Nursing and Health Examples

Health History On Patient

Q: What is the difference between Past Medical History (PMH) and History of Present Illness (HPI)?

The History of Present Illness (HPI) focuses on the *current* health problem – its onset, characteristics, and associated symptoms. The Past Medical History (PMH), on the other hand, details *previous* significant illnesses, chronic conditions, hospitalizations, and surgeries that are not directly related to the current complaint but may influence overall health or treatment.

This example demonstrates a thorough patient health history, crucial for accurate diagnosis and care planning in nursing and healthcare. It covers demographic data, chief complaint, history of present illness, past medical history, family history, social history, and a review of systems. The structure emphasizes clear, organized documentation, essential for effective communication among healthcare providers and for ensuring patient safety. This sample serves as a practical guide for students and professionals seeking to master patient assessment and record-keeping.

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Key considerations

A well-structured health history is essential for accurate patient assessment and care planning.

The systematic approach (Demographics, CC, HPI, PMH, FH, SH, ROS) ensures comprehensive data collection.

Objective, precise language and detailed, quantifiable evidence are hallmarks of high-quality documentation.

Understanding the patient's social history and lifestyle provides crucial context for their health status and potential risks.

Assignment brief

You are a registered nurse conducting a comprehensive health history on a new patient admitted to the cardiology unit. The patient, Mr. Arthur Jenkins, is a 68-year-old male presenting with chest pain. Your task is to document a detailed health history, including demographic information, chief complaint, history of present illness, past medical history, family history, social history, and a review of systems. Ensure your documentation is clear, concise, and organized, adhering to professional standards for patient records.

Reference example

Patient Health History: Arthur Jenkins

Date of History: October 26, 2023

Time of History: 14:30

Patient Name: Arthur Jenkins

Date of Birth: March 15, 1955

Age: 68

Sex: Male

Medical Record Number: 7890123

Admitting Diagnosis: Chest Pain, Rule Out Myocardial Infarction

Source of History: Patient (Arthur Jenkins), reliable.

Chief Complaint: "I've been having this crushing chest pain for a few hours."

History of Present Illness (HPI):

Mr. Jenkins is a 68-year-old male who presented to the Emergency Department today, October 26, 2023, at approximately 13:00, reporting acute onset of chest pain. The pain began about 3 hours prior to arrival, around 10:00 AM, while he was watching television at home. He describes the pain as a "crushing" sensation located substernally. The pain radiates to his left arm and jaw. It is rated as an 8/10 on a pain scale of 0-10, with 10 being the worst pain imaginable. The pain is constant and has not subsided since onset. He reports associated symptoms of shortness of breath, diaphoresis (sweating), and nausea. He denies any vomiting. He denies any cough, fever, or chills. He tried resting, which did not alleviate the pain. He denies taking any medications for the pain prior to arrival.

Past Medical History (PMH):

Hypertension (HTN): Diagnosed approximately 15 years ago. Currently managed with Lisinopril 20 mg daily. Reports adherence to medication. Last blood pressure reading at home yesterday was 145/90 mmHg.
Hyperlipidemia (HLD): Diagnosed approximately 10 years ago. Currently managed with Atorvastatin 40 mg daily. Reports adherence to medication.
Type 2 Diabetes Mellitus (DM2): Diagnosed 5 years ago. Managed with Metformin 1000 mg twice daily. Reports occasional adherence, stating he sometimes forgets to take his evening dose. Last HbA1c 3 months ago was 7.8%.
Osteoarthritis (OA): Affects knees and hips. Manages with over-the-counter ibuprofen as needed. Denies recent exacerbations.
Appendectomy: Performed at age 25, no complications reported.

Past Surgical History (PSH):

Appendectomy (1980)

Allergies:

Penicillin (rash reported as a child)
No known food or environmental allergies.

Medications:

Lisinopril 20 mg PO daily
Atorvastatin 40 mg PO daily
Metformin 1000 mg PO BID
Ibuprofen 200 mg PO PRN (for OA)

Family History (FH):

Father: Deceased at age 72 from a myocardial infarction. History of HTN and HLD.
Mother: Deceased at age 85 from stroke. History of HTN and DM2.
Siblings: One brother, age 70, alive and well. No significant medical history reported.
Children: Two adult children, both alive and well. No significant medical history reported.

