What is the proper method for writing a history of presenting illness?

How to Write a History of Presenting Illness (HPI)

A comprehensive History of Presenting Illness (HPI) should follow a structured approach that includes the nature of presenting symptoms, onset and chronology, symptom characteristics, impact on daily function, and relevant risk factors, integrating information from both patient and informants when appropriate. 1

Core Components of an Effective HPI

1. Nature of Presenting Symptoms

• Document the chief complaint in the patient's own words
• Record specific symptoms that prompted the patient to seek medical attention
• Note any prodromal symptoms (e.g., fever, malaise, upper respiratory symptoms) 2

2. Onset and Chronology

• Document when symptoms began (exact date if possible) 1
• Establish the time course of symptoms (sequential order of onset, frequency, tempo) 2
• Note the date when the rash/symptoms first appeared and document progression 2
• Determine the index date (date of onset of the adverse reaction) 2

3. Symptom Characteristics

• Location: Record precise location of symptoms and any radiation or spread 1
• Quality: Describe the character of symptoms (e.g., sharp, dull, burning)
• Severity: Document intensity using appropriate scales when relevant
• Duration: Record how long symptoms last when they occur 1
• Context: Document circumstances when symptoms occur and any identifiable triggers 1
• Modifying factors: Note what makes symptoms better or worse
• Associated symptoms: Document related symptoms in affected systems 2

4. Impact on Daily Function

• Evaluate impact on activities of daily living 2, 1
• Document effects on interpersonal relationships 1
• Assess impact on work/school performance 1
• Note any safety concerns related to symptoms 1
• Document need for caregiver support if applicable 1

5. Risk Factors and Medical Context

• Record previous or ongoing medical problems 2
• Document all medications taken (including over-the-counter and complementary therapies) 2
• Note any previous history of allergies or similar reactions 2
• Consider other potential causes of the presenting symptoms 2

Gathering Information Effectively

Patient Interview Techniques

• Begin with open-ended questions to allow the patient to tell their story
• Follow with focused questions to clarify specific aspects of the history
• Avoid interrupting the patient's narrative prematurely 1
• Clarify medical terminology that patients may misuse (e.g., "memory loss" may refer to word-finding difficulty) 2

Incorporating Informant Information

• Integrate information from both patient and informant/care partner when appropriate 2, 1
• Acknowledge potential disagreements in perspectives between patient and informants 2
• Consider interviewing patient and informant separately when necessary 2

Documentation Best Practices

Organization

• Present information in chronological order
• Use clear, concise language
• Avoid medical jargon when documenting patient's descriptions
• Include pertinent positives and negatives

Completeness

• Ensure all relevant systems are addressed
• Document both subjective reports and objective observations
• Include temporal relationships between symptoms and potential triggers

Common Pitfalls to Avoid

• Relying solely on closed-ended questions 1
• Failing to integrate information from informants 1
• Neglecting to assess the impact of symptoms on daily function 1
• Interrupting the patient's narrative prematurely 1
• Not exploring the patient's understanding and concerns about their condition 1
• Attributing symptoms to "normal aging" without proper evaluation 2
• Framing history solely around a major event that patient believes is causal 2

Special Considerations for Specific Conditions

For Neurological/Cognitive Complaints

• Document changes in cognition, activities of daily living, mood, and sensorimotor function 2
• Use structured instruments for assessing cognitive domains when appropriate 2
• Explore relationships between symptoms and pertinent events 2

For Dermatological Conditions

• Document specific skin manifestations (e.g., target lesions, blisters) 2
• Note involvement of mucosal sites 2
• Record extent and distribution of lesions 2

For Pain Complaints

• Document onset, quality, intensity, distribution, duration, and course 2
• Include sensory and affective components of pain 2
• Note exacerbating and relieving factors 2
• Document impact on physical conditioning and psychosocial function 2

Efficiency Considerations

• Consider using standardized instruments for specific domains when available 1
• Digital tools may help collect preliminary HPI information before face-to-face evaluation 3
• Focus on information most likely to impact diagnosis and treatment decisions
• Remember that a thorough HPI can lead to diagnosis in approximately 80% of medical conditions 3

The HPI is not merely a diagnostic formulation but can be therapeutic when skillfully negotiated, helping patients make cognitive sense of their illness and sharing the affective burden with the physician 4.