What information should be included in a medical report for a patient with a pre-existing condition?

Writing a Medical Report for a Patient with Pre-Existing Conditions

For patients with pre-existing conditions, your medical report must comprehensively document the complete medical history, current medications with dosages, functional status, disease interactions, and how multiple conditions influence treatment priorities—focusing on interventions that most impact morbidity, mortality, and quality of life. 1

Essential Patient Demographics and Baseline Information

• Document age, gender, date of last comprehensive evaluation, and surrogate decision maker status 2
• Record all known diagnoses with onset dates and disease progression 1, 3
• Include vaccination history, particularly influenza and pneumococcal vaccines 3
• Document the lowest CD4 count and highest viral load if HIV-positive 4

Comprehensive Medical History Documentation

Current Condition Details

• Onset and chronology: When symptoms began, progression over time, patterns or changes in intensity 3
• Location and radiation: Where symptoms occur and if they spread 3
• Character: Patient's description (sharp, dull, burning) 3
• Severity: Impact on daily activities using standardized scales 3
• Duration: How long symptoms last when they occur 3
• Context: Activities or situations that trigger or worsen symptoms 3
• Modifying factors: What improves or worsens symptoms, including specific interventions tried 3
• Associated symptoms: Other manifestations occurring simultaneously 3

Pre-Existing Conditions Assessment

• Document all chronic conditions including cardiovascular disease, heart failure, renal insufficiency, diabetes mellitus, chronic pulmonary disease, peripheral vascular disease, cerebrovascular disease 4, 3
• Record prior HIV-associated complications, opportunistic infections, malignancies if applicable 4
• Include history of tuberculosis exposure with tuberculin skin test results 4
• Document gynecologic problems, sexually transmitted diseases, chickenpox or shingles history 4
• Note travel history to endemic areas (histoplasmosis in Ohio/Mississippi River valleys, coccidioidomycosis in southwestern deserts) 4

Disease Burden and Interaction

• Evaluate how multiple diseases interact with each other and their treatments 1
• Assess disease burden's effect on quality of life using domains-based assessment covering medical management, physical functioning, mental/emotional aspects, and social/environmental factors 1
• Document common comorbidities such as obesity, obstructive sleep apnea, non-alcoholic fatty liver disease 2

Complete Medication Documentation

• List all prescription drugs with exact names, dosages, start dates, and any recent changes 1, 3
• Document over-the-counter medications, dietary supplements, herbal remedies, and methadone 4, 3
• Record prior antiretroviral therapy history if applicable, including drug combinations, response (CD4 count and viral load), duration, reasons for changes, toxicities, adherence, and resistance test results 4
• Document all medication allergies and hypersensitivity reactions, particularly to sulfonamides, nonnucleoside reverse-transcriptase inhibitors, and abacavir 4, 3
• Conduct medication review to assess risk-benefit ratios and potential drug-drug interactions 1

Physical Examination Findings

• Vital signs including blood pressure in both arms 4
• General appearance noting cyanosis, pallor, dyspnea, nutritional status, obesity, skeletal deformities 4
• Cardiovascular examination: carotid pulse contour and bruits, jugular venous pressure, precordial findings 4
• Lung auscultation for rales or evidence of pulmonary congestion 4
• Presence of implanted pacemaker or ICD confirmed by examination 4
• Abdominal palpation and extremity examination for edema and vascular integrity 4

Functional Capacity Assessment

• Document the patient's ability to perform common daily tasks, which correlates with maximum oxygen uptake 4
• Record specific activities the patient can perform (e.g., runs 30 minutes daily vs. sedentary) 4
• Assess physical activity patterns and sleep behaviors, including screening for obstructive sleep apnea 2
• For elderly patients, specifically document functional status, cognitive function, and fall risk 3, 2

Social and Environmental Factors

• Tobacco, alcohol, and recreational drug use (marijuana, cocaine, ecstasy, ketamine, methamphetamine) 4, 3
• For injection drug users: drug-use practices, needle source, needle-sharing behavior 4
• Sexual history obtained in open, nonjudgmental manner: past and current practices, condom and contraceptive use, partner HIV serostatus disclosure 4
• Work-related exposures that may contribute to symptoms 3
• Living conditions impacting health 3
• Social determinants of health: food security, housing stability, transportation access, financial security, community safety 2
• Existing social supports and resources available 2
• Advanced care plan status 2

Laboratory and Diagnostic Results

• Highlight all abnormal findings with clinical significance 1
• Most recent LDL and HDL measurements 2
• Disease-specific monitoring results (CD4 count, viral load for HIV patients) 4
• Results of screening tests for sexually transmitted diseases if indicated 2

Treatment Prioritization and Management Plan

• Prioritize interventions based on potential impact on morbidity, mortality, and quality of life 1
• Clearly document how multiple medical problems and treatments are reconciled 1
• Explain the rationale for treatment choices given disease interactions 1
• Document patient engagement in shared decision-making 1

Pertinent Negatives

• Document important symptoms that are absent, as this is critical for complete assessment 3, 2
• Record negative findings relevant to differential diagnosis 3

Common Pitfalls to Avoid

• Failing to document pertinent negatives leads to incomplete assessment 2
• Not addressing social determinants of health misses critical factors affecting outcomes 2
• Incomplete medication reconciliation risks dangerous drug interactions 1
• Omitting functional status assessment in elderly patients overlooks fall risk and independence 3, 2

Documentation Best Practices

• Use clear, standardized terminology that other providers can understand 4, 3
• Ensure proper patient consent if report will be published 1
• Protect patient confidentiality and remove identifiable information 1
• For case reports, use established reporting guidelines such as CARE 1