Taking a Medication History

It is also important to make note of substances that clients would not consider worth mentioning. For example, caffeine has been noted to decrease the antipsychotic effects of medications. Cigarette smoking has been linked to decreased levels of antidepressant and antipsychotic medications in the blood. Over-the-counter medications should also be documented, particularly antacids that may lead to decreased absorption of the antipsychotic medications. Needless to say, it is important to document all medications and herbal products that a client is taking, even the ones that may not be considered real medications including any over-the-counter medications, vitamins, and diet supplements. 

Careful documentation is essential. Medications that are currently being taken should be distinguished from those that have been taken in the past. Generally, a time frame of at least three months is recommended for documentation of past medication use. Because most individuals may have trouble remembering, especially those who have taken multiple medications, it is important to be supportive and allow the client to search for any medication bottles or prescriptions that will provide accurate information for documentation purposes. 

Professional social workers are not usually responsible for documenting the medication history. We cannot emphasize enough the importance of keeping careful records and documentation that supports the service a member of the interdisciplinary team provides. It is anticipated that the increased emphasis on effective treatment and outcome by managed care and regulatory organizations will require social workers and other mental health professionals to include specific medication-therapy information in counseling documentation. 

Social workers have always relied on some form of documentation of client situations and problems. While the formats have changed, documentation for maintaining case continuity remains a professional priority 

Of the various types of record-keeping, health care facilities frequently use a problem-oriented format. Developed first in medical settings, this type of record-keeping was used to encourage interdisciplinary collaboration and to train medical professionals (Weed, 1969). Working in interdisciplinary health care and mental health settings, social workers find that problem-oriented record-keeping enables them to comply with the facility s documentation requirements. 

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Acute pain is a warning signal and it is necessary to take a medical history and make the appropriate investigations to make a diagnosis and to give causal treatment. In pain of a more chronic nature an analysis of the origin of the pain and its character must be made in order to give the correct treatment (Table 1). 

Consider Fig. 21-3, which is a service blueprint of Feel Great s Med Check service. The blueprint is divided by three lines line of interaction, line ofvisibility, and hne of internal interaction. The line of interaction separates patients from contact employees. It signifies interactions that occur between the patient and the contact employee, such as taking a medication history. The line of visibility separates onstage employee actions from backstage employee actions. Above this line appear the actions that the patient can see, whereas below it are actions that the patient does not see. In Fig. 21-3, the patient sees the pharmacist take a medication his-... 

The physician will take a medical history and perform a physical examination. The details of the mental status examination will be greater from a psychiatrist than a primary care physician, and the primary care physician will probably conduct a more thorough physical examination than most psychiatrists. In common, their consultations will usually include the elements in Table 9.6. 

Social workers are now often expected to assist with taking an initial medication history. It is important to remember that an accurate and responsible history should also explore the possibility for abuse. When the potential for abuse is high, social workers can note this and prepare the team to be aware and avoid possible problems for the client. When taking a medication history, include prescription and nonprescription drugs and drugs for chronic conditions that may not seem worth mentioning. 

Mrs Shabnam is a 32-year-old patient who you are seeing for treatment following an injury. You take a medical history and note that she is taking an antianxiety dmg, diazepam. Mrs Shabnam has quite severe and extensive psoriasis. She tells you that the psoriasis causes her a lot of anxiety and that this is the reason why the doctor has put her on diazepam. She is waiting for an... 

The physician sees patients who complain of symptoms, and, in order to provide rational therapy, he must anive at a correct diagnosis. Accordingly, the physician takes a medical history, performs a physical examination, and obtains whatever laboratory studies are deemed necessary. The physician uses his findings to provide a diagnosis, therapy, and a prognosis. This classical approach to the practice of medicine is depicted in Fig. 1. 

Conduct a medication history (prescription, over-the-counter, and dietary supplements) to determine conditions or causes of hypertension. Does the patient take any medications, supplements, herbal products, or foods that may elevate SBP or DBP Does the patient have drug allergies ... 

Aseptic meningitis syndrome-The incidence of this syndrome was 6%. Fever, headache, meningismus, and photophobia were the most commonly reported symptoms a combination of these 4 symptoms occurred in 5% of patients. Headache - Headache is frequently seen after any of the first few doses and may occur in any of the aforementioned neurologic syndromes or by itself. Seizures - Seizures, some accompanied by loss of consciousness or cardiorespiratory arrest, or death, have occurred independently or in conjunction with any of the neurologic syndromes described below. Patients predisposed to seizures may include those with the following conditions Acute tubular necrosis/uremia fever infection a precipitous fall in serum calcium fluid overload hypertension hypoglycemia, history of seizures and electrolyte imbalances those who are taking a medication concomitantly that may, by itself, cause seizures. 

In the first patient and the fourth patient in our initial series (p. 7), the association of ALPE with anaerobic exercise had not yet been recognized, and their medical histories may have been insufficient, or the patients may not have reported intense exercise over a short duration. In acute renal failure patients with loin pain of unknown etiology, the presence or absence of anaerobic exercise should always be ascertained when taking their medical history. Erley et al. [28] did not comment on exercise in their study. However, when Sato et al. inquired about exercise in 1998 [34], Erley et al. reported that the patient had undertaken exercise. 

A 24-year-old female developed blistering sun-sensitive dermatosis. A medical history revealed that she was taking birth control pills and consumed moderate amounts of alcohol. Analysis of urine showed the presence of uroporphyrins, and... 

The focus of our text is the collaboration between therapist and physician and the use of medication to treat psychiatric symptoms. Although we use medications to treat mental illness, it is critical for the therapist to know that the use of certain medications for general medical conditions can cause psychiatric symptoms. The therapist must take a careful history, including knowledge of all of the medications that a person takes for any reason if it is possible that a medication is causing the mental health problem, the patient must be promptly referred to his or her physician for medication adjustment. 

Doctors must recognise the increasing importance of questioning about self-medication when taking a drug history. 

CB s asthma is currently being treated with a low-dose of the inhaled corticosteroid beclomethasone dipropionate (QVAR, 40 pg b.i.d.). She is in your pharmacy now with prescriptions for both chronic medications written by her new provider. After taking her medical history and reviewing her psychosocial situation, you recognize that she has many risk factors for near-fatal asthma" and believe she should have ready access to rescue therapy in case she experiences an acute episode of severe bronchoconstriction. Consider the structures of the adrenergic agents drawn below, and prepare to make a therapeutic recommendation to CB s new physician. 

DW, a 78-year-old Caucasian man, presents to the emergency room with complaints of a headache persisting over the last 3 days. Repeated blood pressure measurements average 200/11 0 mm Hg. He reports no other symptoms and physical examination and laboratory tests are unremarkable as is his past medical history with the exception of hypertension diagnosed in his early 60s. DW reports that he is struggling on a fixed retirement income with no prescription coverage and takes "what I can afford." Blood pressure medications are carvedilol 25 mg twice daily, amlodipine 10 mg once daily, torsemide (Demadex )... 

Obtain a thorough history of prescription, nonprescription, and herbal medication use. Is the patient taking any medications that can exacerbate HF ... 

Interview the patient and/or caregivers to obtain a complete medical history, which should include family medical history, current and past prescription and nonprescription medications, and dietary intake. Determine whether the patient is taking medication/supplements that could interfere with the therapy. 

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