What should I ask during the history of present illness (HPI) and what should my physical examination (PE) include?

Comprehensive History of Present Illness and Physical Examination Components

The history of present illness (HPI) should focus on obtaining a comprehensive description of the patient's principal symptoms and their impact on daily function, while the physical examination should include a thorough vascular, neurological, and systems assessment relevant to the presenting complaint. 1

History of Present Illness Components

Initial Approach

• Begin with an open-ended question: "What is the main reason you are here to see me and what would you like to accomplish from the visit today?" 1
• Interview both patient and informant(s) (family members/close friends), as informant reports provide added value, especially when cognitive impairment may be present 1
• Consider interviewing patient and informant separately if there appears to be discomfort with honest reporting or friction 1

Key Elements to Cover in HPI

1. Symptom Characterization:

   • Onset (sudden vs. gradual)
   • Duration and progression
   • Frequency and pattern
   • Severity and impact on daily activities
   • Alleviating and exacerbating factors
   • Associated symptoms

2. Specific Symptom Assessment:

   • For cognitive concerns: Ask about memory issues, word-finding difficulties, confusion, behavioral changes 1
   • For cardiovascular symptoms: Inquire about chest pain, dyspnea, claudication, edema, syncope 1
   • For pain: Location, quality, radiation, timing, factors that worsen/improve 1

3. Functional Impact Assessment:

   • Changes in ability to perform activities of daily living
   • Impact on work, relationships, and quality of life
   • Need for assistance with daily tasks

4. Risk Factor Assessment:

   • Cardiovascular: Hypertension, diabetes, dyslipidemia, smoking, family history 1
   • Neurological: Prior head trauma, seizures, strokes, family history of dementia 1
   • Infectious: HIV risk factors, exposure to sexually transmitted infections 1

5. Medication and Substance History:

   • Current medications (prescription and over-the-counter)
   • Dietary supplements and herbal remedies
   • Alcohol, tobacco, and illicit drug use
   • Medication allergies and adverse reactions 1

6. Relevant Past Medical History:

   • Previous diagnoses related to current symptoms
   • Prior hospitalizations or surgeries
   • History of trauma or injuries
   • Previous treatments and their effectiveness 1

Physical Examination Components

Vital Signs

• Blood pressure (measure in both arms at least once) 1
• Heart rate and respiratory rate
• Temperature
• Oxygen saturation (when appropriate)
• Height and weight

General Examination

• General appearance and level of distress
• Mental status (orientation, attention, memory)
• Skin examination for lesions, rashes, or discoloration

Cardiovascular Examination

• Heart sounds (murmurs, gallops, rubs)
• Jugular venous pressure
• Peripheral pulses (femoral, popliteal, dorsalis pedis, posterior tibial) 1
• Assessment for edema
• Auscultation for bruits (carotid, femoral, abdominal) 1

Neurological Examination

• Mental status (orientation, memory, language, attention)
• Cranial nerves
• Motor strength and tone
• Sensory examination
• Deep tendon reflexes
• Coordination and gait
• Pathological reflexes

Abdominal Examination

• Inspection for distention or visible masses
• Auscultation for bowel sounds and bruits
• Palpation for tenderness, masses, organomegaly
• Percussion for ascites or organomegaly

Extremity Examination

• Inspection for color changes, hair distribution, wounds
• Palpation for temperature, pulses, edema
• Assessment for joint deformity or limitation of movement 1

Special Considerations

For Suspected Cognitive Impairment

• Assess for depression and domestic violence using direct questions or validated screening tools 1
• Evaluate for behavioral changes, personality changes, or neuropsychiatric symptoms 1
• Document family history of dementia or neurological disorders 1

For Suspected Cardiovascular Disease

• Document family history of premature coronary disease, sudden death, or cardiomyopathy 1
• Assess for orthostatic changes in blood pressure and heart rate 1
• Evaluate for signs of heart failure (S3 gallop, elevated JVP, edema) 1

For Suspected Peripheral Arterial Disease

• Comprehensive vascular examination including pulse palpation and auscultation for bruits 1
• Inspection of legs and feet for wounds, color changes, or hair loss 1
• Assessment for claudication or rest pain 1

Common Pitfalls to Avoid

1. Failing to obtain collateral history when cognitive impairment is suspected, as patients may lack insight into their condition 1

2. Misinterpreting terminology used by patients (e.g., "memory loss" may refer to word-finding difficulties rather than true amnesia) 1

3. Overlooking non-typical symptoms of serious conditions (e.g., atypical presentations of peripheral arterial disease) 1

4. Not measuring blood pressure in both arms, which may miss subclavian stenosis 1

5. Focusing only on the chief complaint without exploring related systems that may provide diagnostic clues

6. Neglecting medication review, which may identify potential causes of symptoms or drug interactions 1

7. Inadequate pain assessment when pain is the presenting symptom (failing to characterize location, quality, timing, etc.) 2

By systematically addressing these components in the HPI and physical examination, you will gather comprehensive information needed for accurate diagnosis and appropriate management of the patient's condition.