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.
Different sources include different questions to be asked while conducting a PMH, but in general, they include the following:
Several acronyms have been developed to categorize the appropriate questions to include:
In prehospital medicine, namely EMS, the acronyms SAMPLE or CHAMPS are used.
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]
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. [6]
Type of history | CC | HPI | ROS | Past, family, and/or social |
---|---|---|---|---|
Problem focused | Required | Brief | N/A | N/A |
Expanded problem focused | Required | Brief | Problem pertinent | N/A |
Detailed | Required | Extended | Extended | Pertinent |
Comprehensive | Required | Extended | Complete | Complete |
Medicine is the science and practice of caring for a patient, managing the diagnosis, prognosis, prevention, treatment, palliation of their injury or disease, and promoting their health. Medicine encompasses a variety of health care practices evolved to maintain and restore health by the prevention and treatment of illness. Contemporary medicine applies biomedical sciences, biomedical research, genetics, and medical technology to diagnose, treat, and prevent injury and disease, typically through pharmaceuticals or surgery, but also through therapies as diverse as psychotherapy, external splints and traction, medical devices, biologics, and ionizing radiation, amongst others.
Delirium is a specific state of acute confusion attributable to the direct physiological consequence of a medical condition, effects of a psychoactive substance, or multiple causes, which usually develops over the course of hours to days. As a syndrome, delirium presents with disturbances in attention, awareness, and higher-order cognition. People with delirium may experience other neuropsychiatric disturbances, including changes in psychomotor activity, disrupted sleep-wake cycle, emotional disturbances, and perceptual disturbances, although these features are not required for diagnosis.
Sulfonamide is a functional group that is the basis of several groups of drugs, which are called sulphonamides, sulfa drugs or sulpha drugs. The original antibacterial sulfonamides are synthetic (nonantibiotic) antimicrobial agents that contain the sulfonamide group. Some sulfonamides are also devoid of antibacterial activity, e.g., the anticonvulsant sultiame. The sulfonylureas and thiazide diuretics are newer drug groups based upon the antibacterial sulfonamides.
Benadryl is a brand of various antihistamine medications used to stop allergies, whose content varies in different countries, but which includes some combination of diphenhydramine, acrivastine, and/or cetirizine.
Ileus is a disruption of the normal propulsive ability of the intestine. It can be caused by lack of peristalsis or by mechanical obstruction. The word 'ileus' is from Ancient Greek eileós. The term 'subileus' refers to a partial obstruction.
The terms medical record, health record and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdiction. A medical record includes a variety of types of "notes" entered over time by healthcare professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, X-rays, reports, etc. The maintenance of complete and accurate medical records is a requirement of health care providers and is generally enforced as a licensing or certification prerequisite.
Diphenoxylate/atropine, also known as co-phenotrope, is a combination of the medications diphenoxylate and atropine, used to treat diarrhea. It should not be used in those in whom Clostridioides difficile infection is a concern. It is taken by mouth. Onset is typically within an hour.
The medical history, case history, or anamnesis of a patient is a set of information the physicians collect over medical interviews. It involves the patient, and eventually people close to him, so to collect reliable/objective information for managing the medical diagnosis and proposing efficient medical treatments. The medically relevant complaints reported by the patient or others familiar with the patient are referred to as symptoms, in contrast with clinical signs, which are ascertained by direct examination on the part of medical personnel. Most health encounters will result in some form of history being taken. Medical histories vary in their depth and focus. For example, an ambulance paramedic would typically limit their history to important details, such as name, history of presenting complaint, allergies, etc. In contrast, a psychiatric history is frequently lengthy and in depth, as many details about the patient's life are relevant to formulating a management plan for a psychiatric illness.
The SOAP note is a method of documentation employed by healthcare providers to write out notes in a patient's chart, along with other common formats, such as the admission note. Documenting patient encounters in the medical record is an integral part of practice workflow starting with appointment scheduling, patient check-in and exam, documentation of notes, check-out, rescheduling, and medical billing. Additionally, it serves as a general cognitive framework for physicians to follow as they assess their patients.
