Past medical history
Encyclopedia
In a medical
encounter, a past medical history (abbreviated PMH), is the total sum of a patient
's health
status prior to the presenting problem.
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):
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.
Medicine
Medicine is the science and art of healing. It encompasses a variety of health care practices evolved to maintain and restore health by the prevention and treatment of illness....
encounter, a past medical history (abbreviated PMH), is the total sum of a patient
Patient
A patient is any recipient of healthcare services. The patient is most often ill or injured and in need of treatment by a physician, advanced practice registered nurse, veterinarian, or other health care provider....
's health
Health
Health is the level of functional or metabolic efficiency of a living being. In humans, it is the general condition of a person's mind, body and spirit, usually meaning to be free from illness, injury or pain...
status prior to the presenting problem.
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. cancerCancerCancer , known medically as a malignant neoplasm, is a large group of different diseases, all involving unregulated cell growth. In cancer, cells divide and grow uncontrollably, forming malignant tumors, and invade nearby parts of the body. The cancer may also spread to more distant parts of the...
, heart diseaseHeart diseaseHeart disease, cardiac disease or cardiopathy is an umbrella term for a variety of diseases affecting the heart. , it is the leading cause of death in the United States, England, Canada and Wales, accounting for 25.4% of the total deaths in the United States.-Types:-Coronary heart disease:Coronary...
, hypertensionHypertensionHypertension or high blood pressure is a cardiac chronic medical condition in which the systemic arterial blood pressure is elevated. What that means is that the heart is having to work harder than it should to pump the blood around the body. Blood pressure involves two measurements, systolic and...
, diabetes. - HospitalHospitalA hospital is a health care institution providing patient treatment by specialized staff and equipment. Hospitals often, but not always, provide for inpatient care or longer-term patient stays....
izations: 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. anaphylaxisAnaphylaxisAnaphylaxis is defined as "a serious allergic reaction that is rapid in onset and may cause death". It typically results in a number of symptoms including throat swelling, an itchy rash, and low blood pressure...
, rashRashA rash is a change of the skin which affects its color, appearance or texture. A rash may be localized in one part of the body, or affect all the skin. Rashes may cause the skin to change color, itch, become warm, bumpy, chapped, dry, cracked or blistered, swell and may be painful. The causes, and...
, itching. - Immunizations: take a careful record of all immunizations, including tetanusTetanusTetanus is a medical condition characterized by a prolonged contraction of skeletal muscle fibers. The primary symptoms are caused by tetanospasmin, a neurotoxin produced by the Gram-positive, rod-shaped, obligate anaerobic bacterium Clostridium tetani...
, diphtheriaDiphtheriaDiphtheria is an upper respiratory tract illness caused by Corynebacterium diphtheriae, a facultative anaerobic, Gram-positive bacterium. It is characterized by sore throat, low fever, and an adherent membrane on the tonsils, pharynx, and/or nasal cavity...
, pertussisPertussisPertussis, also known as whooping cough , is a highly contagious bacterial disease caused by Bordetella pertussis. Symptoms are initially mild, and then develop into severe coughing fits, which produce the namesake high-pitched "whoop" sound in infected babies and children when they inhale air...
, polio, Hepatitis B, measlesMeaslesMeasles, also known as rubeola or morbilli, is an infection of the respiratory system caused by a virus, specifically a paramyxovirus of the genus Morbillivirus. Morbilliviruses, like other paramyxoviruses, are enveloped, single-stranded, negative-sense RNA viruses...
, mumpsMumpsMumps is a viral disease of the human species, caused by the mumps virus. Before the development of vaccination and the introduction of a vaccine, it was a common childhood disease worldwide...
, rubellaRubellaRubella, commonly known as German measles, is a disease caused by the rubella virus. The name "rubella" is derived from the Latin, meaning little red. Rubella is also known as German measles because the disease was first described by German physicians in the mid-eighteenth century. This disease is...
