Past medical history
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Not to be confused with Medical history or History of medicine.
"Past history" redirects here. It is not to be confused with History of presenting complaint (history of the present illness).
In a medical encounter, a past medical history (abbreviated PMH),[1] is the total sum of a patient's health status prior to the presenting problem.
Contents
Questions to include
Different sources include different questions to be asked while conducting a PMH, but in general, they include the following:
- General state of health: e.g. excellent, good, fair, poor. Note any significant change from previous state.
- Past illnesses: e.g. cancer, heart disease, hypertension, diabetes.
- Hospitalizations: including all medical, surgical, and psychiatric hospitalizations. Note the date, reason, duration for the hospitalization.
- Injuries, or accidents: note the type and date of injury.
- Surgeries: note the type of procedure, date, hospital, surgeon, and any complications.
- Current medications: note name, dosage, frequency of any medication, including any over-the-counter medications and herbal remedies. Note whether patient is taking the medications according to the prescribed instructions.
- Allergies: note any environmental, food, or drug allergies, as well as the specific type of reaction, e.g. anaphylaxis, rash, itching.
- Immunizations: take a careful record of all immunizations, including tetanus, diphtheria, pertussis, polio, Hepatitis B, measles, mumps, rubella, Haemophilus influenzae type B, influenza.
- Substance abuse: note any alcohol, tobacco, and illicit drug use, include type, amount, and duration, as well as any past treatment or drug rehabilitation.
- Diet: ask about everything the patient has eaten the day before and for the past week. Note the type of food consumed and do a nutritional status assessment.
- Sleep: a useful mnemonic for sleep patterns is BEARS, for Bedtime problems (e.g. snoring, sleep apnea, or nightmares), Excessive daytime sleepiness, Awakenings at night, Regularity and duration of sleep, Snoring.[2]
- Alternative therapies: e.g. acupuncture, massage, herbal medicine, vitamins, chiropractice.
- Obstetric/Gynecologic history (if female): include total number of pregnancies, whether they are full term, preterm, miscarriages, abortions, living, as well as any complications. Include menopause and date. Include sexual history and any history of sexually transmitted diseases.
Acronyms
Several acronyms have been developed to categorize the appropriate questions to include:
- "MMASH", for Medical Illnesses, Medications, Allergies, Surgeries, Hospitalizations.[3]
- "PAM HUGS FOSS",[4] for
- Previous presence of the symptom (same chief complaint)
- Allergies (drugs, foods, chemicals, dust, etc.)
- Medicines (any drugs the patient used)
- Hospitalization for any illness in the past
- Urinary changes (especially if diabetic or elderly)
- Gastrointestinal complains (diet changes, bowel movements, etc.)
- Sleep pattern (waking up/going to sleep, etc.)
- Family history (similar chief complaints/serious illness)
- OB/GYN history (LMP, abortions, etc.)
- Sexual habits (active/preferences/STD, etc.)
- Social life (job/house/smoking/alcohol, etc.)
Medicare definitions
The Centers for Medicare and Medicaid Services[5] has published criteria for what constitutes a reimbursable PMH. A PMH is considered one of three elements of the "Past, Family, and Social History" (abbreviated as PFSH):[6]
- Past medical history: "the patient's past experiences with illnesses, operations, injuries and treatments";
- Family history: "a review of medical events in the patient's family, including diseases which may be hereditary or place the patient at risk";
- Social history: "an age-appropriate review of past and current activities".
A pertinent PFSH consists of at least one of the three components; a full PFSH consists of two or three components for an established patient, or all three components for a new patient visit.[7]
See also
References
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- ↑ Swartz, Mark (2002). Textbook of Physical Diagnosis: History and Examination. Philadephia: Saunders. pp. 19–23. ISBN 1-4160-2405-0.
- ↑ http://www.sciencedaily.com/releases/2004/09/040907083159.htm Science News: Enlarged Tonsils, Adenoids And Allergies May Affect A Child's Bite, Facial Appearance And/Or Behavior
- ↑ Useful Acronyms for Facilitators and Students
- ↑ HPI (history of present illness)
- ↑ http://www.cms.hhs.gov/
- ↑ Evaluation and Management Coding and Electronic Health Records
- ↑ Evaluation and Management Coding and Electronic Health Records