Somnology is the scientific study of sleep. It includes clinical study and treatment of sleep disorders and irregularities. Sleep medicine is a subset of somnology.
A drug allergy is an allergy to a drug, most commonly a medication, and is a form of adverse drug reaction. Medical attention should be sought immediately if an allergic reaction is suspected.
ASHICE is one of several mnemonic acronyms used by emergency medical services in the United Kingdom and the Republic of Ireland to pass summarised advance details of a patient to the next group of persons or organisation dealing with them, otherwise known as a "Pre-Alert" other pre-alert acronyms include 'ATMIST' and 'CASMEET'. In the English and Welsh NHSs the procedure is not used for non-critical patients on their eventual journey to hospital but is used as standard procedure for handovers of patients before transport to hospital where a site or event is staffed by trained personnel of both paid or voluntary ambulance services. This procedure is in addition to written records of the patient's personal and medical details and any treatment or medication applied prior to transport to the hospital.
An admission note is part of a medical record that documents the patient's status, reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care.
Over-the-counter counseling refers to the counseling that a pharmacist may provide on the subject of initiating, modifying, or stopping an over-the-counter (OTC) drug product. OTC counseling requires an assessment of the patient's self-care concerns and drug-related needs. The types of drugs that are involved in OTC counseling are, for example, used to treat self-diagnosable conditions like heartburn, cough, and rashes, though prescription drugs and professional diagnoses are also relevant to the recommendation process.
Nausea is a diffuse sensation of unease and discomfort, sometimes perceived as an urge to vomit. While not painful, it can be a debilitating symptom if prolonged and has been described as placing discomfort on the chest, abdomen, or back of the throat.
Generally, seizures are observed in patients who do not have epilepsy. There are many causes of seizures. Organ failure, medication and medication withdrawal, cancer, imbalance of electrolytes, hypertensive encephalopathy, may be some of its potential causes. The factors that lead to a seizure are often complex and it may not be possible to determine what causes a particular seizure, what causes it to happen at a particular time, or how often seizures occur.
Sleep state misperception (SSM) is a term in the International Classification of Sleep Disorders (ICSD) most commonly used for people who mistakenly perceive their sleep as wakefulness, though it has been proposed that it be applied to those who severely overestimate their sleep time as well. While most sleepers with this condition will report not having slept in the previous night at all or having slept very little, clinical recordings generally show normal sleep patterns. Though the sleep patterns found in those with SSM have long been considered indistinguishable from those without, some preliminary research suggest there may be subtle differences.
There are approximately 88,000 pharmacies in the United States. Over half are located within drug stores, grocery stores, hospitals, department stores, medical clinics, surgery clinics, universities, nursing homes, prisons, and other facilities. The remaining pharmacies are considered to be independent or privately owned. The top 25 pharmacy chain stores represent about 38,000 pharmacy locations in the U.S. and employ about 149,000 on-staff pharmacists. California has 8,015 pharmacies, the most of any state. Texas, Florida, New York, and Pennsylvania round out the top five states for pharmacy locations. Nationwide, the number of community pharmacies increased by 6.3% between 2007-2015, and the number of pharmacies per 10,000 people (2.11) did not change. However, the number of pharmacies per-capita varies substantially across counties, ranging from 0 to 13.6 per- 10,000 people in 2015.
Travel health nursing is a nursing specialty which promotes the health and safety of national and international travelers. Similar to travel medicine, it is an interdisciplinary practice which draws from the knowledge bases of vaccines, epidemiology, tropical medicine, public health, and health education. Travel nursing has experienced an increase in global demand due to the evolution of travel medicine. Travel health nursing was recognized during the 1980s as an emerging occupation to meet the needs of the traveling public, and additional education and training was established. Travel health nurses typically work in "private practice, hospital outpatient units, universities, the government, and the military", and have more opportunities and leadership roles as travel has become more common. However, they also experience organizational and support-related conflicts with general practitioners and patients in healthcare settings.