From the Guidelines
To take a comprehensive history as a final year medical student, it is essential to follow a structured approach that covers all essential elements, including chief complaint, history of present illness, past medical history, surgical history, medications, allergies, family history, social history, and review of systems, as this will provide up to 80% of the information needed for accurate diagnosis. When taking a comprehensive history, start by introducing yourself and obtaining consent for the interview. The history should follow a logical sequence, beginning with the chief complaint and history of present illness, including onset, duration, character, aggravating/relieving factors, and associated symptoms 1.
Past Medical History
It is crucial to inquire about past medical history, including HIV diagnosis, duration of infection, HIV-related conditions, and prior use of antiretroviral therapy, as well as comorbidities such as coronary heart disease, dyslipidemia, diabetes mellitus, kidney disease, and osteoporosis 1. Additionally, ask about psychiatric history, including treatment for or symptoms of depression, anxiety, suicidal ideation, or posttraumatic stress disorder.
Social History
A thorough social history should include occupation, living situation, smoking, alcohol, and recreational drug use, as these factors can significantly impact the patient's health and well-being. It is also essential to ask about sexually transmitted diseases, including gonorrhea, chlamydia, pelvic inflammatory disease, and syphilis, as well as gynecologic and obstetric history in women 1.
Review of Systems
The review of systems should be comprehensive, including questions about symptoms such as irritation, tearing, burning, stinging, dry or foreign body sensation, and photophobia, as well as exacerbating conditions like wind, air travel, and decreased humidity 1. It is also important to ask about topical medications, contact lens history, allergic conjunctivitis, and ocular surgical history.
Key Elements
Some key elements to include in the comprehensive history are:
- Chief complaint and history of present illness
- Past medical history, including HIV diagnosis and antiretroviral therapy
- Surgical history
- Medications, including over-the-counter drugs and supplements
- Allergies
- Family history
- Social history, including occupation, living situation, smoking, and recreational drug use
- Review of systems, including questions about symptoms and exacerbating conditions. By following this structured approach and including all essential elements, you can gather the necessary information to provide accurate diagnosis and effective patient care.
From the Research
Comprehensive History Taking
To take a comprehensive history in a patient, a final year medical student should follow a structured but flexible process of gathering relevant information from patients to inform diagnosis and treatment 2. This process involves:
- Active listening
- Empathetic communication
- Cultural sensitivity
- Actively engaging the patient in a conversation about their health issues to facilitate their participation and autonomy
Key Components of History Taking
The key components of history taking include:
- Chief complaint: identifying the patient's main reason for seeking medical attention
- History of present illness: gathering information about the patient's current symptoms and medical history
- Past medical history: gathering information about the patient's previous medical conditions and treatments
- Family history: gathering information about the patient's family medical history
- Social history: gathering information about the patient's lifestyle and social factors that may impact their health
Importance of Reflection and Practice
Reflective practice is an essential component of history taking, as it allows medical students to learn from their experiences and improve their skills 3. By reflecting on their practice and receiving feedback from patients and colleagues, medical students can refine their history-taking skills and provide better care for their patients.
Considerations for Specific Patient Populations
When taking a comprehensive history, medical students should consider the specific needs and experiences of different patient populations. For example:
- Patients with long-COVID may require ongoing support and empathy from their healthcare providers 4
- Patients with neurological conditions may present with chest pain or other symptoms that require careful evaluation and diagnosis 5
- Patients with cardiovascular disease may experience chest pain and shortness of breath, which can be influenced by a range of factors, including sociodemographic characteristics, pain elsewhere, and anxiety and depression 6