What questions should be asked during the initial evaluation of a patient in internal medicine?

Essential Questions for Initial Internal Medicine Evaluation

The initial internal medicine evaluation should systematically cover demographics, comprehensive medical/psychiatric/substance use history, medications/allergies, family history, social determinants, functional status, and patient-centered goals—with specific attention to disease burden, quality of life impact, and what matters most to the patient.

Core Demographic and Background Information

Begin by establishing foundational data 1:

• Demographics: Age, sex, race/ethnicity, birthplace, primary language, education level, occupation, literacy status, living situation, marital status, and emergency contact
• Chief concern: Use an open-ended question such as "What can I do for you today?" rather than closed-ended confirmations 2. This approach significantly improves patient satisfaction and allows patients to present concerns in their own terms.

Comprehensive Medical History

Current and Past Medical Conditions

Document all known diagnoses with specific attention to 3, 1:

• Cardiovascular: Myocardial infarction, arrhythmia/atrial fibrillation, heart failure, angina, peripheral artery disease, hypertension, hyperlipidemia
• Cerebrovascular: Stroke (hemorrhagic/ischemic), TIA, carotid disease
• Pulmonary: Chronic lung disease, asthma, COPD, sleep disorders including sleep apnea
• Endocrine: Diabetes mellitus, thyroid disease
• Renal: Chronic kidney disease, dialysis history
• Hepatic: Chronic hepatitis, cirrhosis
• Neurological/Cognitive: Dementia, neurocognitive disorders, head injuries, seizures
• Psychiatric: Depression, anxiety, treated mental health conditions
• Rheumatologic: Lupus, rheumatoid arthritis, other collagen vascular diseases
• Malignancy: Cancer history (site, date of diagnosis, treatment)
• Infectious disease: HIV, hepatitis C, tuberculosis, sexually transmitted diseases

For each condition, document year of onset, severity, and current treatment status 4.

Symptom Assessment with Life Impact

Critical distinction: Don't just catalog symptoms—assess their impact on daily functioning 5:

Ask: "How do your symptoms interfere with your ability to do what you want to do in your daily life?" and "What areas of your life are affected most?"

For specific symptom domains 4, 6:

• Cardiopulmonary: Dyspnea at rest, dyspnea on exertion (specify activity level required), orthopnea (number of pillows), paroxysmal nocturnal dyspnea, chest pain, palpitations
• Functional capacity: Ability to perform activities of daily living, exercise tolerance, fatigue limiting usual activities
• Pain: Location, severity, impact on function
• Neurological: Cognitive changes, memory problems, concentration difficulties, gait problems, balance issues, incontinence
• Gastrointestinal: Swallowing difficulties, abdominal symptoms, bowel changes
• Constitutional: Weight changes (amount and timeframe), fever, night sweats

Medication History

Obtain a complete medication reconciliation 1, 7, 8:

• All prescription medications (name, dose, frequency, duration, adherence)
• Over-the-counter medications
• Herbal supplements and vitamins
• Alternative/complementary therapies
• Previous medications tried and reasons for discontinuation
• Allergies and adverse drug reactions (specify type of reaction, not just "allergy")
• Side effects experienced from current medications

Assess for drug-drug and drug-disease interactions, prescribing cascades, and medication burden 8.

Psychiatric and Substance Use History

This is frequently inadequate in routine evaluations 9. Systematically assess 10, 7:

Psychiatric history:

• Current and past psychiatric diagnoses
• Suicidal ideation (current and past, including aborted attempts, methods, intent, lethality)
• Self-harm behaviors without suicidal intent
• Aggressive or homicidal thoughts (past and current)
• History of violent behaviors
• Psychiatric hospitalizations and emergency visits
• Past psychiatric treatments and response
• Current symptoms: depression, anxiety, panic attacks, sleep abnormalities, impulsivity

Substance use (ask in non-judgmental manner):

• Tobacco: Type, amount, duration
• Alcohol: Quantity, frequency, pattern
• Illicit drugs: Marijuana, cocaine, methamphetamine, heroin, hallucinogens, MDMA
• Prescription drug misuse
• For injection drug users: needle source, sharing practices
• History of substance use disorders

Family History

Document in first-degree relatives 11, 7:

• Cardiovascular disease (specify age of MI: <55 years in males, <65 years in females)
• Stroke and vascular disease
• Dementia and neurological diseases
• Psychiatric disorders (especially suicide and violence for at-risk patients)
• Malignancies
• Diabetes, hypertension, hyperlipidemia
• Age at death and age at disease onset

