What are the key components of taking a patient's medical history?

Key Components of Medical History Taking

Begin by establishing rapport in a comfortable environment, then systematically collect information starting with the chief complaint using open-ended questions, followed by structured documentation of past medical history, medications, family history, social history, and review of systems—all while maintaining active listening and recording the patient's narrative in their own words. 1

Creating the Right Environment

• Introduce yourself and explain the purpose of the history-taking session to set clear expectations with the patient 1
• Position yourself with appropriate body language by orienting your lower body toward the patient and maintaining eye contact to demonstrate engagement 1
• Establish confidentiality parameters at the beginning, particularly important for adolescents and when discussing sensitive topics 1

Chief Complaint and Present Illness

• Start with open-ended questions such as "What questions do you have?" rather than closed-ended phrases like "Do you have any questions?" to allow the patient to tell their story without interruption 1, 2
• Document the patient's narrative in sufficient detail to accurately retell their story, including the patient's own words when describing symptoms 1
• For every presenting complaint, systematically document: onset and chronology, location, quality, severity, duration, context, and modifying factors 1
• Ask specifically about time of day when symptoms worsen, as morning worsening suggests certain conditions while evening worsening suggests others 3, 1
• Document exacerbating conditions such as wind, air travel, decreased humidity, or prolonged visual efforts associated with decreased blink rate 3

Past Medical History

Cardiovascular History

• Document myocardial infarction, arrhythmia/atrial fibrillation, coronary procedures (angioplasty, stent, bypass), pacemaker, congestive heart failure, angina, and peripheral artery disease 3, 1
• For each condition, phrase questions as "Have you been diagnosed with _________?" and "Do you have symptoms of __________?" 3

Cerebrovascular Disease

• Record stroke (hemorrhagic or ischemic), transient ischemic attack, and endarterectomy 3, 1
• Inquire about cognitive difficulties arising after surgery 3

Other Medical Conditions

• Document diabetes mellitus, hypertension, hyperlipidemia, renal disease, chronic viral infections (hepatitis C, HIV), autoimmune diseases, depression, and substance abuse 3, 1
• Include dermatological diseases (rosacea, psoriasis, varicella zoster virus), systemic inflammatory diseases (Sjögren syndrome, GVHD, rheumatoid arthritis, systemic lupus erythematosus), and neurological conditions (Parkinson disease, Bell's palsy) 3

Medication History

• Document all prescription medications including names, dosages, frequencies, and duration of use 1
• Include over-the-counter medications, topical medications and their associated preservatives (artificial tears, eyewash, antihistamines, glaucoma medications, vasoconstrictors, corticosteroids), dietary supplements, and herbal remedies 3, 1
• Record systemic medications that may contribute to symptoms, such as antihistamines, diuretics, hormones, antidepressants, cardiac antiarrhythmic drugs, isotretinoin, beta-adrenergic antagonists, and any drug with anticholinergic effects 3

Family History

• Obtain a three-generation family history focusing on first-degree relatives 1
• Document history of stroke, vascular disease including myocardial infarction, dementia, and other neurological diseases 3, 1
• For all conditions, record the age at death and the age when the event occurred 3

Social History

Substance Use

• Document tobacco use and exposure to second-hand smoke 3, 1
• Record alcohol use and history of alcohol abuse 3, 1
• Ask about recreational drug use including heroin, marijuana, and cocaine 1

Occupational and Environmental Factors

• Record occupation, years of education, literacy, and living situation 3
• Document environmental exposures such as second-hand smoke, pesticides, and medications 3, 1
• Ask about technique and frequency of facial washing, including eyelid and eyelash hygiene 3

Lifestyle Factors

• Document diet, activity level, and menopause status 3
• Record living situation and level of support available to the patient 3

Surgical History

• Document ocular surgical history (prior keratoplasty, cataract surgery, keratorefractive surgery, punctal surgery, eyelid surgery) 3
• Record nonocular surgery (bone-marrow transplant, head and neck surgery, trigeminal neuralgia surgery) and whether cognitive difficulties arose after surgery 3
• Include history of orbital radiation 3

Review of Systems

• Conduct a comprehensive symptom review covering constitutional, HEENT (head/eyes/ears/nose/throat), cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, dermatologic, and neurologic symptoms 1
• For specific presentations, ask about symptoms such as irritation, tearing, burning, stinging, dry or foreign body sensation, photophobia, blurry vision, contact lens intolerance, redness, mucous discharge, increased frequency of blinking, eye fatigue, and diurnal fluctuation 3
• Document nonocular symptoms including dry mouth, dental cavities, oral ulcers, fatigue, joint pain/muscle ache 3
• Document pertinent negatives to demonstrate thoroughness 1

Assessment of Learning Readiness and Psychosocial Factors

• Document if the patient is cognitively impaired using qualitative statements or formal mental status assessment scores 3
• Record low literacy skills, preferred language for communication, visual disturbances, and uncorrected hearing impairment 3
• Assess for depression through documentation of diagnosis or observation of depressed mood or affect 3
• Gently inquire about recent stresses or significant events, but do not probe injudiciously if a history of trauma is not forthcoming, as repeated uninvited questioning can undermine the therapeutic relationship 3

Vital Signs and Physical Examination

• Record height, weight, blood pressure (including orthostatic), waist circumference, ankle-brachial index, heart rate, vision, and hearing 3
• Measure oxygen saturation using pulse oximetry in all breathless and acutely ill patients 3
• Document respiratory rate, pulse rate, blood pressure, and temperature 3
• Pay particular attention to skin findings (scleroderma, facial changes consistent with rosacea, seborrhea) and eyelid abnormalities 3

Documentation Best Practices

• Use clear language and document the source of information 1
• Structure your documentation to establish the overall level of impairment, the syndrome, and likely causes 4
• Use validated structured instruments to ensure comprehensive assessment rather than relying solely on unstructured interview 4
• Avoid "copy/paste" of entire notes without editing as this propagates errors 1
• Include the patient's own words when documenting symptoms or concerns 1

Common Pitfalls to Avoid

• Never accept vague terminology like "memory loss" or "confusion" without clarification; encourage patients to provide concrete examples of how symptoms manifest in daily life 4
• Never discontinue oxygen therapy to obtain an oximetry measurement on room air in patients who clearly require oxygen therapy 3
• Do not assume absence of adversity or distress means the disorder is not functional 3
• Avoid missing important information about related symptoms and medical history by being systematic 5