Medication History Case
Medication History Case
Please assess the student as they take the following history.
Student's Email

CASE - The evaluating student should read the following case and role-play for their peer

Dear Student: The following exercise is meant to be done as a role-play.  One student should read the case and role-play the patient.  The other student should act as the physician, and should not read the case or the checklist in advance. A third student, or the "patient", should complete the checklist during the interview to track their peer's progress.


Case:  Mr. SD


You are Mr. SD, a 66 year-old retired consultant.  You are going to the doctor today as a new patient, looking to meet your new physician and go over your past medical history and medication list.


You suffer from hypertension, high cholesterol, and diabetes, though all diseases are currently being well-managed with medications.  You were first diagnosed with hypertension and high cholesterol at the age of 56 and began treatment with medications at that time.  You began treatment for diabetes last year.  You have never had surgery.  You have never been hospitalized, except for one time when you broke his leg at age 14 by falling out of a tree.  You have no known allergies.


Currently, your medications include:

  • ·        Hydrochlorothiazide (for hypertension): 25mg in AM, PO
  • ·        Atorvastatin (for high cholesterol): 40mg in AM, PO
  • ·        Metformin (for diabetes): 500mg in AM and PM (1000mg/day), PO
  • ·        Aspirin (for CAD prevention): 81mg in AM, PO


You used to take ramipril for your blood pressure but switched to hydrochlorothiazide after 5 months because it was making you feel too tired.


You do not take any herbal or alternative medications.  You take a multivitamin most days; you and your wife try to remember together.  You don’t use any over-the-counter medications regularly, but occasionally you take ibuprofen when you have a sore muscle or headache.  You smoked 1 pack of cigarettes per day from age 15 to age 50.  You do not use any recreational drugs.  You drink a glass of wine with dinner 5 days per week.


Since your diagnosis of diabetes, you have tried to watch your diet but find it difficult, as your wife is an excellent cook! You started playing hockey once a week in a men’s league two months ago and enjoy it.  You take your health really seriously, especially since your diagnosis of diabetes; you now check your sugars regularly.  You use timers to remind you to take your medications and use a dosette to organize your pills.  You rarely miss your medications; maybe a pill or two every month.


You live with your wife, a retired administrator.  Your only daughter is 38 years-old and lives a 10 minute drive away.  You enjoy spending time with your family, especially your 5 year-old grandson.  

INTRODUCTION - The student should perform the following:

Washes hands
Introduces self to patient

IDENTIFYING DATA - The student should inquire about the following:

Name of patient
Age of patient

CHIEF CONCERN - The student should inquire about the following:

The chief concern should include the nature and duration of the concern.  This is not relevant for this case.

HISTORY OF PRESENT ILLNESS - The student should inquire about the following:

The history of presenting illness should be characterized in detail, including obtaining information about the complaint, its associated symptoms, pertinent positives/negatives, and the impact of illness on quality of life and function.  This is not relevant for this case.

MEDICATIONS AND ALLERGIES - The student should inquire about the following:

Previous medications (includes: name, reason for changes, and side effects)
Current medication names (includes: prescription, over-the-counter, and herbal/alternative medicines)
Dose and frequency
Duration of use
Route of administration
Last dose taken
Reason for taking the drug

Common strategies to improve compliance with medications include: dosettes, blister packs, alarms/timers.

Side effects from medications (includes: characterize)
Allergies to drugs or otherwise (includes: nature of reaction, timing of reaction, formal testing performed)

PAST MEDICAL HISTORY - The student should inquire about the following:

Diagnosed illnesses

SOCIAL HISTORY AND HABITS - The student should inquire about the following:

Smoking (includes: pack years; if they quit, when)
Alcohol (includes: quantify)
Drugs (includes: types, frequency of use, quantity, methods)
Living arrangement
Relationships & Children
Hobbies & Interests

REVIEW OF SYSTEMS - The student should inquire about the following:

Though it is important to perform a thorough review of systems, this is not relevant for this case.