What is the best approach to taking a history of present illness?

Best Approach to Taking a History of Present Illness

The best approach to taking a history of present illness (HPI) is to use a structured yet flexible framework that systematically documents the nature of presenting symptoms, onset and chronology, characterization of symptoms, impact on function, and risk factors while integrating information from both patient and informants when appropriate. 1

Core Components of an Effective HPI

1. Documenting Symptoms

• Nature of presenting symptoms: Record the patient's chief complaint in their own words 1
• Onset and chronology: Document when symptoms began (exact date if possible) and establish the time course (sequential order, frequency, tempo) 2, 1
• Symptom characteristics:
  • Location and radiation
  • Duration and patterns (intermittent, constant, cyclical)
  • Severity and quality
  • Context and triggers
  • Modifying factors (what makes it better or worse)
  • Associated symptoms 1

2. Assessing Impact and Response to Treatment

• Evaluate impact on activities of daily living
• Document effects on interpersonal relationships
• Assess impact on work/school performance
• Note any safety concerns related to symptoms
• Record prior treatments and their effectiveness 1

3. Risk Factor Assessment

• Document individualized risk factors relevant to the presenting complaint
• Include both modifiable and non-modifiable risk factors 1
• Inquire about epidemiological risk factors specific to the condition 2

Special Considerations for Different Patient Populations

For Infectious Disease Presentations

• Include detailed information about:
  • Abrupt or gradual onset and duration of symptoms
  • Stool characteristics (if relevant)
  • Frequency of bowel movements
  • Presence of dysenteric symptoms
  • Symptoms of volume depletion
  • Associated symptoms and their intensity 2
• Ask about potential epidemiological risk factors:
  • Travel history
  • Exposure to others with similar symptoms
  • Recent medications (especially antibiotics)
  • Underlying medical conditions 2

For HIV-Infected Patients

• Include date of diagnosis and approximate date of infection
• Obtain thorough medication history for patients who have received antiretroviral therapy
• Document CD4 cell count and viral load history
• Record reasons for treatment changes and prior drug resistance test results 2

For Patients with Cognitive/Behavioral Concerns

• Obtain information from both the patient and an informant/care partner
• Document the time course of cognitive and behavioral symptoms
• Assess impact on daily function and interpersonal relationships
• Note changes in comportment 2

For Pediatric Anxiety Disorders

• Interview both parent/guardian and patient, either separately or together
• Use developmentally sensitive approaches
• Gather input from collateral sources (teachers, other providers)
• Assess for medical conditions that may present with anxiety 2

Implementation Strategies

Structured Approach

• Use a consistent framework to ensure comprehensive data collection
• Consider using standardized instruments for specific domains when available 1
• Avoid interruptions that may cause interactions to be brief and fragmented 3

Communication Techniques

• Begin with open-ended questions: "What is the main reason you are here to see me and what would you like to accomplish from the visit today?" 2
• Ask patients specific questions about the rate of onset of symptoms 2
• Listen actively to the patient's narrative, as the HPI is not simply a diagnostic formulation but can be therapeutic 4

Enhancing Patient Participation

• Consider using digital tools to obtain preliminary HPI information before face-to-face evaluation 3
• Teach patients how to present their symptoms and history more clearly 2
• Encourage patients to ask questions and verify information received 2

Common Pitfalls to Avoid

• Relying solely on closed-ended questions, which may miss important contextual information
• Failing to integrate information from informants when cognitive impairment is present
• Neglecting to assess the impact of symptoms on daily function
• Interrupting the patient's narrative prematurely
• Not exploring the patient's understanding and concerns about their condition

By following this structured yet flexible approach to taking a history of present illness, clinicians can gather comprehensive information that facilitates accurate diagnosis while also building therapeutic rapport with patients.