Past Medical History
This section is the same as would be included in any standard surgical or medical history. Details to include are; diagnosis / symptoms, date, effect of patient, hospital / doctor and the outcome. Remember to include surgery and any non medical treatments / interventions and there outcomes.
Note should be given to to the psychological effect of medical illnesses and also to those medical conditions which can cause psychiatric symptoms e.g. thyroid disease, SLE, parkinsons.
Allow the patient plenty of time to remember what they list to make sure nothing is missed (I am often surprised at how the past medical history the patients give compares to that found in their notes!)
'Just take a moment to recall any problems you've had in the past with your health?'
'Have seen a doctor about any problems or had a prescription medicine?
'Are you currently seeing a doctor or receiving any treatment?'
'Have you ever been admitted to hospital or had any operations?'
| Example. Jonnie |
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Cleft lip
Surgical repair carried out at 1 year (1981)
Ongoing medical and dental follow-up. Jonnie has some psychological worries about the scar – although is small and not obvious.
Asthma (diagnosed Jul 1988)
Managed by GP. Manages his condition well. As a youth he was embarrass to use his inhalers in front of peers led to several admission with acute attacks. His asthma does limit his physical activity particularly in the winter.
Fractured Tibia (May 1990)
Done whilst “moving furniture at home”. At the time the social services child protection became involved in the case due to mismatching stories from Jonnie and his mother.
Septic Arthritis / Osteomyelitis (Oct 2000)
Of the left hand joints due to cat bite. Late presentation so was admitted to hospital for 3 days and given IV antibiotics. Residual joint damage narrowing and bony changes. |
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