, Haemophilus influenzaeHaemophilus influenzaeHaemophilus influenzae, formerly called Pfeiffer's bacillus or Bacillus influenzae, Gram-negative, rod-shaped bacterium first described in 1892 by Richard Pfeiffer during an influenza pandemic. A member of the Pasteurellaceae family, it is generally aerobic, but can grow as a facultative anaerobe. H...
type B, influenzaInfluenzaInfluenza, commonly referred to as the flu, is an infectious disease caused by RNA viruses of the family Orthomyxoviridae , that affects birds and mammals...
. - Substance abuseSubstance abuseA substance-related disorder is an umbrella term used to describe several different conditions associated with several different substances .A substance related disorder is a condition in which an individual uses or abuses a...
: note any alcoholAlcoholIn chemistry, an alcohol is an organic compound in which the hydroxy functional group is bound to a carbon atom. In particular, this carbon center should be saturated, having single bonds to three other atoms....
, tobaccoTobaccoTobacco is an agricultural product processed from the leaves of plants in the genus Nicotiana. It can be consumed, used as a pesticide and, in the form of nicotine tartrate, used in some medicines...
, and illicit drug use, include type, amount, and duration, as well as any past treatment or drug rehabilitationDrug rehabilitationDrug rehabilitation is a term for the processes of medical or psychotherapeutic treatment, for dependency on psychoactive substances such as alcohol, prescription drugs, and so-called street drugs such as cocaine, heroin or amphetamines...
. - DietDiet (nutrition)In nutrition, diet is the sum of food consumed by a person or other organism. Dietary habits are the habitual decisions an individual or culture makes when choosing what foods to eat. With the word diet, it is often implied the use of specific intake of nutrition for health or weight-management...
: 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. - SleepSleepSleep is a naturally recurring state characterized by reduced or absent consciousness, relatively suspended sensory activity, and inactivity of nearly all voluntary muscles. It is distinguished from quiet wakefulness by a decreased ability to react to stimuli, and is more easily reversible than...
: 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. - Alternative therapies: e.g. acupunctureAcupunctureAcupuncture is a type of alternative medicine that treats patients by insertion and manipulation of solid, generally thin needles in the body....
, massageMassageMassage is the manipulation of superficial and deeper layers of muscle and connective tissue to enhance function, aid in the healing process, and promote relaxation and well-being. The word comes from the French massage "friction of kneading", or from Arabic massa meaning "to touch, feel or handle"...
, herbal medicine, vitamins, chiropractice. - Obstetric/Gynecologic history (if female): include total number of pregnancies, whether they are full termFull TermFull Term in the universities of Oxford and Cambridge refers to the eight weeks within the longer academic term during which lectures are given and students are required to be in residence...
, preterm, miscarriages, abortions, living, as well as any complications. Include menopauseMenopauseMenopause is a term used to describe the permanent cessation of the primary functions of the human ovaries: the ripening and release of ova and the release of hormones that cause both the creation of the uterine lining and the subsequent shedding of the uterine lining...
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.
- "PAM HUGS FOSS", 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/STDSexually transmitted diseaseSexually transmitted disease , also known as a sexually transmitted infection or venereal disease , is an illness that has a significant probability of transmission between humans by means of human sexual behavior, including vaginal intercourse, oral sex, and anal sex...
, etc.) - Social life (job/house/smoking/alcohol, etc.)
Medicare definitions
The Centers for Medicare and Medicaid ServicesCenters for Medicare and Medicaid Services
The Centers for Medicare & Medicaid Services , previously known as the Health Care Financing Administration , is a federal agency within the United States Department of Health and Human Services that administers the Medicare program and works in partnership with state governments to administer...
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):
- Past medical history: "the patient's past experiences with illnesses, operations, injuries and treatments";
- Family historyFamily history (medicine)In medicine, a family history consists of information about disorders from which the direct blood relatives of the patient have suffered. Genealogy typically includes very little of the medical history of the family, but the medical history could be considered a specific subset of the total history...
: "a review of medical events in the patient's family, including diseases which may be hereditary or place the patient at risk"; - Social historySocial history (medicine)In medicine, a social history is a portion of the Admission note addressing familial, occupational, and recreational aspects of the patient's personal life that have the potential to be clinically significant.-Components:...
: "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.