Past Medical History | Basic History - MedSchool
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Basic History
 
 
Basic History
 
 
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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.
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Past Medical History

 
 
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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.
Last updated on October 6th, 2017
 
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 Boehlecke B, Sperber AD, Kowlowitz V, Becker M, Contreras A, McGaghie WC. Smoking history?taking skills: a simple guide to teach medical students. Medical education. 1996 Jul 1;30(4):283-9. Deandrea S, Lucenteforte E, Bravi F, Foschi R, La Vecchia C, Negri E. Risk Factors for Falls in Community-dwelling Older People: A Systematic Review and Meta-analysis. Epidemiology. 2010 Sep 1:658-68. Dhame S, Sheikh A. History-taking and examining allergies. The Foundation Years. 2007 Oct; 3(5): 185-187. Edwards IR, Aronson JK. Adverse drug reactions: definitions, diagnosis, and management. The lancet. 2000 Oct 7;356(9237):1255-9. Freedman DO, Weld LH, Kozarsky PE, Fisk T, Robins R, von Sonnenburg F, Keystone JS, Pandey P, Cetron MS. Spectrum of disease and relation to place of exposure among ill returned travelers. New England Journal of Medicine. 2006 Jan 12;354(2):119-30. Hark LI, Deen Jr DA. Taking a nutrition history: a practical approach for family physicians. American family physician. 1999 Mar;59(6):1521-8. House HR, Ehlers JP. Travel-related infections. Emergency medicine clinics of North America. 2008 May 31;26(2):499-516. Hu FB. Sedentary lifestyle and risk of obesity and type 2 diabetes. Lipids. 2003 Feb 1;38(2):103-8. Jose JA. History Taking. Work. 2012; 41: 5369-5370. Le Marchand L, Wilkens LR, Kolonel LN, Hankin JH, Lyu LC. Associations of sedentary lifestyle, obesity, smoking, alcohol use, and diabetes with the risk of colorectal cancer. Cancer research. 1997 Nov 1;57(21):4787-94.
Manley AF. Physical activity and health: A report of the surgeon general. DIANE Publishing; 1996 Nov 1.
Manson JE, Skerrett PJ, Greenland P, VanItallie TB. The escalating pandemics of obesity and sedentary lifestyle: a call to action for clinicians. Archives of internal medicine. 2004 Feb 9;164(3):249-58.
 Mayfield D, McLeod G, Hall P. The CAGE questionnaire: validation of a new alcoholism screening instrument. American journal of psychiatry. 1974 Oct;131(10):1121-3. Phelan M, Blair G. Medical history-taking in psychiatry. Advances in Psychiatric Treatment. 2008; 14: 229-234.
Rackemann FM. History taking in allergic diseases. Journal of the American Medical Association. 1936 Mar 21;106(12):976-9.
 Rusznak C, Davies RJ. ABC of allergies: Diagnosing allergy. BMJ: British Medical Journal. 1998 Feb 28;316(7132):686.
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