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One important word in the HPI (Part 4 of 4)
Making "Past Medical History of" history
Robert Oubre, MD
July 22, 2023 • Estimated Reading Time: 5 minutes
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“Why?”
It’s a powerful question.
In medicine, the answer is often because that’s how it’s always been done.
I hate that answer.
But what about why we use “past medical history of” in our HPI’s?
It doesn’t make sense to me. Are their problems in the past? Or are they still active?
I asked Dr. Adam Rodman, medical historian, host of the “Bedside Rounds podcast”, and professor at Harvard IM Residency:
“You know, that’s a great question. In early 20th century notes, you often just see the word "Past history". it's used as a synonym for the older term "anamnesis" -- which would NOT have been a summary of everything that has ever happened to the person, but rather be a history of relevant past findings. This lingo still shows up in many other countries.
Past medical history or PMH seems to be post world war II
People are unconsciously adapting quite old language and referring to "past medical history" or saying "history of" instead of pointing out comorbidities
He then included the following picture from a VA casebook from 1926:
He suspects we continued to use this language when we standardized the H&P and transitioned to the problem oriented medical record.
This old language made more sense when people had a “history of” appendicitis, “history of” rheumatic fever, “history of” measles, etc
Now, most people live WITH their chronic conditions. Therefore, we should update our language and use “with” instead.
Example: “68-year-old male with CAD (on asa/plavix), atrial fibrillation (eliquis), and HFrEF (LVEF 35%) presents with bright red blood per rectum x 3 days.”
Is this just semantics?
No.
It has coding implications as well.
In the coding world, “history of” means no longer active. (Coding guidelines don’t always make sense, but in this case I agree with them.)
So, when coders see “with” they understand it’s active.
It’s often unclear if a problem is still active when it’s only mentioned in the HPI (preceded by “past medical history of”) and not in the A&P. Therefore, you get a query to clarify. Using “with” may save you from such a query.
You should use “history of” only to indicate something is no longer active.
One complicated example is cancers. “History of breast cancer” indicates the patient is completely cancer free and is no longer undergoing any treatment or monitoring.
That is different from breast cancer that is in remission, but the patient is still on tamoxifen. The breast cancer is still being treated and therefore “is still active” for coding.
Oh…and “with” vs “past medical history of” is less words…which is always a win for conciseness😉.
FYI, if you missed parts 1 - 3 of my 4-week HPI breakdown, check them out here.
That’s all for now!
Please feel free to reach out and ask questions as they help inspire future issues!
Cheers,
Robert
P.S. This issue is a week late due to…life happening. Sick kids and all. Funny story though: I brought my 2.5 year old to an ENT. He started kicking and screaming when he saw the otoscope - being used to his father awkwardly jamming it down his ear (I’m…not a pediatrician…). But this ENT managed to look in his ear and suck out a bunch of goop all in about 10 seconds. My 2.5 year old sat up in joy, “it didn’t hurt!” and then turned to me and said, “Dad, you not a doctor. He a doctor.”
#humblepie
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