"Caffeine Use" in the general inquiry

[sarcopenia]

Greetings,

I have run across this several times in the past and again recently as a patient.

What is the point of asking about "caffeine use" during the social history? They usually peg it in right after smoking / alcohol / illicit drugs. I can see the value in specifically asking about "herbals and supplements" because some patients might not consider such things as "medically relevant" even though they can have interactions with various medications (e.g. coumadin).

But caffeine use? What's the difference between a healthy person who drinks 0 or 4 cups of coffee per day? What about a sick person? The only possible relevance I could see is for specific disorders (e.g. GERD, insomnia, overactive bladder). But my complaint was severe gastroenteritis, presumably acquired through consumption of "bad sushi."

I would feel silly writing "Drinks 3 cups of coffee and 1 cup of tea per day" on a medical admission for, say, CAP (even though I would still ask about alcohol, tobacco, and illicit drugs, because use of these products has known chronic effects on major organ systems).

Maybe it's more of a pet peeve than a question. Or maybe I'm overlooking something obvious. If so, please educate me.

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[deleted87716]

It doesn't take that long to ask about it, does it...?

Thoroughness is never a bad thing in this business.

 

[sarcopenia]

Fair enough Blue Dog, and you obviously know far more than me (no, I'm not being sarcastic). But if we extend that logic too far, then our histories would never end.

A friend of mine was doing IM residency at McGill, where there was a "culture" of doing 5-7 page admission notes, and staying until 1900 every night "no matter what." He got burnt out after awhile, and transferred to a program in Ontario that is probably comparable in caliber (though admittedly far less famous, if any Canadian school can truly be considered so). In this new program, writing such a rambling history would probably bring ridicule upon the offending physician. Significant cultural shift. Is one way "better" than another? I guess it depends on who is reading, and for what purpose.

I'm for efficiency and working smarter, not harder. That's why I favour (when possible) the use of "waiting room checkbox lists" for patients to fill out before their interviews (especially for a major appointment / yearly physical). This almost constitutes a pre-fab ROS with zero effort, and allows prioritization of limited time.

I guess I was hoping for a more "caffeine-specific" answer to highlight some medical implication about caffeine use that I am (apparently) not aware of.

Again, no disrespect intended.

 

[deleted87716]

I favour (when possible) the use of "waiting room checkbox lists" for patients to fill out before their interviews (especially for a major appointment / yearly physical). This almost constitutes a pre-fab ROS with zero effort, and allows prioritization of limited time.

Good luck with that. I expect you'll re-evaluate the appropriateness of this the first time you get an entirely positive ROS. I favor working smarter, as well. That's why I don't have my patients (or anyone else) take my histories for me. History-taking is as much an art as it is a science, and it takes every bit as much time to confirm somebody else's history as it does to ask yourself.

I guess I was hoping for a more "caffeine-specific" answer to highlight some medical implication about caffeine use that I am (apparently) not aware of.

It sounds to me like you are aware of the medical implications.

 

[hawkeye pierce]

Well, I will say to you caffeine causes upset stomach, high blood pressure, anxiety, among other things. The most rediculous thing asked is marital status.

 

[deleted87716]

The most rediculous thing asked is marital status.

You're kidding, right? You do realize this is the family medicine forum...?

 

[deleted6669]

I think as long as you ask about it when relevant you are being appropriate. for example I work in emergency medicine and we ask about caffeine and other otc stimulants when working up chest pain, htn, arrythmias, etc especially in the young. I have seen several folks with chest pain, htn, and tachycardia after ingestion of several red bull products.

 

[deleted6669]

Well, I will say to you caffeine causes upset stomach, high blood pressure, anxiety, among other things. The most rediculous thing asked is marital status.

obviously you're not married.....being married can be a significant stressor... or offer significant support for recovery at home vs in a hospital depending on the situation...

 

[lowbudget]

Well, I don't know about you, but I always ask about scorpion bites in patients who present with abdominal pain.

 

[deleted87716]

Well, I don't know about you, but I always ask about scorpion bites in patients who present with abdominal pain.

Well, if you live in the Southwest, it's probably relevant.

 

[leviathan]

The scorpion that is associated with pancreatitis isn't even found in the US...if that's what you were getting at.

 

[hawkeye pierce]

Yes this is family medicine, but if you are treating my family you would already know.

 

[deleted87716]

Yes this is family medicine, but if you are treating my family you would already know.

If you already know, you don't have to ask, do you?

The point is that we treat patients in the context of their family and community. Their marital status is absolutely relevant.

 

[Reductio]

I think the OP's point, which is worth considering (especially for those that are just learning to take a good history), is that some points on the Social Hx have a higher diagnostic yield than others. (Clearly, the resident has just had a bit of a , while the old attending... )

If the patient is young and in excellent health, no Hx of GERD, insomnia, or palpitations... c/o N/V/D x2 days s/p bad sushi. Daily caffeine use is of low/no clinical utility.

