Unit 3

Past medical and family

history
Past medical and family history
 An accurate family history is a well-
established method for recognising genetic
disorders and susceptibilities that may pose
risks for future health problems.

 Early identification of families with

increased risk for chronic disease such as
heart disease, diabetes, and certain cancers
can often improve, delay, or even prevent
adverse health outcomes to individual
members.
Past Medical History components

What are the components of the PMH?

While taking the Past Medical History of

the patient you should cover these 8 points.
 PMH
(Past Medical History)

1. Past illness: patients may forget some illnesses but

remember more recent ones. They can be vague about the
details, even adults.
2. Childhood illnesses: Patients remember childhood illnesses
if they were traumatic or if they took a long period off
school e.g. chickenpox, mumps, measles. Also ask about
unusual illnesses.
3. Immunisation: Important information, especially for
children + women of child-bearing age. Patients don’t
remember details.
4. Surgical Procedures: Some patients understand little about
surgical procedures and some may not even know the
reason for their hospitalisation or exploratory
investigations.
5. Accident and injuries: Be aware of repeated injuries in women
(might indicate domestic violence) and the elderly. Repeated
injuries might possibly indicate drug or alcohol abuse.

6. Pregnancy: Ask all women of child-bearing age about pregnancy

+ related problems. Difficult for some to discuss abortion or
miscarriage.

7. Allergies: Patients may not think to mention allergies to

medications + food, but will remember hay fever, etc. Presenting
complain may be a reaction to food or current medication.

8. Medications: Patients forget to mention over- the- counter

medications + vitamins. Reluctant to mention alternative medicines
+ medications prescribed by another doctor.
 Patient speak

Expressions used by patients to describe

how they are feeling:

off colour under the

off weather

out of run
poorly sorts down

low
What is the problem with a patient using
these expressions to describe their health?

 They are very vague and doesn’t tell

anything about the presenting complaint
or the PMH.
 However, these expressions are very
common
  The patient express how sick he is by
using those expressions.
 Example:
I’ve been feeling out of sorts for a
while now.

He’s not been that good these last

few weeks.
I’ve not been feeling too great
lately.
Signposting and summarising
Here are some expressions the doctor use
to do the following:
 Change direction = moving on
 Refer to an earlier point = going back to
 Ask for more detail = elaborate on
 Summarise = to sum up
 End = finally
Writing the patient note

1. Remain objective when writing the

patient note.
2. Maintain accurate and concise records
3. Write legibly (clearly)
4. Use standard abbreviations in English.
 Standard medical abbreviations
 HTN: hypertension * f: female
 m: male * FH: family history
 b: black * w: white
 yo: year(s) old * ETOH: alcohol (drinks- doesn’t)
 Neuro: neurologic * ICU: intensive care unite
 cig: cigarettes (smoker-non smoker) * c/o: complaining of
 CXR: chest X-ray * A&W: alive and well
 PMH: Past Medical History
 MRI: magnetic resonance imaging
 Abd: abdomen
 r: right
 GI: gastrointestinal
 h/o: history of
 L: left
Rewrite these medical notes in full
25 yo b m presents c/o Abd pains on l side. Patient
h/o GI problems.
PMH car accident – 2001 in ICU 2/12. FH father and
mother A&W. No cig, ETOH 25 unites/week.
Answer
- A 25 year old black male presents complaining of
abdominal pains on his left side. The patient has
history of gastrointestinal problems. Past medical
history: the patient had a car accident in 2001 and
was in the intensive care unite for two months.
Family history: the patient’s father and mother are
alive and well. The patient is a non-smoker and
drinks on average 25 units of alcohol a week.