What questions should I ask during a History of Present Illness (HPI) interview?

History of Present Illness (HPI) Interview Questions

When conducting an HPI interview, you must systematically obtain information across four core domains: (1) cognition, (2) activities of daily living, (3) mood and neuropsychiatric symptoms, and (4) sensory and motor function, while integrating both patient and informant perspectives to characterize symptoms, establish their time course, explore relationships to events, and evaluate functional impact. 1

Essential Interview Structure

Start with Open-Ended Questions

• Begin by asking the patient to describe their chief concern in their own words using open-ended questions 2, 3, 4
• Open-ended questions elicit significantly more information from patients compared to closed-ended approaches 3, 5
• Use facilitation techniques (comments or behaviors that encourage continued talking) to maximize information gathering 5

Core Symptom Characterization

For each presenting symptom, systematically document:

• Onset and chronology: When symptoms began, their progression over time, patterns, and changes in intensity 2
• Location: Where symptoms occur and whether they radiate or move 2
• Quality: How symptoms feel (sharp, dull, burning, etc.) 2
• Severity: Impact on daily activities, using scales when appropriate 2
• Duration: How long symptoms last when they occur 2
• Context: Activities or situations when symptoms occur or worsen 2
• Modifying factors: What makes symptoms better or worse, including medications or interventions 2
• Associated symptoms: Other symptoms occurring simultaneously 2

Temporal Relationships

• Establish the sequential order of symptom onset, frequency, tempo, and nature of change over time 1
• Explore plausible relationships between events and presenting symptoms, including potential triggers or contextual features 1

Domain-Specific Assessment

Cognitive Function

• Ask about changes in memory, attention, language, executive function, and visuospatial abilities 1
• Patients and caregivers often lack vocabulary to describe cognitive changes, requiring structured inquiry 1

Activities of Daily Living

• Evaluate impact on basic ADLs (bathing, dressing, eating, toileting, transferring, continence) 1
• Assess instrumental ADLs (managing finances, medications, transportation, shopping, meal preparation, housework) 1
• Determine the need for care partner support and changes in independence 1

Mood and Neuropsychiatric Symptoms

• Screen for depression, anxiety, apathy, agitation, hallucinations, delusions, and sleep disturbances 1
• Assess diabetes distress, fear of hypoglycemia, and disordered eating when relevant 6

Sensory and Motor Function

• Inquire about gait problems, tremor, balance issues, swallowing difficulties, and incontinence 1

Informant Interview (Critical Component)

Always seek an informant (care partner, family member) when possible 1

Document informant details:

• Relationship to patient and length of relationship 1
• Amount and type of contact with patient 1
• Informant's age, education, and living situation relative to patient 1

Integrate information from both patient and informant interviews, as patients may under-report, misclassify, or misattribute symptoms 1

Risk Factor Assessment

Systematically obtain information about individualized risk factors for cognitive decline and disease: 1

Cardiovascular Risk Factors

• Myocardial infarction, arrhythmia/atrial fibrillation, heart failure, angina, peripheral artery disease 1
• Hypertension, hyperlipidemia, diabetes mellitus 1

Cerebrovascular Disease

• Prior stroke (hemorrhagic or ischemic), transient ischemic attacks, carotid endarterectomy 1

Modifiable Contributing Conditions

• Obstructive sleep apnea, medications impairing cognition, mood disorders, alcohol consumption 1
• Chronic infections (periodontal disease, bronchitis), autoimmune diseases 1

Medication and Treatment History

Document comprehensively:

• All prescription drugs, over-the-counter medications, supplements, and herbal remedies 2, 6
• Medication allergies and hypersensitivity reactions 2
• Prior treatments for current condition and their effectiveness 2
• Medication-taking behavior, including rationing due to cost 6

Environmental and Occupational Exposure

For suspected hypersensitivity pneumonitis or environmental illness:

• Use structured questionnaires adapted to regional geography, customs, climate, and season 1
• Assess workplace exposures: understand current/prior jobs and extent of exposures 1
• Survey home environment: detailed indoor and surrounding space assessment 1
• Include vocational activities, travel/migration history, and all animal contact 1
• Consider involving family members in exposure history-taking to reduce recall bias 1

Family History

• Document first-degree relatives with stroke, vascular disease, myocardial infarction, dementia, and neurological diseases 1
• Record age at death and age when events occurred 1
• Note age when family members developed conditions related to presenting complaint 2

Social Determinants of Health

Assess systematically:

• Food insecurity (affects up to 20% of individuals with diabetes and impacts self-care) 6
• Housing insecurity/homelessness and financial barriers to care 6
• Social support networks and community resources 6
• Tobacco, alcohol, and recreational drug use 2, 6
• Occupational exposures impacting health 2
• Living conditions and support systems 2

Functional Impact Assessment

Evaluate how symptoms affect:

• Interpersonal relationships 1
• Personal and public health and safety 1
• Work performance and vocational activities 1
• Community engagement 1

Documentation Best Practices

• Document pertinent negatives (important symptoms that are absent) 2
• Use the open-to-closed cone technique: begin nondirective, then gradually narrow focus 5
• Provide verbal summarization of information gathered to ensure accuracy 5
• Use clear language understandable by other providers 2

Common Pitfalls to Avoid

• Failing to use structured approaches leads to missed symptoms, as patients often lack vocabulary to describe changes and may under-report 1
• Relying solely on closed-ended questions significantly reduces information obtained 3, 5
• Neglecting to interview an informant misses critical collateral information, particularly for cognitive and behavioral symptoms 1
• Interrupting patients too early prevents full symptom expression 5
• Omitting environmental and occupational history can miss reversible causes 1