Past Medical History

Transcription

1 Past Medical History Statement of Goals Know how to obtain a thorough, age appropriate past medical history. Learning Objectives A. Describe a past medical history (PMH) as a record of the patient s past experiences with illnesses and medical treatments. B. List the components of a complete PMH as described in Bates: 1. Childhood illnesses 2. Adult illnesses: a. Medical illnesses b. Surgeries c. Obstetric/gynecologic d. Psychiatric illnesses 3. Health maintenance: a. Immunizations b. Screening tests C. List the components of a complete pediatric PMH 1. Birth History a. Prenatal b. Natal c. Neonatal 2. Illnesses 3. Hospitalizations 4. Surgeries 5. Injuries 6. Psychiatric Illnesses 7. Preventive Care: Check Ups, immunizations, screening tests Be able to discuss the importance of each of these components. D. Describe techniques for obtaining a thorough, accurate PMH in an efficient manner: A transition statement that prepares the patient for this portion of the medical interview. Effective use of directed and relatively closed ended questions. The use of written medical history forms, when appropriate. The use of additional office visits to complete the PMH, when appropriate.

2 E. Obtain a past medical history. Record the information in the front of a medical record. Student s Preparation for the Unit Reading Assignments: Required: Bates 9th Edition Bates: p 7 8 (Past History); pp 7 11; p 15 (Example of past history as part of the medical record); pp 17 19; p (The Mental Health History) pp 47 52; pp Curriculum Comments Objective B Childhood illnesses should include chronic childhood illnesses as well as infectious diseases such as chicken pox, measles, mumps, rheumatic fever, rubella and whooping cough. Adult medical illnesses should include chronic conditions such as hypertension, diabetes, hepatitis, and asthma. Hospitalizations should also be listed, including diagnoses, dates and treatments. Bates lists number and gender of sexual partners and at risk sexual practices in medical illnesses as well. Some clinicians include this information in the obstetric/gynecologic history for females, social history or genital/reproductive review of symptoms. In FCM, we are including this information in the social history. The surgical history should include the dates, indications and types of operations. The obstetric/gynecologic history includes menarche (age at onset of menses) and other details of the menstrual history, obstetric history, birth control practices, and sexual function. The psychiatric history should include dates and diagnoses of psychiatric disorders as well as hospitalizations and treatments. Health maintenance includes immunizations and screening tests. Examples of immunizations include measles, mumps and rubella, hepatitis B, tetanus, influenza and pnuemococcal vaccines. Screening tests include Pap smears, mammograms, TB tests, etc. You should list screening tests with the results and dates when last performed that are appropriate for the patient. You will learn more about screening tests in subsequent curriculum units.

3 Recommendations for screening tests in different age groups vary based on the group making the recommendations. For asymptomatic adults, the following are fairly standard: Blood pressure every visit Lipid profile every 4 5 years (if normal) beginning at age 20 Pap smears in women, yearly until 2 3 consecutive negative smears and a stable sexual relationship is established, then every 2 3 years Mammograms in women every 1 2 years from age 40 to 50 then yearly thereafter Colon cancer screening (colonoscopy every 10 years or flexible sigmoidoscopy every 3 5 years) beginning at age 50. Some groups recommend fecal occult blood testing beginning at 40 Bone densitometry for women age 65 and over. Earlier screening may be warranted in women with risk factors for osteoporosis Objective C The prenatal history includes the location and duration of prenatal care, any complications during pregnancy, (maternal infections, preterm labor, etc.), tobacco, alcohol and drug (prescription and illicit) use during the pregnancy, maternal age and parental attitudes concerning the pregnancy. The natal history documents the events of labor and delivery. It includes the duration of labor, analgesia used, type of delivery, (vaginal, forceps or vacuum assisted, cesarean), complications during delivery, APGAR scores, resuscitation efforts (if necessary), birth weight and birth order if a multiple birth. The neonatal history describes the hospital course (problems with feeding, infection, respiratory distress, cyanosis, jaundice, seizures, congenital anomalies, etc.) as well as parental bonding/caregiving. Childhood illnesses include. Repeated ear infections, chicken pox, rheumatic fever, pertussis (whooping cough), and asthma. These are some of the more common childhood illnesses, but they are not limited to them, and all should be documented. Hospitalizations and surgeries should include dates, (or ages at time of occurrence), diagnoses/procedures and treatments.

4 (Examples of injuries include burns, fractures, ingestions, motor vehicle accidents) Be sure to document the circumstances surrounding the injuries as well. As in adults, the psychiatric history should include dates and diagnoses of psychiatric disorders as well as hospitalizations and treatments. The pediatric immunization history is very important. This is when patients receive the bulk of their immunizations. The current immunization schedule is included in the session on pediatrics (#'s 12 and 13). In addition to listing immunizations received, adverse reactions should be documented. Recommended screening tests vary worldwide. The American Academy of Pediatrics publishes guidelines that are often adhered to in clinical practice in the United States. Examples of screening tests include lead and hemoglobin, vision and hearing, and the newborn screen. Results and dates should be listed as well. Objectives D and E Directed questions (relatively "closed ended" questions) are appropriate in obtaining specific information about the PMH. Directed questions must be carefully worded, using the following guidelines, in order to avoid bias: Begin with a general question and follow this with more specific questions. "Tell me about any serious illnesses you have had in the past..." before asking, "Have you ever been told that you had high blood pressure?" Ask in a neutral fashion. "Have you ever been told that you had high blood pressure?" NOT, "You have never had high blood pressure, have you?" Ask one question at a time. "Have you ever been told that you had high blood pressure?" NOT "Have you ever had high blood pressure, diabetes, asthma, or arthritis? Some of the information in the PMH may have already been elicited while the information for the history of the present illness was being obtained. Such information belongs in the PMH. However, the HPI should include elements of the PMH that are relevant to the patient s present illness. For example, a patient may present with a chief complaint of abdominal pain. Information about any past abdominal surgeries although

5 part of the patient s past medical history should also be present in the HPI because it may impact the patient s present illness. One example of the documentation of the PMH in the medical record is available in Bates, p. 17. Apply Your Skills: Note how the information about the patient s past medical history is obtained in your preceptor s office. Does your preceptor ask patients to fill out a medical history form at their first visit? Are previous medical records obtained for review? Observe your preceptor obtaining a past medical history from a patient. If possible, interview a patient to obtain this component of the medical record. Record the past medical history of one patient in your patient encounter note. Study Questions: 1. What is a transition statement? Practice one. 2. Can you name the components of the past medical history for an adult? A child? 3. What types of illnesses are included as childhood illnesses? 4. What types of illnesses are included in adult illness? 5. What is included in an OB/GYN history? 6. What is included in health maintenance? 7. What information is included in a pediatric birth history?