Social History and Determinants of Health

Psychosocial Assessment

Essential for understanding disease burden and treatment feasibility 10, 1, 6:

• Living situation: Type of residence, who lives with patient, housing stability
• Social support: Family involvement, caregiver availability, isolation concerns
• Financial status: Employment, insurance, ability to afford medications
• Education and health literacy
• Transportation access
• Legal issues: Pending charges, probation, incarceration history

Trauma and Adverse Experiences

Early life adversity significantly impacts health outcomes 5. Ask about:

• Physical, emotional, or sexual abuse
• Witnessed domestic violence
• Caregiver with substance abuse or mental illness
• Family member incarceration
• Combat exposure (for veterans)

Consider using the Adverse Childhood Experience Questionnaire for systematic screening 5.

Functional and Sexual History

• Activities of daily living: Bathing, dressing, eating, toileting, transferring, continence 4
• Instrumental activities: Cooking, shopping, managing finances, medications, transportation
• Sexual history (ask openly and non-judgmentally) 7:
  • Current and past sexual practices
  • Number and gender of partners
  • Condom and contraceptive use
  • Sexual dysfunction or concerns
  • Reproductive history

Lifestyle Factors

• Diet and nutrition: Eating patterns, special diets, nutritional concerns
• Physical activity: Type, frequency, limitations
• Sleep: Quality, duration, sleep disorders
• Occupational exposures: Chemical, physical, or biological hazards
• Environmental exposures: Secondhand smoke, pesticides, mold

Patient-Centered Goals and Preferences

What Matters Most

This is the foundation of medical decision-making 8. Explore:

Ask: "What worries or concerns do you have about your symptoms?" 5

• Patient's personal values and priorities
• Quality of life considerations: What makes life meaningful?
• Functional goals: What activities does the patient want to maintain or regain?
• Treatment preferences: Attitudes toward medications, procedures, hospitalizations
• Health literacy and understanding of their conditions
• Disease-specific anxiety: Fears about progression, complications, prognosis

Advance Care Planning

For patients with serious illness or advanced age 8:

• Surrogate decision-maker: Who would make decisions if patient unable?
• Values regarding acceptable quality of life: What would be unacceptable?
• Preferences for life-sustaining treatments
• Goals of care: Cure-focused vs. comfort-focused
• Documentation status: Healthcare proxy, living will, POLST/MOLST

Physical Examination Priorities

At minimum, perform focused examination 12:

• Vital signs: Blood pressure (including orthostatic), heart rate, respiratory rate, temperature, oxygen saturation, height, weight, BMI
• Airway assessment
• Cardiovascular: Heart sounds, murmurs, peripheral pulses, edema
• Pulmonary: Auscultation, respiratory effort
• Neurological: Mental status, gait, focal deficits (when indicated)
• Functional assessment: Observe mobility, transfers, self-care abilities

For specific conditions, targeted examination based on history 3, 13.

Immunization Status

Document and update 4, 7:

• Influenza (date of most recent)
• Pneumococcal (date, type)
• Tetanus/diphtheria/pertussis
• Hepatitis A and B (especially for at-risk patients)
• Herpes zoster
• COVID-19

Healthcare Utilization

• Primary care relationship: Does patient have ongoing PCP?
• Specialist involvement: Current consultants and reasons
• Recent hospitalizations: Dates, reasons, outcomes
• Emergency department visits: Frequency, reasons
• Surgeries and procedures: Dates, complications, cognitive changes post-operatively

Common Pitfalls to Avoid

1. Inadequate social, psychiatric, and substance use histories are the most frequent deficiencies 9
2. Overly directed interview style that doesn't allow patient narrative 9
3. Failing to assess functional impact and quality of life—not just disease presence 5
4. Missing medication reconciliation including OTC and supplements 1, 8
5. Not exploring patient's concerns and fears about their conditions 5
6. Inadequate assessment of social determinants that affect treatment adherence 1
7. Skipping advance care planning discussions in appropriate patients 8

Documentation Strategy

Structure the interview in three phases 14:

1. Open-ended elicitation: Let patient tell their story
2. Guided elicitation: Direct questioning for specific domains
3. Hypothesis-driven elicitation: Targeted questions to refine differential diagnosis

This systematic approach ensures comprehensive evaluation while maintaining patient-centeredness and identifying factors that truly impact outcomes: morbidity, mortality, and quality of life.