Can a patient make a history of present illness?

Can a Patient Provide Their Own History of Present Illness?

Yes, patients can and should provide their own history of present illness whenever possible, though the quality and completeness may be limited by their clinical condition, cognitive status, or insight into their symptoms. 1

When Patients Can Reliably Provide HPI

Patients with intact cognition and awareness can effectively provide their own HPI, which remains the cornerstone of medical diagnosis. 1 The clinician should:

• Begin by asking open-ended questions such as "What is the main reason you are here to see me and what would you like to accomplish from the visit today?" 1
• Allow patients to describe symptoms in their own words, then probe for specific examples when terms like "memory loss" or "confusion" are used, as these may mean different things to patients versus clinicians 1
• Document the onset, chronology, location, quality, severity, duration, context, modifying factors, and associated symptoms 2

When Patient-Provided HPI Is Insufficient or Unreliable

In several clinical scenarios, relying solely on the patient's history is inadequate or potentially misleading:

Cognitive or Behavioral Impairment

• Patients with suspected dementia, MCI, or other neurodegenerative conditions often have diminished insight and awareness, making their self-report unreliable 1
• In these cases, informant reports from family members or close friends provide added value and are essential for accurate diagnosis 1
• The clinician should interview the patient and informant separately if there is discomfort with honest reporting or overt friction 1

Acute Critical Illness

• Neurocritically ill patients may be unable to provide coherent history due to altered mental status, intubation, or severity of illness 3
• Collateral information from family, emergency medical services, or prior medical records becomes essential 3

Psychiatric Conditions

• Patients with depression, anxiety, or other psychiatric conditions may attribute cognitive or functional changes to these conditions rather than recognizing underlying medical illness 1
• Providers should assess for depression and domestic violence through direct questions or validated screening tools 1

Specific Clinical Contexts Requiring Enhanced History-Taking

HIV-Infected Patients

When obtaining HPI from HIV patients, specifically inquire about: 1

• Date of HIV diagnosis and approximate date of infection (based on prior negative tests, acute retroviral syndrome symptoms, or timing of high-risk activities)
• Complete antiretroviral therapy history including specific drugs, duration, CD4 counts, viral loads, reasons for changes, toxicities, adherence, and resistance testing
• HIV-related complications (opportunistic infections, malignancies, neuropathy)
• Pre- or post-exposure prophylaxis use

Patients with Communication Barriers

• Use qualified medical interpreters when needed to conduct interviews in the patient's primary language 1
• Document the patient's literacy level and primary language 4
• Consider using appropriate communication aids for patients with hearing or speech impairments 2

Common Pitfalls to Avoid

Never accept incomplete or contradictory information without clarification. 3 Specific errors include:

• Failing to obtain collateral history when the patient has cognitive impairment - this is perhaps the most critical error, as patients often lack insight into their deficits 1
• Accepting the patient's or family's attribution of symptoms to a single event (surgery, trauma) without exploring the full temporal course 1
• Confusing "common in aging" with "normal aging" - changes may warrant evaluation even if common 1
• Allowing time pressure or interruptions to fragment the history - approximately 80% of diagnoses can be made from thorough history alone 5
• Not documenting pertinent negatives - important absent symptoms should be recorded 4, 2

Practical Approach

For routine clinical encounters: The patient should provide their own HPI with the clinician using structured questioning to ensure completeness 2, 6

For suspected cognitive/behavioral syndromes: Obtain history from both patient and informant, recognizing that divergent perspectives are diagnostically valuable 1

For acute critical illness: Prioritize available sources (patient if able, family, EMS, records) and be prepared to revise the history as new information emerges 3

Digital tools may assist in collecting structured HPI information before the clinical encounter, though outcomes data remain inconsistent 5