6.4 Past Medical History, Medications, and Baseline Function
Key Takeaways
- Past medical history helps explain risk, but it should not distract from current life threats.
- Medication containers, medical alert tags, caregivers, and facility records can fill gaps when the patient cannot answer.
- Blood thinners, inhalers, seizure medications, diabetes supplies, and cardiac medications are common high-value clues.
- Baseline function helps distinguish new emergencies from chronic findings.
History Clues: What Changed From Baseline
Past medical history can make a scenario clearer, but it should not become a distraction. The EMR needs enough history to understand risk, identify time-sensitive clues, and communicate to the next provider. The question is not how much information you can collect; it is what information changes care.
Baseline function is especially important for older adults, children with disabilities, and patients from care facilities. A patient who is normally confused may not have a new altered mental status. A patient who normally walks independently but now cannot stand has a meaningful change. A nonverbal patient may show distress through behavior, breathing, color, or caregiver report.
High-Value History Clues
| Clue | Why it matters | Example handoff phrase |
|---|---|---|
| Blood thinner use | Higher concern after falls, head injury, or bleeding | Takes warfarin per family, fell today |
| Inhaler or oxygen use | Respiratory history and treatment context | Uses rescue inhaler, no relief today |
| Diabetes supplies | Altered mental status or weakness clue | Family reports insulin use and missed meal |
| Seizure medication | Seizure history and missed dose clue | Known seizures, missed medication yesterday |
| Medical alert tag | Rapid identification when patient cannot answer | Bracelet lists severe allergy to bee stings |
| Baseline mobility | Helps define what is new | Usually ambulates, now unable to stand |
Medication review does not mean diagnosing or changing prescriptions. Read labels if available, gather containers, ask what was taken today, and report missed or extra doses. If a patient has multiple pill bottles, take or document them according to local procedure so the next crew can review them.
Allergies should be specific when possible. Ask what the allergy is and what reaction occurs. A rash, swelling, breathing problem, or prior use of epinephrine are different levels of concern. If the patient is in active respiratory distress or shock after an exposure, treat the life threat first and collect detail as time permits.
Past history should be tied to the complaint. For chest discomfort, ask about heart problems, prior similar episodes, medications, and onset. For shortness of breath, ask about asthma, chronic lung disease, inhalers, oxygen, allergies, fever, or choking. For trauma, ask about blood thinners, loss of consciousness, pain, and events.
Caregivers can be essential. Parents know a child's usual behavior. Facility staff may know baseline mental status, mobility, recent illness, code status documents handled by policy, and medication changes. Witnesses can describe a collapse, seizure, fall, or exposure when the patient cannot.
Do not let history override current findings. A patient with anxiety history can still have a pulmonary embolism, heart attack, allergic reaction, or asthma attack. A patient with chronic confusion can still be more altered than usual. Treat what you find today.
The exam may present a medication or history clue as the key. Blood thinners after head trauma increase concern. Nitroglycerin or cardiac history with chest pressure increases concern. A prescribed inhaler with no relief suggests worsening respiratory distress. Use the clue to prioritize, not to exceed EMR scope.
Why is blood thinner use important after an older adult falls and strikes the head?
A caregiver says a nonverbal patient usually smiles and tracks people, but today is limp and staring. What does this history provide?
What should an EMR do with medication containers found near a patient with altered mental status?