What type of history should be taken from a patient (pt)?

Comprehensive Patient History Taking

A comprehensive patient history must include present illness details (onset, duration, severity, characteristics, modifying factors, and functional impact), complete past medical history (chronic conditions, prior diagnoses, medications, allergies), social history (substance use, sexual practices, occupational exposures), family history, and systematic review of symptoms. 1, 2, 3

History of Present Illness (HPI)

The HPI forms the foundation of clinical assessment and should document:

• Temporal characteristics: Establish exact onset date, frequency, duration, and progression of symptoms over time 2
• Symptom characterization: Use specific descriptors rather than vague terms to describe the nature and quality of symptoms 2
• Severity quantification: Document intensity using appropriate scales or descriptors to establish baseline for comparison 2
• Modifying factors: Identify triggers, exacerbating factors, and alleviating factors that influence symptoms 2
• Functional impact: Assess how symptoms affect activities of daily living, work capacity, interpersonal relationships, and quality of life 2
• Associated symptoms: Document presence or absence of related symptoms that establish patterns or syndromes 2
• Prior treatments: Record all interventions attempted (including self-treatments) and their effectiveness 2

Past Medical History

Document comprehensive information about:

• Chronic conditions: Duration of each condition, dates of diagnosis, and prior negative test results 1, 3, 4
• HIV-related history (if applicable): Date of diagnosis, approximate date of infection based on prior negative tests or acute retroviral syndrome, lowest CD4 count, highest viral load 1
• Prior antiretroviral therapy: Specific drug combinations, duration, response (CD4 count and viral load), reasons for changes, toxicities, adherence patterns, and drug resistance test results 1
• Opportunistic infections and malignancies: Thrush, oral hairy leukoplakia, herpes zoster, cervical/anal dysplasia or cancer, Pneumocystis pneumonia, Kaposi sarcoma, lymphoma 1
• Sexually transmitted diseases: Gonorrhea, chlamydia, pelvic inflammatory disease, chancroid, syphilis, herpes simplex, viral hepatitis, HPV 1
• Comorbidities: Coronary heart disease, dyslipidemia, diabetes mellitus, kidney disease, osteoporosis, and associated risk factors 1, 4
• Psychiatric history: Depression, anxiety, suicidal ideation, posttraumatic stress disorder, psychiatric hospitalizations 1
• Surgical history: All prior procedures, including dates and complications 1, 4
• Hospitalizations: Dates, reasons, and outcomes 4

Medication History

Obtain detailed information about:

• Current medications: All prescription drugs, over-the-counter medications, methadone, dietary supplements, and herbal products (many interact with antiretrovirals) 1, 4
• Allergies and adverse reactions: Document specific reactions, dates, and severity 1, 4
• Immunization history: Influenza, pneumococcal, and other vaccinations with dates 1, 4

Social History

Critical elements include:

• Substance use: Tobacco (type, amount, duration), alcohol (quantity, frequency, CAGE questions), and illicit drugs (types, routes, frequency) 1, 4
• Sexual history: Number and gender of partners, types of sexual practices (vaginal, anal, oral), condom use, partner HIV status 1
• Injection drug use: Sharing of needles, syringes, cotton, cooker, or water; HIV status of sharing partners 1
• Occupational history: Current and past employment, potential exposures 4
• Living situation: Housing stability, household composition 1
• Travel history: Recent and remote travel to endemic areas 4

Family History

Document:

• First-degree relatives: Medical conditions, age of onset, cause of death 4
• Genetic risk factors: Coronary disease, diabetes, malignancies, psychiatric disorders 4

Review of Systems

Perform systematic inquiry across all organ systems:

• Constitutional: Fever, weight changes, fatigue, night sweats 1
• Cardiovascular: Chest pain, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema, palpitations 2, 3
• Respiratory: Cough, sputum production, hemoptysis, wheezing 1
• Gastrointestinal: Nausea, vomiting, diarrhea, constipation, abdominal pain, dysphagia 2
• Genitourinary: Dysuria, hematuria, discharge, menstrual history (for women) 1
• Neurological: Headache, dizziness, weakness, numbness, cognitive changes 1
• Psychiatric: Mood changes, sleep disturbances, concentration difficulties 1
• Dermatologic: Rashes, lesions, changes in skin or nails 1

Screening for High-Risk Behaviors

For HIV-infected patients, systematically assess:

• Sexual risk behaviors: Multiple or anonymous partners, sex work, unprotected sex with HIV-negative or unknown-status partners 1
• Injection drug use: Current or past use, sharing practices 1
• STD screening indicators: Past STD history, partner risk behaviors, high-prevalence geographic areas 1
• Domestic violence and depression: Use direct questions or validated screening tools 1

Special Population Considerations

For women:

• Gynecologic history: Menstrual patterns, contraception, pregnancy plans, mammography 1, 4
• Cervical cancer screening history 1

For patients with specific symptoms:

• Tailor questions to the presenting complaint while maintaining comprehensive approach 2

Critical Pitfalls to Avoid

• Overlooking functional impact: Effect on daily activities provides crucial diagnostic and treatment context 2
• Missing modifying factors: Information about what improves or worsens symptoms offers essential diagnostic clues 2
• Incomplete medication reconciliation: Failure to document all medications, including supplements, risks dangerous drug interactions 1, 4
• Neglecting risk factor assessment: Individualized risk assessment is essential for appropriate screening and prevention 2
• Inadequate social history: Substance use and sexual practices directly impact treatment decisions and screening needs 1

Documentation Best Practices

• Include patient narrative: Document the patient's story in sufficient detail to accurately represent their experience 3
• Record pertinent negatives: Document relevant symptoms that are absent to support differential diagnosis 2
• Avoid copy-paste errors: Do not copy entire previous notes without editing, as this propagates outdated or contradictory information 3
• Use clear language: Avoid ambiguous terms; be specific and precise 4
• Document information source: Note whether information came from patient, family, or medical records 4