Social History (SH):

Occupation: Retired accountant.
Marital Status: Married for 45 years.
Living Situation: Lives at home with his wife.
Tobacco Use: Smoked 1 pack per day for 30 years (quit 10 years ago). Total 30 pack-year history.
Alcohol Use: Drinks socially, approximately 2-3 beers per week. Denies current or past history of alcohol abuse.
Illicit Drug Use: Denies any history of illicit drug use.
Diet: Reports a diet high in carbohydrates and fats, with limited intake of fruits and vegetables. Admits to frequent consumption of fast food.
Exercise: Sedentary lifestyle. Reports minimal physical activity, primarily walking around the house.
Caffeine Intake: Drinks 2 cups of coffee per day.

Review of Systems (ROS):

General: Reports feeling generally well prior to today's event. Denies recent weight loss or gain, fever, chills, or fatigue.
Cardiovascular: Positive for chest pain, radiation to left arm and jaw, diaphoresis, and nausea as described in HPI. Denies palpitations, edema, or orthopnea.
Respiratory: Positive for shortness of breath. Denies cough, wheezing, or hemoptysis.
Gastrointestinal: Positive for nausea. Denies vomiting, diarrhea, constipation, abdominal pain, or dysphagia.
Neurological: Denies headache, dizziness, syncope, numbness, or tingling. Reports jaw pain radiating from chest.
Musculoskeletal: Reports occasional knee and hip pain due to OA. Denies recent joint swelling or stiffness.
Endocrine: Denies polyuria, polydipsia, or polyphagia. Reports occasional forgetfulness with medication.
Psychiatric: Denies anxiety, depression, or suicidal ideation.
Skin: Denies rashes, lesions, or itching. Reports diaphoresis.

Physical Examination (Briefly noted for context, full exam to follow):

Vitals: BP 150/95, HR 98, RR 20, Temp 98.6F, SpO2 96% on room air.
General Appearance: Appears uncomfortable, diaphoretic, clutching chest.
Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops appreciated at this time.
Respiratory: Lungs clear to auscultation bilaterally.

Assessment and Plan:

Mr. Jenkins presents with symptoms highly suggestive of acute myocardial infarction. Further diagnostic workup including ECG, cardiac enzymes, and chest X-ray is indicated. Management will focus on pain relief, cardiac stabilization, and treatment of underlying causes. Close monitoring is essential.

[Nurse's Signature]

[Nurse's Printed Name]

[Date and Time]

Understanding the Structure of a Health History

A comprehensive health history is the cornerstone of effective patient care. It provides a detailed narrative of a patient's health status, past experiences, and lifestyle, enabling healthcare professionals to make informed diagnoses and develop personalized treatment plans. The structure of a health history is designed to be systematic and thorough, ensuring no critical information is overlooked. It typically begins with basic demographic data, followed by the patient's immediate reason for seeking care (chief complaint and history of present illness), and then delves into their medical background, family influences, social context, and a systematic review of bodily systems. This organized approach facilitates clear communication among healthcare teams and serves as a vital legal and clinical record.

Analysis of the Sample Health History

1. Thesis/Claim: The Central Purpose

The implicit thesis of this health history is to provide a complete and accurate picture of Mr. Arthur Jenkins' health status at the time of his admission, with a particular focus on his presenting complaint of chest pain. Every section of the history serves to support this overarching goal by gathering relevant data. For instance, the detailed HPI aims to characterize the chest pain precisely, while the PMH, FH, and SH explore potential risk factors and contributing conditions (like hypertension, hyperlipidemia, diabetes, and family history of heart disease) that could be related to his current cardiac event. The ROS further screens for other potential symptoms that might be associated with or indicative of cardiac compromise or other systemic issues.

