From the Guidelines
History taking in patients with conjunctivitis should include a comprehensive assessment of symptoms, medical history, and social history to guide diagnosis and treatment, as outlined in the conjunctivitis preferred practice pattern 1. When taking a history from a patient with conjunctivitis, it is essential to ask about symptoms and signs, such as conjunctival injection, mattering and adherence of eyelids, itching, tearing, discharge, irritation, pain, photophobia, and blurred vision. The duration of symptoms and time course, as well as exacerbating factors, should also be explored.
- Key elements of the history include:
- Unilateral or bilateral presentation
- Character of discharge
- Recent exposure to an infected individual
- Trauma: mechanical, chemical, ultraviolet
- Recent surgery
- Mucus fishing behavior
- Contact lens wear: lens type, hygiene, and use regimen
- Symptoms and signs potentially related to systemic diseases The ocular history should include details about previous episodes of conjunctivitis, concomitant ocular surface diseases, and previous ophthalmic surgery.
- The medical history should consider:
- Compromised immune status
- Current or prior systemic diseases
- Vaccination history The social history should include smoking habits, exposure to second-hand smoke, occupation and hobbies, exposure to air pollutants, travel, exercise habits, diet, sexual activity, and use of illicit drugs, as recommended in the conjunctivitis preferred practice pattern 1. By taking a thorough and systematic history, healthcare providers can gather essential information to guide diagnosis, treatment, and management of conjunctivitis, ultimately improving patient outcomes and quality of life.
From the Research
Importance of History Taking
- History taking is a crucial step in the diagnosis and management of health conditions, with a significant proportion of diagnoses made based on patient history, often alongside physical assessments and laboratory investigations 2.
- Taking a thorough patient history is fundamental for accurate diagnosis and effective management of health conditions 2.
Process of History Taking
- History taking is a structured but flexible process of gathering relevant information from patients to inform diagnosis and treatment 2.
- The process involves preparing the environment, using effective communication skills, and following a logical order to gather information 3.
- The chief complaint is a patient's self-reported primary reason for presenting for medical care and is a vital part of the history-taking process 4, 5.
Communication Skills for History Taking
- 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.
Applications of History Taking
- History taking can be used for syndromic surveillance, with chief complaints providing valuable information for automatic extraction and encoding of data stored in free text patient records 6.
- The use of chief complaints can help quantify, analyze, and plan for emergency care, particularly in limited-resource settings 5.