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Past medical history examples

Example 4:

Student's report

Lucy has a set of medical conditions that are summarised as HERNS (Hereditary Endotheliopathy, Retinopathy, Neuropathy and Stroke). 10 years ago, she experienced symptoms of proptosis, tachycardia, thirst and vomiting and was diagnosed with Grave's disease. She was treated with Neomercazole. The coexisting medical condition may be exerting an impact on Lucy's current anxious state. In addition, her apparent poor coping mechanisms, which she has described as part of her personality trait, might also be facilitating her anxious state.

In 1996, Lucy experienced a minor stroke, which caused temporary paralysis in her left arm. She was monitored in hospital for three weeks and recovered.

3 years ago, Lucy was diagnosed as lupus carrier. Since the diagnosis, Lucy has been taking Warfarin and she expects to maintain Warfarin therapy for life. Her condition has exacerbated a series of endotheliopathies, predisposing Lucy to retinal microvascular occlusion.

2 weeks prior to her current hospital admission, Lucy was also diagnosed with hypercholesterolemia, a suspected genetic disorder. She is currently taking Lipitol to manage this.

Writing tip 1:

Significant events in the Medical History are placed in chronological order, which helps with clarity of reporting.

Specific dates are used to help establish chronology clearly and succinctly.

Writing tip 2:

In this section, the simple past tense predominates but tenses shift when events bear significance to the patient's present context.

Refer to earlier points made, under notes to Example 5, on the use of English tense in case presentations.

For example:

  • "Since the diagnosis, Lucy has been taking (present perfect continuous) Warfarin and she expects (present) to maintain Warfarin therapy for life."
  • "Her condition has exacerbated (present perfect) a series of endotheliopathies. She is currently taking (present continuous) Lipitol to manage this."

Click on the highlighted text to see the comments.

Example 5:

Bloch and Singh, 2001:92

The patient, the eldest in a family of three daughters, still lives at home. Her mother, a 45-year-old primary-school teacher and her father, a 50-year-old electrician, are described as strict and intrusive, a pattern she ascribes to their strong Catholic beliefs. Their marriage is described as 'over years ago; they never talk or touch' and the atmosphere at home as tense. The patient is close to her younger sister in whom she confides. One sister has responded to a similarly distant relationship with both parents by getting married after a whirlwind romance, the other by moving to another city. Her mother was hospitalised with post-natal depression twenty years ago. There is no other family history of psychiatric illness.

Writing tip 3:

In Australian culture, when a person is married with children and living away from the parental home, we tend to think of the family unit as comprising the couple and their children. In other words, the couple, as parents, head the so-called nuclear family unit.

In some cultures, though, we place emphasis on one's own parents in family structures. Hence, even when a person is married with children and living away from the parental home, we may think of the family unit as incorporating the extended family and continue to emphasise an individual's parents as the head of the family unit, which is larger than the nuclear family unit.

Obviously, your perspective on family unit will influence the way you report on the patient's family relationships. As stated above, in Australian culture, while relationships with one's parents are integral to an individual, we tend to view the family unit as consisting of principally the couple and their children. Hence, the couple is at the head of the unit, while the couple's relatives, including their parents, comprise the extended family. Consequently, in your report, in such a situation, you would focus immediately on discussing the patient's relationships with their partner and children before moving on to discuss their relationships with their parents and siblings. If the family unit is different, and larger, then you will need to consider your approach to reporting on the patient's family relationships. Do not occupy unnecessary space by reporting on all the familial relationships if the family is a large one and do not defer discussion of the patient's relationship with their partner and children (it is probably one of the most influential).

Comment 1

Family size

Comment 2

Parents' ages and occupations

Comment 3

Parents' personality characteristics

Comment 4

Parents' marital relationship

Comment 5

Family atmosphere

Comment 6

Special relationship

Comment 7

Parents' relationship with children

Comment 8

Family history of psychiatric illness

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