2. Evidence: Gathering Pertinent Information

The 'evidence' in a health history is the factual information gathered from the patient. This sample effectively collects specific, measurable, and relevant data points. For example: * Quantifiable Data: Pain rated 8/10, duration of 3 hours, 1 pack per day for 30 years (30 pack-year history), Lisinopril 20 mg, Atorvastatin 40 mg, Metformin 1000 mg BID, HbA1c 7.8%, BP 145/90 mmHg. * Qualitative Data: Description of pain as 'crushing,' radiation to 'left arm and jaw,' associated symptoms like 'diaphoresis' and 'nausea,' family history of 'myocardial infarction' and 'stroke.' * Adherence and Lifestyle: Reports of medication adherence (or occasional forgetfulness), social alcohol consumption, sedentary lifestyle, diet high in carbohydrates and fats. This detailed evidence allows for a comprehensive assessment of the patient's current condition and potential underlying causes.

3. Organization and Flow: A Logical Progression

The health history is organized in a standard, logical sequence that guides the reader from the immediate problem to broader health contexts. The flow is as follows: 1. Demographics: Basic patient identifiers. 2. Chief Complaint (CC): The patient's primary reason for seeking care in their own words. 3. History of Present Illness (HPI): A detailed, chronological account of the chief complaint, using the PQRST or OLDCARTS mnemonic (Onset, Location, Duration, Character, Aggravating/Alleviating factors, Radiation, Timing, Severity). 4. Past Medical History (PMH): Chronic illnesses, significant past acute illnesses, hospitalizations. 5. Past Surgical History (PSH): Previous surgical procedures. 6. Allergies: Medications, food, environmental. 7. Medications: Current prescription, over-the-counter, and herbal supplements. 8. Family History (FH): Health status of immediate family members, focusing on inheritable conditions or conditions with genetic predispositions. 9. Social History (SH): Lifestyle factors including occupation, living situation, marital status, substance use (tobacco, alcohol, drugs), diet, exercise, and caffeine intake. 10. Review of Systems (ROS): A systematic head-to-toe inquiry about symptoms in each major body system. 11. Brief Physical Exam Note: Contextualizes the history with immediate objective findings. 12. Assessment and Plan: A summary of the nurse's/clinician's initial impression and proposed course of action. This structure ensures that information is presented in a way that is easy to follow and understand for any healthcare professional reviewing the chart.

4. Tone and Language: Professional and Objective

The tone of this health history is professional, objective, and clinical. It uses precise medical terminology (e.g., 'substernally,' 'diaphoresis,' 'hyperlipidemia,' 'myocardial infarction,' 'auscultation') rather than colloquialisms. Direct quotes from the patient ('crushing' chest pain) are used sparingly and appropriately to capture the patient's subjective experience, but the overall narrative is framed objectively. The language is clear and concise, avoiding ambiguity. This professional tone is crucial for maintaining the integrity of the medical record and ensuring accurate communication among healthcare providers.

5. Revision Opportunities: Enhancing Completeness and Clarity

While this is a strong example, potential areas for revision or further enhancement could include: More Granular HPI Details: For a suspected MI, further detail on the exact* timing of onset (e.g., "started approximately 3 hours prior to ED arrival, around 10:00 AM") and any precipitating factors (e.g., exertion, stress) could be beneficial. The OLDCARTS mnemonic could be more explicitly applied. Medication Reconciliation: While listed, a more detailed reconciliation might include dosage, frequency, and route for all medications, including PRN ones, and confirmation of whether the patient is taking them as prescribed. For Metformin, noting the 'occasional adherence' is good, but understanding the impact* of this (e.g., recent blood glucose readings) would be valuable. * Dietary Specificity: Instead of 'high in carbohydrates and fats,' asking for typical daily meals (e.g., "Breakfast: Cereal and coffee. Lunch: Sandwich and chips. Dinner: Fried chicken and mashed potatoes.") provides a clearer picture. * Psychosocial Impact: While psychiatric history is denied, exploring the patient's current emotional state regarding his symptoms (e.g., anxiety about chest pain) could be relevant. * Clarification of Allergies: For Penicillin, specifying the type of reaction ('rash') is good. If there were other allergies, they would be listed here. Pain Management Prior to Arrival: While he denies taking medication for the pain*, confirming he took his regular morning medications (Lisinopril, Atorvastatin, Metformin) is important for continuity of care.

