Lie there

■ "Do you have sex with men, women, or both?" The health implications Q of heterosexual, homosexual, or bisexual experiences are significant. Individuals may have sex with persons of the same gender, yet they may not

^ consider themselves gay, lesbian, or bisexual.

■ "How many sexual partners have you had in the last 6 months?" "In the ^ last 5 years?" "In your lifetime?" Again, these questions give the patient ^ an easy opportunity to acknowledge multiple partners.

■ It is important to ask all patients "Do you have any concerns about HIV disease or AIDS?" because no explicit risk factors may be present. Ask also about routine use of condoms.

Note that these questions make no assumptions about marital status, sexual preference, or attitudes toward pregnancy or contraception. Listen to each of the patient's responses and ask additional questions as indicated. When patients are uncomfortable using sexual terminology, you may have to initiate more of the discussion.

Remember that sexual behavior, too, can start at a young age. Encourage parents to talk to their children about sexuality during their early years. It is frequently easier to discuss normal physiologic functions before children have been heavily socialized outside the home. For adolescents, because they often keep sexual behaviors from parents, be sensitive to the need for confidentiality (see p._"Talking With Adolescents").

Domestic and Physical Violence. Because of the high prevalence of physical, sexual, and emotional abuse, many authorities recommend the routine screening of all female patients for domestic violence. Some men are also at risk. As with other sensitive topics, start this part of the interview with general "normalizing" questions: "Because abuse is common in many women's lives, I've begun to ask about it routinely." "Are there times in your relationships that you feel unsafe or afraid?" "Many women tell me that someone at home is hurting them in some way. Is this true for you?" "Within the last year, have you been hit, kicked, punched, or otherwise hurt by someone you know? If so, by whom?" As in other parts of the history, use a pattern that goes from general to specific, less difficult to more difficult.

Physical abuse—often not mentioned by either victim or perpetrator— should be considered in the following settings:

■ If injuries are unexplained, seem inconsistent with the patient's story, are concealed by the patient, or cause embarrassment

■ If the patient has delayed getting treatment for trauma

■ If there is a past history of repeated injuries or "accidents"

■ If the patient or a person close to the patient has a history of alcohol or O drug abuse.

Also be suspicious if a partner tries to dominate the interview, will not leave the room, or seems unusually anxious or solicitous.

Wh en you suspect abuse, it is important to spend part of the encounter alone with the patient. You can use the transition to the physical examination as an excuse to ask the other person to leave the room. If the patient is also resistant, you should not force the situation, potentially placing the victim in jeopardy. Be aware that certain diagnoses have a higher association with abuse, such as pregnancy and somatization disorder.

Child abuse is also common. Asking parents about their approach to discipline is a routine part of well-child care. You can also ask parents how they cope with a baby who will not stop crying or a child who misbehaves. "Most parents get very upset when their baby cries (or their child has been naughty). How do you feel when your baby cries?" "What do you do when your baby won't stop crying?" "Do you have any fears that you might hurt your child?" You should also inquire about how other caretakers or companions handle these situations.

The Mental Health History. Many cultures make ingrained distinctions between mental and physical illnesses causing marked differences in social acceptance and attitudes. Think how easily people talk about diabetes and taking insulin compared to discussing schizophrenia and using psy-chotropic medication. Use both open-ended and directed questions to elicit the individual and family history of mental illness. For example, you might begin by asking "Have you ever had any problem with emotional or mental illnesses?" Then move to more specific questions such as "Have you ever visited a counselor or psychotherapist?" . . . "Have you or has anyone in your family ever been hospitalized for an emotional or mental health problem?"

For patients with depression or thought disorders such as schizophrenia, a careful history is in order. Depression is common worldwide but still remains underdiagnosed and undertreated. For such patients, be open to their changes in mood or symptoms such as fatigue, unusual tearfulness, weight loss, insomnia, and vague somatic complaints. Two opening questions are "How have your mood or spirits been over the past month?" and "What about your level of interest or pleasure in each day's activities?" For serious depression, be sure to ask about thoughts of suicide . . . "Have you ever thought about hurting yourself or ending your life?" As with chest pain, you must evaluate severity— both are potentially lethal. For further approaches, turn to the mental status sections of Chapter 16, The Nervous System.

Many patients with schizophrenia or other psychotic disorders can function in the community and tell you about their diagnoses, symptoms, hospital-izations, and current medications. You should feel free to ask about symptoms and assess any impact on mood or daily activities.

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