Database

• Present Condition (PC)

  • The present condition of the patient
• History of Present Condition (HPC)

  • How did the episode start?
  • What has brought the patient into hospital?
  • Has the GP been involved?
  • Interventions prior to admission?
  • Description of operation if appropriate
• Past Medical History (PMH)

  • The entire list of relevant medical and surgical problems that the patient has had in the past
  • May include:
  • Acute illnesses
  • Chronic conditions
  • Previous operations
• Social History (SH)

  • Level of support available at home
  • Home layout
  • Occupation & hobbies
  • Smoking history
  • Alcohol
  • Previous level of mobility / ability to perform ADLs
• Smoking – Pack Years

  • Number of cigarettes per day, divided by 20, multiplied by number of years smoked
• Family History (FH)

  • Any relevant major illnesses of close family members?
• Drug History (DH)

  • A summary of the medication that the patient was on before coming into hospital
  • Any drug allergies
• Results of Investigations or Tests

  • Arterial blood gases
  • Spirometry
  • Full lung function tests
  • Blood tests
  • Sputum analysis
  • CT scan