Checklist for Documenting a Health History

Demographics: Patient name, DOB, age, sex, MRN, date/time of history.
Chief Complaint: Patient's primary reason for visit (verbatim if possible).
History of Present Illness (HPI): Detailed description of CC using OLDCARTS/PQRST (Onset, Location, Duration, Character, Aggravating/Alleviating, Radiation, Timing, Severity), associated symptoms, relevant negatives.
Past Medical History (PMH): Chronic illnesses, significant past illnesses, hospitalizations.
Past Surgical History (PSH): All previous surgeries.
Allergies: Medications, food, environmental, and reaction type.
Medications: List all current medications (prescription, OTC, herbal) with dose, route, and frequency. Note adherence.
Family History (FH): Health status of immediate family, focus on inheritable/relevant conditions.
Social History (SH): Occupation, living situation, marital status, tobacco, alcohol, drug use, diet, exercise, caffeine.
Review of Systems (ROS): Systematic inquiry of symptoms by body system (general, CV, resp, GI, GU, MSK, Neuro, Skin, Psych, Endo, Heme/Lymph, Allergic/Immune).
Source of History: Indicate if patient, family member, or other source and reliability.
Assessment and Plan: Initial clinical impression and proposed actions.
Signature and Credentials: Your name, title, and date/time.

Example Block: Documenting Social History Details

Social History - Detailed Example

Instead of a brief mention, a more detailed social history might look like this: Social History: * Occupation: Retired accountant (retired 3 years ago). * Marital Status: Married for 45 years to Eleanor Jenkins. Reports a supportive relationship. * Living Situation: Lives in a single-family home with his wife in a suburban neighborhood. Home is a single story, no reported accessibility issues. * Tobacco Use: Former smoker. Smoked 1 pack of cigarettes per day for 30 years, quitting abruptly 10 years ago. Denies current use or recent relapse. Has not sought smoking cessation support. * Alcohol Use: Reports occasional social alcohol consumption, typically 2-3 beers on weekends when socializing. Denies daily use, binge drinking, or history of alcohol-related problems. Last drink was 2 weeks ago. * Illicit Drug Use: Denies any history of recreational or illicit drug use. * Diet: Describes diet as 'typical American.' Breakfast usually consists of cereal and coffee. Lunch is often a sandwich or leftovers. Dinner frequently includes meat, potatoes, and a vegetable, but admits to eating fast food 2-3 times per week (e.g., burgers, fried chicken). Reports low intake of fruits and whole grains. Drinks 2 cups of coffee daily. Does not follow any specific diet. * Exercise: Describes lifestyle as sedentary. Walks around the house daily but engages in no structured exercise. Wife encourages him to walk more, but he reports difficulty due to knee pain. * Caffeine Intake: 2 cups of coffee per day, usually in the morning.

FAQs

What is the difference between Past Medical History (PMH) and History of Present Illness (HPI)?

The History of Present Illness (HPI) focuses on the current health problem – its onset, characteristics, and associated symptoms. The Past Medical History (PMH), on the other hand, details previous significant illnesses, chronic conditions, hospitalizations, and surgeries that are not directly related to the current complaint but may influence overall health or treatment.

Why is the Review of Systems (ROS) important even if the HPI is detailed?

The Review of Systems (ROS) is crucial because it systematically screens for symptoms across all major body systems that the patient might not have mentioned or considered relevant to their chief complaint. This can uncover secondary issues, comorbidities, or even alternative diagnoses that might otherwise be missed, providing a more holistic view of the patient's health.

How can I ensure my health history documentation is professional and objective?

Maintain a professional tone by using accurate medical terminology and avoiding slang or subjective opinions. Present information objectively by sticking to facts reported by the patient or observed during examination. Use direct quotes sparingly to capture specific patient descriptions, but frame the narrative impersonally. Ensure clarity and conciseness in your writing.

What are the key components of a thorough Social History?

A thorough Social History includes details about occupation, living situation, marital status, tobacco use (type, amount, duration, quit date), alcohol consumption (type, frequency, amount), illicit drug use, diet, exercise habits, and caffeine intake. These factors significantly impact health and can contribute to or exacerbate medical conditions.