What is the proper way to present the History of Present Illness (HPI)?

The Proper Way to Present the History of Present Illness (HPI)

The History of Present Illness (HPI) should be presented in chronological order, beginning with the onset of symptoms, and include the nature of presenting symptoms, their characteristics, progression over time, impact on daily function, and relevant risk factors to ensure diagnostic accuracy and effective patient care. 1

Structure and Components of an Effective HPI

Essential Elements

• Chronology: Present symptoms in sequential order of onset with clear timeline 1, 2
• Symptom characteristics: Include location, quality, severity, duration, context, modifying factors, and associated symptoms 1
• Impact assessment: Document effects on activities of daily living, work/school performance, and interpersonal relationships 1
• Risk factors: Include relevant exposures, family history, and other contributing factors 1

Organization Approach

1. Begin with open-ended questions to allow patients to tell their story in their own words 1
2. Follow with focused questions to clarify specific aspects of the history 1
3. Present information chronologically to establish a clear timeline of events 2
4. Use clear, concise language without medical jargon 1
5. Include pertinent positives and negatives relevant to the differential diagnosis 1

The "All-Inclusive History of Present Illness" (AIHPI) Method

The AIHPI approach organizes the HPI by applying Bayesian statistical concepts to improve diagnostic reasoning 3:

1. Start with the chief complaint
2. Chronologically sequence both:
   • Relevant historical risk factors
   • Known medical events
3. Generate pre-event probabilities of likely diagnoses
4. Conclude with a clear assessment of the most likely diagnosis

This organization helps deliver well-organized, succinct verbal case presentations and improves diagnostic efficiency 3.

Therapeutic Aspects of the HPI

The HPI is not merely a diagnostic tool but also has therapeutic potential when skillfully conducted 4:

• Helps patients make cognitive sense of their illness
• Serves as a vehicle for sharing the emotional burden with the physician
• Establishes a therapeutic physician-patient relationship

To maximize this therapeutic potential, clinicians should convey:

• A sense of safety
• Sensitivity to patient concerns
• Affective competence
• Cognitive competence

Common Pitfalls to Avoid

• Attributing symptoms to "normal aging" without proper evaluation 1
• Framing history solely around a major event that patient believes is causal 1
• Relying solely on closed-ended questions 1
• Failing to integrate information from informants when appropriate 1
• Neglecting to assess impact of symptoms on daily function 1
• Interrupting the patient's narrative prematurely 1
• Using vague symptom descriptions that diminish diagnostic value 5

Best Practices for Different Clinical Contexts

For Patients with Cognitive/Behavioral Symptoms

• Evaluate impact on activities of daily living and work/school performance 1
• Document effects on interpersonal relationships 1
• Obtain information from a reliable informant 1

For Patients with Infectious Diseases

• Document travel history, exposure risks, and immunization status 1
• Consider epidemiologic context and potential exposures 6

For Patients with Suspected Hypersensitivity Pneumonitis

• Use a structured environmental and occupational questionnaire 6
• Characterize exposure types and sources in detail 6

By following these guidelines, clinicians can create an HPI that serves both as an effective diagnostic tool and as a therapeutic intervention that strengthens the physician-patient relationship.