Taking a Comprehensive Patient History in Medicine
Begin by obtaining the chief complaint and history of present illness using the OPQRST framework, followed by a systematic review of past medical history, medications, social history, family history, and a complete review of systems—all documented in a structured format that prioritizes patient-reported information while maintaining engagement throughout the encounter. 1
History of Present Illness: The OPQRST Framework
When documenting the presenting complaint, systematically address each component:
- Onset: Document the exact time the patient was last known to be well, who witnessed the symptom onset, and whether onset was sudden or gradual 1
- Provocation/Palliation: Identify exacerbating conditions (e.g., environmental triggers, activities, body position) and what provides relief 1
- Quality: Have the patient describe the symptom in their own words (e.g., burning, stinging, pressure, sharp) 1
- Radiation: Document if symptoms spread to other locations 1
- Severity: Use validated scales when available or have patients quantify on a 0-10 scale 1
- Timing: Record duration of symptoms, diurnal fluctuation, and whether symptoms worsen at specific times of day 1
Past Medical History
Systematically document all relevant conditions with year of diagnosis:
- Cardiovascular: History of hypertension (including blood pressure readings >140/90 mmHg on multiple occasions), heart failure, myocardial infarction, arrhythmias (specifically atrial fibrillation), coronary interventions 1
- Metabolic: Diabetes (document type, year of onset, treatment method including diet, oral agents, or insulin), dyslipidemia, thyroid disorders 1
- Infectious: HIV status, hepatitis B and C serology 1
- Other: Prior surgeries, trauma, seizures, malignancies 1
Medication History
Document with specificity:
- All current medications including over-the-counter preparations, herbal supplements, and homeopathic remedies 1
- Anticoagulation therapy status (particularly warfarin) 1
- Preservatives in topical medications 1
- For patients with prior treatment: complete antiretroviral or chemotherapy history with cumulative doses 1
Social History
Address high-risk behaviors using direct, non-judgmental questions:
- Substance use: Smoking status, alcohol consumption, illicit drug use (specifically cocaine, amphetamines) 1
- Sexual history: Use structured questions such as "Have you had vaginal, anal, or oral sex in the past 12 months?" and "Do you know the HIV status of your partners?" 1
- Occupational/environmental exposures: Digital screen time, exposure to cardiotoxic substances, radiation exposure 1
- Living situation: Assess for domestic violence using direct questions or validated screening tools 1
Family History
Document in first-degree relatives (parents, siblings, children):
- Cardiovascular: Premature coronary disease (age <55 in males, <65 in females), sudden cardiac death, cardiomyopathy, conduction system disease 1
- Other: Muscular dystrophy, diabetes, hypertension, malignancies 1
Review of Systems
Conduct a systematic organ-based review, asking specifically about:
- Constitutional: Fever, weight changes, fatigue 1
- Neurological: Headaches, weakness, sensory changes, seizures 1
- Cardiovascular: Chest pain, palpitations, edema, orthopnea 1
- Respiratory: Dyspnea, cough, wheezing 2
- Gastrointestinal: Nausea, vomiting, diarrhea, constipation 1
- Genitourinary: Dysuria, frequency, discharge 1
- Musculoskeletal: Joint pain, muscle weakness 1
- Dermatological: Rashes, lesions (specifically rosacea, psoriasis) 1
- Psychiatric: Screen for depression and anxiety using validated tools or direct questions 1
Documentation Strategy During the Encounter
Critical pitfall: Avoid allowing computer documentation to interfere with patient engagement 1
Employ these evidence-based techniques:
- Review the patient's chart before calling them in 1
- Start the visit by asking about the patient's concerns and building rapport before computer use 1
- Maintain body orientation toward the patient, especially lower body positioning 1
- Explain computer use and verbalize actions (e.g., "I'm looking up your previous lab results") 1
- Share the screen with the patient when appropriate 1
- Separate computer work from critical communication moments, particularly when discussing sensitive topics or treatment options 1
- Consider documenting after the visit for complex or emotionally charged encounters 1
Special Considerations
- For patients with communication barriers: Obtain history from caregivers closest to the patient when self-report is not possible (e.g., aphasia, cognitive impairment), but document this clearly 1
- For time-sensitive conditions: Prioritize obtaining time of symptom onset and contraindications to time-sensitive treatments (e.g., anticoagulation status for stroke) 1
- For sensitive topics: Use validated questionnaires (e.g., OSDI for dry eye, SPEED for symptom tracking) to standardize and facilitate disclosure 1