If the patient is elderly, with Hx of PUD, GERD, HTN, and is c/o insomnia secondary to nighttime heartburn x1 month, Daily caffeine use is very clinically relevant.

Marital status has been shown to correlate with clinical outcomes. So, it's clinically relevant. However, since you as a physician can't (ethically) modify that factor, and since you can't base a clinical decision on it, it is of low clinical utility.

While scorpion stings do cause acute pancreatitis, it's never of any use to ask a patient who's never left the US, c/o abdominal pain radiating to the back, if they've been stung by a scorpion.

Take home - the same points on the Social Hx will vary in relevance depending on the patient; and a perfectly relevant point may vary in how clinically useful it is.

 

[lowbudget]

The scorpion in my part of town likely has alcohol in its venom. And potato chip grease.

 

[justwondering]

our clinic's new pt forms have caffeine on them as well. i think it's just for the sake of getting all the info without having to customize it to every situation/pt.
i could see in a residency context that it could be useful as part of the routine since not all residents would think about it when it IS relevant (so they might forget to ask). if i was doing my own h and p or making my own form, i wouldnt ask unless it was relevant to the encounter. although, occasionally, it gives you the opportunity to counsel if they're drinking excessive caffeine (like this one guy i had who would drink 2 party sized (2 liters each?) bottles of caffeine per day).

 

[Instatewaiter]

Fair enough Blue Dog, and you obviously know far more than me (no, I'm not being sarcastic). But if we extend that logic too far, then our histories would never end.

A friend of mine was doing IM residency at McGill, where there was a "culture" of doing 5-7 page admission notes, and staying until 1900 every night "no matter what." He got burnt out after awhile, and transferred to a program in Ontario that is probably comparable in caliber (though admittedly far less famous, if any Canadian school can truly be considered so). In this new program, writing such a rambling history would probably bring ridicule upon the offending physician. Significant cultural shift. Is one way "better" than another? I guess it depends on who is reading, and for what purpose.

I hate to ridicule but staying until 7pm every night is no biggie. Places like McGill in Canada, MGH or Hopkins in the US typically have a culture of being incredibly thorough and tend to have much sicker patients which requires staying later. Plus, these places also tend to be very front loaded meaning almost all of the time as an intern is spent inpatient on wards meaning you are going to be busier. The students these places attract tend to be pretty hardcore anyway.

 

[smq123]

The scorpion in my part of town likely has alcohol in its venom. And potato chip grease.

We have a KFC around the corner from our outpatient office. And a liquor store down the street.

 

[Shinken]

Marital status has been shown to correlate with clinical outcomes. So, it's clinically relevant. However, since you as a physician can't (ethically) modify that factor, and since you can't base a clinical decision on it, it is of low clinical utility.

Marital status is not only clinically relevant, it has high clinical utility. I make clinical decisions based on marital status all the time. Does a patient need a home health nurse to come over and change his dressing? Or can his wife do it with a bit of coaching? Is a patient's husband able to help with his wife's medication regimen? Is the patient's depression tied to his/her spouse? etc.

Non-modifiable factors are taken into consideration in my practice all the time. Marital status, sexual orientation, age, gender, family history, all are non-modifiable yet I use those factors to guide my clinical decisions every day.

 

[Reductio]

Marital status is not only clinically relevant, it has high clinical utility. I make clinical decisions based on marital status all the time. Does a patient need a home health nurse to come over and change his dressing? Or can his wife do it with a bit of coaching? Is a patient's husband able to help with his wife's medication regimen? Is the patient's depression tied to his/her spouse? etc.

Non-modifiable factors are taken into consideration in my practice all the time. Marital status, sexual orientation, age, gender, family history, all are non-modifiable yet I use those factors to guide my clinical decisions every day.

 

[lowbudget]

... have a culture of being incredibly thorough and tend to have much sicker patients which requires staying later...

Hmmm... maybe.

There's a very fine line between thorough and inefficient. Sometimes, it's easy to get lost in the differential when the actual diagnosis is staring you in the face.

 

[ghost dog]

I hate to ridicule but staying until 7pm every night is no biggie. Places like McGill in Canada, MGH or Hopkins in the US typically have a culture of being incredibly thorough and tend to have much sicker patients which requires staying later. Plus, these places also tend to be very front loaded meaning almost all of the time as an intern is spent inpatient on wards meaning you are going to be busier. The students these places attract tend to be pretty hardcore anyway.

What a complete load of CRAP.

Interns everywhere ,I believe, could be classified as "pretty hardcore". If you aren't staying late in the hospital during your first year ,regardless of where you are, something is wrong, somewhere.

I hate this culture in medicine of this hyper-competitive, "we had it harder than you did". At UofT, being surrounded by type A tools like this, is possibly one of the reasons why med school was such a god-damned miserable experience (when it really did not have to be).

 

[montessori2md]

www.takeasheet.com

How many of these do you think a 14 year old could use before they show up in the ED?