Interviewing patient, drug history

The medical record is another source of medication and health-related information. Access to this record may be limited in certain practice settings however, it can be a valuable tool to review prior to conducting your patient drug history interview. Some practitioners use medical release forms to obtain medical record information such as laboratory data from other institutions required for drug therapy monitoring. 

Evaluate the patient s medical record and medication history, and conduct a patient interview to assess for the presence of drug allergies, adverse drug reactions, and drug interactions. 

A 56-year-old man with a history of diabetes and coronary artery disease presents to the emergency room with complaints of weakness, fever, and chills. On interviewing the patient, you determine that he went to the dentist about 3 weeks ago and since that time has lost about 5 lb. The patient reports that the symptoms began about 1 to 2 weeks ago. He denies any use of alcohol or illicit drugs but admits to smoking about V2 pack of cigarettes per day. 

The project director at each site interviewed each patient to explain the nature of the experiment and to obtain informed consent. A project social worker gathered data on SES nutritional habits alcohol consumption, smoking and drug habits history of past pregnancies and so on. Additional information was obtained from hospital records. 

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