■ Have you ever felt the need to Cut down on drinking?
■ Have you ever felt Annoyed by criticism of drinking?
■ Have you ever felt Guilty about drinking?
■ Have you ever taken a drink first thing in the morning (Eye-opener) to steady your nerves or get rid of a hangover?
Adapted from Mayfield D, MeLeod G, Hall P: The CAGE questionnaire: Validation of a new alcoholism screening instrument. Am J Psychiatry 131:1121-1123, 1974.
Two or more affirmative answers to the CAGE Questionnaire suggest alcoholism. They indicate that you need to ask more questions about blackouts (loss of memory for events during drinking), seizures, accidents or injuries while drinking, job loss, marital conflict, or legal problems. Also ask specifically about drinking while driving or operating machinery.
lestions about drugs are similar. "How much marijuana do you use? Co-aine? Heroin? Amphetamines? (ask about each one by name). "How about ^prescription drugs such as sleeping pills?" "Diet pills?" "Pain-killers?" Another approach is to adapt the CAGE questions to screening for substance abuse by adding "or drugs" to each question. If the patient is using illegal substances, ask further questions such as "How do you feel when you take it?" . . . "Have you had any bad reactions?" "What happened?" . . . "Any drug-related accidents, injuries, or arrests?" "Job or family problems?" . . . "Have you ever tried to quit? Tell me about it."
Talking about drug use with adolescents can be even more challenging. It may be helpful to ask about substance use by friends or family members first.
"A lot of young people are using drugs these days. How about at your school? Any of your friends?" Once patients realize you are concerned and nonjudgmental, they may be more open about their own patterns of use. Remember that alcohol and drug use can start at young ages. These topics should be introduced, along with tobacco use, in front of the parent with children at ages 6 or 7.
The Sexual History. Asking questions about sexual function and practices can be life-saving. Sexual practices determine risks for pregnancy and sexually transmitted diseases (STDs), including AIDS—good interviewing helps prevent or reduce these risks. Sexual practices may be directly related to the patient's symptoms and integral to both diagnosis and treatment. Many patients have questions or concerns about sexuality that they would discuss more freely if you have asked about sexual health. Finally, sexual dysfunction may result from use of medication or from misinformation that, if recognized, may be readily addressed.
You can introduce questions about sexual function and practices at multiple points in a patient's history. If the Chief Complaint involves genitourinary symptoms, include the sexual history in the Present Illness. Chronic illness or serious symptoms such as pain or shortness of breath may also affect sexual function. For women, you can ask these questions as part of the Obstetric/Gynecologic section of the Past Medical History. You can include them during discussions about Health Maintenance, along with diet, exercise, and screening tests, or as part of the lifestyle issues or important relationships covered in the Personal and Social History. Or, in a comprehensive history, you can query about sexual practices during the Review of Systems.
An orienting sentence or two is often helpful. "Now I'd like to ask you some questions about your sexual health and practices." or "I routinely ask all patients about their sexual function." For more specific complaints, you might state "To figure out why you have this discharge and what we should do about it, I need to ask some questions about your sexual activity."
In general, ask about both specific sexual behaviors and satisfaction with sexual function. Specific questions are included in the chapters on Male Genitalia and Hernias (pp. - ) and Female Genitalia (pp. - ). Be sure to ask such questions as:
■ "When was the last time you had intimate physical contact with anyone?" "Did that contact include sexual intercourse?" Using the term "sexually active" can be ambiguous. Patients have been known to reply "No, I just
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