What is the recommended format for taking a history of presenting illness?

Format for History of Presenting Illness

The history of presenting illness should follow a chronological, narrative structure that documents the onset, progression, and current status of the patient's symptoms, incorporating both patient-reported information and relevant chart review data to create a comprehensive timeline.

Essential Components to Document

Temporal Elements

• Document the exact date when symptoms first appeared and track the progression of the illness from onset to present 1
• Establish the "index date" by identifying when the patient first developed any symptom or sign of the disorder 1
• Record when the illness began (abrupt vs. gradual onset) and the duration of all symptoms 1

Symptom Characterization

• Document the quality, intensity, distribution, duration, and course of the primary complaint, including both sensory and affective components 1
• Record stool characteristics (watery, bloody, mucous, purulent, greasy), frequency of bowel movements, and relative quantity for gastrointestinal complaints 1
• Note exacerbating and relieving factors for the presenting symptoms 1

Associated Symptoms and System Review

• Document all associated symptoms with their frequency and intensity, including nausea, vomiting, pain, cramps, headache, myalgias, and altered sensorium 1
• Record additional symptoms such as motor, sensory, and autonomic changes 1
• For cardiac presentations, document dyspnea, orthopnea, paroxysmal nocturnal dyspnea, weight changes, swelling, and fatigue with onset and duration 2

Prior Diagnostic and Therapeutic History

• Record all previous diagnostic tests and their results that are relevant to the current presentation 1
• Document results of previous therapies and current treatments, including dates when treatments were started and stopped 1
• Note any medication errors or brand switches that may be relevant 1

Epidemiological and Risk Factor Assessment

Travel and Exposure History

• Document travel to developing areas, day-care center attendance or employment, and consumption of unsafe foods 1
• Record contact with animals, knowledge of other ill persons, and recent swimming in untreated water 1
• For febrile illness in returned travelers, document all locations visited, dates of travel, dates of symptom onset, and specific risk activities undertaken 1

Medication and Substance History

• Record all medicines taken over the previous 2 months, including over-the-counter and complementary/alternative therapies with exact dates 1
• Document recent or regular use of antibiotics, antacids, and anti-motility agents 1
• Note any history of drug allergies with details of the reaction type 1

Underlying Medical Conditions

• Document conditions predisposing to the current illness, such as AIDS, immunosuppressive medications, prior gastrectomy, and extremes of age 1
• Record history of chronic conditions including renal disease, lung disease, dementia, depression, liver disease, and malignancy 2

Integrating Chart Review Information

Best Practices for Chart Integration

• Begin with the patient's own narrative, then integrate relevant chart review information to establish a clear timeline and progression 3
• Clearly distinguish between information obtained directly from the patient versus information obtained from chart review 3
• Use chart review to fill gaps in the patient's recollection and document objective findings that may not be recalled 3

What to Include from Chart Review

• Focus on information relevant to the current presentation that helps establish previous diagnostic workup and results 3
• Include documented objective findings and prior treatments attempted with their outcomes 3
• Cross-reference information from multiple sources when possible to verify accuracy 3

Psychosocial Context

• Document the impact of the illness on the patient's ability to perform activities of daily living 1
• Record the influence of symptoms on mood, ability to sleep, and interpersonal relationships 1
• Note family, vocational, or legal issues and involvement of rehabilitation agencies 1

Structured Documentation Approach

Chronological Organization

• Use a timeline-based format (Chronology of Present Illness) to improve clarity and efficiency of documentation and communication 4
• Organize information chronologically rather than by symptom category to facilitate diagnostic reasoning 4
• This structured approach improves written notes, verbal handoffs, and overall efficiency 4

Common Pitfalls to Avoid

• Avoid "copy/paste" of entire notes without editing, as this propagates factual errors, outdated information, and contradictory data 2
• Do not overrely on chart review information, which may perpetuate previous diagnostic errors; verify key historical elements directly with the patient 3
• Avoid allowing patients to feel their narrative is being ignored by ensuring they tell their story in their own words before integrating chart review 3
• Do not include excessive chart review details that make the HPI unwieldy; be selective and include only information relevant to the current presentation 3