What is the recommended approach to taking a patient's medical history?

Recommended Approach to Medical History Taking

Begin by establishing rapport in a comfortable environment, then systematically gather information starting with an open-ended question about the chief complaint, followed by detailed history of present illness, past medical history, medications, family history, social history, and review of systems—with particular emphasis on obtaining collateral information from family members or informants when cognitive or behavioral concerns are present. 1, 2

Creating the Optimal Environment

• Introduce yourself and explain the purpose of the visit to set clear expectations from the outset 2
• Position yourself with appropriate body language, orienting your lower body toward the patient and maintaining eye contact to demonstrate engagement 2
• Explain confidentiality parameters at the beginning, particularly when interviewing adolescents or discussing sensitive topics 2
• Create a safe space where disagreement is welcomed, especially when interviewing patients with potential cognitive impairment alongside family members, as divergent perspectives provide valuable diagnostic clues 1

The Opening Question and History of Present Illness

Start with the open-ended query: "What is the main reason you are here to see me and what would you like to accomplish from the visit today?" 1

• Allow the patient to tell their story in their own words without interruption initially, as the history of present illness is the cornerstone of medical diagnosis 1, 2
• Encourage specific examples when patients use vague terms like "memory loss" or "confusion," as their meaning may differ substantially from clinical definitions 1
• Document the patient's own words when describing symptoms or concerns 2
• Determine whether the patient or a family member initiated the visit, as this distinction is particularly important in cognitive or behavioral syndromes where insight may be impaired 1

Essential Role of Informants

Actively seek an informant when evaluating cognitive, behavioral, or complex medical concerns, as informant reports provide added value beyond patient self-report 1

• Document the informant's relationship to the patient, length of relationship, amount and type of contact, birthdate, gender, ethnicity, education, and living status 1
• Interview the patient and informant separately when necessary due to discomfort with honest reporting or overt friction 1
• Recognize that diminished insight is common in cognitive-behavioral syndromes, making informant perspectives critical for accurate diagnosis 1

Systematic Data Collection

Demographics and Basic Information

• Record name, date of birth, gender, race/ethnicity including birthplace and parents' places of origin, years in current country, primary language, years of education, occupation, literacy level, living situation and independence level, marital status, handedness, and contact person 1, 3

Past Medical History

• Document all cardiovascular diseases including myocardial infarction, arrhythmia/atrial fibrillation, angioplasty, stent, coronary artery bypass graft, valvular surgery, pacemaker, congestive heart failure, angina, and peripheral artery disease 1, 4
• Record cerebrovascular diseases including stroke (hemorrhagic or ischemic), transient ischemic attack, and endarterectomy 1, 4
• Include duration of chronic conditions, dates of diagnosis, and prior negative tests 4
• Document all previous hospitalizations, surgeries, and blood product receipt 4
• Record history of infectious diseases, sexually transmitted diseases, and vaccination history 4

Medication History

• Compile a complete list of all medications including prescription drugs, over-the-counter preparations, supplements, dosages, and frequencies 1, 3, 4
• Document prior medication use including specific drugs, duration of therapy, complications, side effects, drug resistance, and adherence 4
• Record all allergies and intolerances with dates and types of reactions 4

Family History

• Obtain a 3-generation family history focusing on strokes, vascular disease including myocardial infarction, dementia, and other neurological diseases in first-degree relatives 1, 3, 4
• Record age at death and age of disease events for all affected relatives 1

Social History

• Document health-related behaviors including tobacco, alcohol, and drug use with specific quantities and duration 1, 4
• Record employment history and potential occupational exposures 4
• Include environmental exposures such as second-hand smoke, pesticides, and medications 1
• Document diet, lifestyle, and living situation details 1

Review of Systems

• Record subjective symptoms and their onset including cognitive and behavioral symptoms, gait problems, tremor, balance, swallowing, incontinence, and pseudobulbar affect 1
• Assess impact on daily function, interpersonal relationships, and comportment 1
• Include gentle inquiry about recent stressors or significant life events 2

Physical Examination Components

• Document vital signs including temperature, blood pressure (including orthostatic measurements), heart rate, respiratory rate, oxygen saturation, height, weight, and waist circumference 1, 3
• Perform targeted physical examination based on presenting complaint, including general appearance, mental status, and neurological examination 1, 3
• Complete NIH Stroke Scale, timed gait, motor movements, reflexes, and Babinski signs when evaluating vascular cognitive impairment 1

Communication Techniques

• Practice active listening by maintaining eye contact, nodding, and providing verbal acknowledgment 2
• Use motivational interviewing techniques particularly for sensitive topics or health behavior change 2
• Follow a structured but flexible approach that allows for spontaneity and nimble redirection based on unexpected responses 1

Special Population Considerations

• Use developmentally appropriate approaches for adolescents and consider seeing them alone for part of the interview 2
• Take extra time with elderly patients who may be at higher risk for medication errors and require more detailed functional and cognitive assessments 3, 2
• For women, document gynecologic and obstetric history, plans for pregnancy, birth control practices, menstrual history, and mammogram history 4

Critical Pitfalls to Avoid

• Never rush through the history without allowing sufficient time for the patient to tell their story 2
• Do not focus exclusively on biomedical aspects while ignoring psychosocial factors that may be central to diagnosis 2
• Avoid overreliance on templates or electronic health records at the expense of direct patient engagement 2
• Do not fail to document allergies and adverse medication reactions, as this can lead to preventable adverse events 4
• Never overlook family history, which can miss genetic risk factors for disease 4

Documentation Best Practices

• Document the patient's story in sufficient detail to accurately retell it 2
• Include pertinent negatives, use clear language, and document the source of information 4
• Record information about the patient's literacy and primary language 4
• Make post-visit phone calls when necessary to clarify information or obtain additional history from informants 1