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Basic History
 
 

Past Medical History

 
 
 
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On this page:Disease History

Overview

The patient's past medical history provides the medical context that underpins their current presentation. By understanding the natural history and course of their existing medical conditions, it is possible to predict their risk of complications and narrow down the differential diagnosis of their presenting complaint.
  • Ask About

  • Medical conditions
  • Recent hospital admissions
  • Admissions to the intensive care unit
  • Specific Conditions To Ask About 

    Use simple terms when asking questions, rather than medical terms such as ‘hypertension' or ‘dyslipidaemia'.
  • Asthma
  • Diabetes
  • Heart disease
  • High blood pressure
  • High cholesterol
  • Cancer
  • Sources of Past Medical History

  • The patient
  • Collateral - from family or friends
  • The patient's file - especially discharge summaries
  • Other hospitals - especially discharge summaries or transfer letters
  • The patient's GP
  • Letters from specialists
Often the patient's medication list also provides clues regarding the patient's medical conditions.

Disease History

These are examples of questions to ask to further ellucidate the course of each of the patient's medical conditions.
  • Diagnosis

  • When they were diagnosed
  • Who diagnosed the condition
  • How it was diagnosed - clinically, based on blood tests, imaging or invasive investigations
  • Underlying cause (if known) - e.g. diabetic nephropathy as a cause of chronic kidney disease, or alcohol as a cause of cirrhosis
  • Severity

  • Severity of symptoms - e.g. exercise tolerance before shortness of breath, chest pain or claudication
  • Stage of disease
  • Frequency of exacerbations, hospital or ICU admissions
  • Recent test results - e.g. eGFR, HbA1c or echo
  • Management

  • Watchful waiting
  • Lifestyle changes
  • Medications
  • Surgery
  • Chemotherapy / radiotherapy
  • Follow Up

  • Who manages the condition, such as their GP or a specialist.
  • Complications

  • Whether the condition results in any undesired effects, such as diabetic neuropathy.
  • Functional Impact

  • How the symptoms associated with the condition are affecting their day to day life.
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