From the Guidelines
Taking a medical history involves systematically gathering information about a patient's health status, including symptoms, medical history, and social history, to guide accurate diagnoses and treatment plans. When taking a medical history, it is essential to consider various elements, such as symptoms and signs, duration of symptoms, exacerbating factors, and unilateral or bilateral presentation, as outlined in the conjunctivitis preferred practice pattern study 1.
Key Components of Medical History
- Symptoms and signs, including conjunctival injection, mattering and adherence of eyelids, itching, tearing, discharge, irritation, pain, photophobia, and blurred vision
- Duration of symptoms and time course
- Exacerbating factors
- Unilateral or bilateral presentation
- Character of discharge
- Recent exposure to an infected individual
- Trauma, including mechanical, chemical, and ultraviolet trauma
- Recent surgery
- Mucus fishing behavior and contact lens wear
- Symptoms and signs potentially related to systemic diseases, such as genitourinary discharge, dysuria, dysphagia, fever, upper respiratory infection, and skin and mucosal lesions
Ocular and Medical History
The ocular history should include details about previous episodes of conjunctivitis, concomitant ocular surface diseases, and previous ophthalmic surgery, as noted in the study 1. The medical history should consider compromised immune status, current or prior systemic diseases, and vaccination history.
Social History
The social history should encompass smoking habits, exposure to second-hand smoke, occupation, hobbies, exposure to air pollutants, travel, exercise habits, diet, sexual activity, and use of illicit drugs, as recommended in the conjunctivitis preferred practice pattern study 1.
Approach to History-Taking
Throughout the history-taking process, it is crucial to use open-ended questions, maintain eye contact, show empathy, and clarify information when needed, as this comprehensive approach ensures gathering all relevant information to make accurate diagnoses and develop appropriate treatment plans.
From the Research
Importance of Taking a Medical History
- A significant proportion of diagnoses are made based on history taking, often alongside physical assessments and laboratory investigations 2
- Taking a thorough patient history is fundamental for the accurate diagnosis and effective management of health conditions 2
Process of Taking a Medical History
- History taking is a structured but flexible process of gathering relevant information from patients to inform diagnosis and treatment 2
- Important communication skills for nurses when history taking include active listening, empathetic communication, and cultural sensitivity 2
- By actively engaging the patient in a conversation about their health issues, the nurse facilitates their participation and autonomy 2
Benefits of Taking a Comprehensive Health History
- Taking a comprehensive health history allows the nurse and patient to establish a therapeutic relationship 3
- A comprehensive health history can provide insight into an advanced nurse practitioner's history-taking skills, thereby enhancing clinical practice 3
- General health checks, which include taking a medical history, can lead to increased detection of chronic diseases, moderate improvements in controlling risk factors, and improvements in patient-reported outcomes 4
Tools and Techniques for Taking a Medical History
- Medical imaging techniques, such as X-ray, computed tomography (CT), and magnetic resonance imaging (MRI), can be used in conjunction with a medical history to diagnose and manage complex patient abnormalities 5
- Advanced medical imaging modalities, such as PET/CT hybrid and simultaneous PET/MRI, can provide high resolution, better reliability, and safety to diagnose, treat, and manage complex patient abnormalities 5