Past Medical History- what are you looking for?

While taking the medical history doesn't often fall to the therapist, it should be part of any evaluation and chart review. But sorting through a thick chart can get complex. Here are some important conditions to look for in your PMH. (not necessarily in order of importance)
  1. Cardiac conditions- this includes prior MI, HTN, A-Fib, CHF, TIA, CVA. Important for pacing of activities and planning exercise programs. From my experience, many people who have had a prior cardiac event continue to remain at-risk instead of taking the steps toward lifestyle change necessary to decrease their risk factors.
  2. COPD and other respiratory conditions- Is your pt. on oxygen at home, or should you be working on weaning to room air? Is this person prone to quick desaturation? Will you need a pulse-oximeter or portable O2 tank for this person? You may need to do endurance building activities, and be especially wary of hot showers!
  3. Cancer- many sources advocate against aggressive strengthening programs for individuals with active cancer, and especially metastases. Also, a woman with a mastectomy should never be lifted by that arm or have a blood pressure taken in that arm.
  4. Orthopedic surgery- obviously, a recent joint replacement will have a weight bearing status and appropriate precautions to note. But hip precautions are in effect for 3 months, and some of the hospital clientele will certainly be readmitted during that time period. If a person didn't receive adequate therapy following a joint replacement, they may still lack ROM in that joint.
  5. Falls- many hospital patients are labeled as at-risk for falls. But it's important to know how often and where your patient has been falling. Does this person need extra practice on tub transfers? A home evaluation and education on modifications? An assistive device? Increased supervision and physical assistance?
  6. DVT/PE- If your patient has a history of clots, you should be extra vigilant of preventative measures implemented by the MD and nursing staff. This includes the sequential compression devices for legs and the TED hose. Our facility has guidelines for usage of these and documentation to accompany it. You should also be aware if your patient develops a pain (particularly in the leg), and talk to the nursing staff about the possibility of this being a DVT. Pt. may need to rest that day, get a doppler study just to clear everything up. Better to be safe than sorry.
  7. Diabetes and other diet restrictions- important to note especially for cooking activities or just to have a quick answer for "Can I have a Coke?"
  8. Current UTI- this may not mean much in the history column, as most every person in the world has had at least one in the lifetime. However, a current UTI can cause a decrease in your pt's cognition, endurance, and balance. If there is a history of frequent UTI, that can be connected to incontinence, which is a good thing to take note of prior to getting someone totally dressed for ADLs.
So this is the short list that I came up with... there's lots of other relevant information to make a full chart review, but here's a good start on a medical history relevant to your acute care therapy clients. Perhaps another entry can focus on the pediatric medical review.


Natan said...

A couple things:

With regard to orthopedic surgery, if they did have a hip replacement within the last three months, it is also important to know what method was done (i.e. posterior vs. anterior approach), as they have different sets of precautions.

Also, along the same note of not taking a blood pressure on the same side of where a mastectomy was done, if they have an AV Fistula (used for dialysis) in an arm, that arm can also not be used for taking a blood pressure.

Finally, if a patient has an IVC/Greenfield filter placed, you don't have to worry so much for a DVT, as that will 'filter out' any clot from becoming a PE.

Cheryl said...

Thanks for expanding! :)
I only recently saw my first pt with a filter, but only after his had become so completely clogged that it caused massive edema in both legs! He was an extreme case though.