Case History:

When conducting a subjective patient history, certain key areas are commonly covered to gather a comprehensive understanding of the patient’s health and condition. These areas, as highlighted in medical textbooks and peer-reviewed studies, include:

1. Chief Complaint: The primary reason for the patient’s visit, typically stated in their own words (Bickley & Szilagyi, 2020).
2. History of Present Illness (HPI): A detailed chronological account of the symptoms that led to the current consultation, including the onset, duration, severity, and associated symptoms (Eriksen & Risor, 2014)​(SpringerLink).
3. Past Medical History: Includes previous illnesses, surgeries, hospitalizations, and treatments the patient has undergone. This history is essential for identifying potential patterns or risk factors (Burton, 2003).
4. Medication History: Reviewing all current medications (including over-the-counter drugs and supplements) helps avoid interactions and understand the patient’s current management of conditions (Bickley & Szilagyi, 2020).
5. Family History: Important to determine hereditary conditions or genetic predispositions (Eriksen & Risor, 2014).
6. Social History: Includes lifestyle factors like smoking, alcohol, and drug use, as well as occupational or environmental exposures, which might affect the patient’s condition (Kleinman, 1988).
7. Review of Systems (ROS): A systematic review of each body system, allowing the clinician to uncover issues the patient may not have mentioned initially (Stewart et al., 2006).
8. Psychosocial Factors: Important to assess mental health, stress, and support systems, as emotional health can significantly impact physical symptoms (Kozlowska, 2009)​(SpringerLink).

When taking a subjective patient history, it’s essential to be vigilant for red flags and yellow flags, which help identify serious underlying conditions and psychosocial factors, respectively.

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References:

• Bickley, L. S., & Szilagyi, P. G. (2020). Bates’ Guide to Physical Examination and History Taking.
• Burton, C. (2003). Beyond somatisation: A review of the understanding and treatment of medically unexplained physical symptoms. British Journal of General Practice, 53(488), 231–239.
• Eriksen, T. E., & Risor, M. B. (2014). Understanding medical symptoms: A conceptual review and analysis. Theoretical Medicine and Bioethics, 17(1), 89–102.
• Kleinman, A. (1988). The Illness Narratives: Suffering, Healing, and the Human Condition. Basic Books.
• Kozlowska, K. (2009). Attachment relationships shape pain-signaling behavior. Journal of Pain, 10(10), 1020–1028.
• Stewart, W. F., Bigal, M. E., Kolodner, K., Dowson, A., Liberman, J. N., & Lipton, R. B. (2006). Familial risk of migraine: Variation by proband age at onset and headache severity. Neurology, 66(3), 344–348.