem with this approach occurs when the patient says “no” without thinking carefully, as the following vignette illustrates.
CLINICAL VIGNETTE
A 36-year-old woman with several past hospitalizations for depression was asked if she had any medical problems, to which she replied, “No.” Later, when the resident asked what medications she took, she listed a number of psychotropics and then said, “and I also take Synthroid.” The resident said, “I thought you had no medical problems,” to which the patient replied, “I don’t. I used to have hypothyroidism, but that was corrected with the Synthroid.”
Primary Care Doctor
In the preceding vignette, asking about illness elicited invalid information. One way to increase the validity of your medical history questions is to first ask if the patient is being seen by a doctor.
Do you see a doctor regularly?
What does he/she treat you for?
By referring to a relationship with a caregiver, you will typically jog the patient’s memory for past diagnoses and treatments. You can also learn information about the patient’s character:
Interviewer: Do you see a doctor regularly?
Patient: Yeah, I see someone at the clinic. Not that he gives a damn about me.
Such a statement could be explored further and might be a clue to character traits that may interfere with treatment, such as passive-aggressive or self-defeating traits.
While you’re at it, ask the patient if you may contact his doctor to share information. Discussing the patient with the primary care physician will help round out your evaluation, as well as provide useful information to the caregiver who referred the patient to you.
Allergies
The usual screening question is
Do you have allergies to any medications?
This may work, but again there are potential pitfalls. Some patients have idiosyncratic understandings of what constitutes an allergy. They may think you’re asking about serious allergic reactions, such as bronchospasm, and therefore may answer in the negative even if they’ve had milder allergic reactions. They also may not realize that you’re interested in hearing about any negative reactions to medications, and not just allergies per se. Better to ask
Have you ever had any allergies, reactions, or side effects to any medication?
A patient may say that he is allergic to a number of medications that only uncommonly produce true allergic reactions, such as neuroleptics and antidepressants. If so, pursue the nature of the allergy.
What kinds of reactions did you have to that medicine?
If the patient’s response is vague, make some suggestions based on your knowledge of drug effects:
Did the Haldol give you muscle spasms? Did it make your hands shake or your body move slowly?
When you document allergies in your write-up, specify the nature of the reaction. For example, writing that a patient is “allergic to neuroleptics” is probably inaccurate and might mean that the patient will never again be offered a neuroleptic, even if she could benefit from it. A more accurate statement would be, “Haldol causes dystonia.” This leaves the door open to trials of other neuroleptics.
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