Can you help me write a History of Present Illness (HPI)?

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From the Guidelines

I can help you write a History of Present Illness (HPI) by following a structured approach that includes the chief complaint, onset timing, symptom characteristics, aggravating and alleviating factors, related symptoms, treatments tried, and impact on daily functioning, as outlined in the most recent guidelines 1. To write an effective HPI, begin with the patient's main concern in their own words, then detail when symptoms started (sudden vs. gradual), their duration, frequency, and progression.

  • Describe symptom qualities (sharp, dull, radiating), severity (using a scale if appropriate), and factors that worsen or improve the condition.
  • Include relevant associated symptoms, previous treatments attempted with their effectiveness, and how the condition affects the patient's daily activities. The HPI should be chronological, concise yet comprehensive, and typically ranges from 3-7 sentences for straightforward cases to longer narratives for complex presentations, as suggested by recent studies 1. This structured approach ensures you capture all clinically relevant information while maintaining a logical flow that helps with clinical decision-making and documentation requirements, and is supported by the latest research in ophthalmology 1.

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From the Research

Writing an HPI

To write an HPI (History of Present Illness), consider the following key points:

  • The HPI should include a chronological sequence of events related to the patient's current illness, as suggested by studies on diagnostic reasoning 2
  • It should start with the patient's chief complaint (CC) and provide a clear description of the symptoms, including their onset, duration, and severity
  • The HPI should also include any relevant historical risks and known medical events that may be related to the patient's current illness, as seen in the case of a 29-year-old man with a 5-month history of worsening dry cough, exertional dyspnea, and chest tightness 3
  • The use of a structured format, such as the "All-Inclusive History of Present Illness" (AIHPI), can help improve the organization and delivery of verbal case presentations, as well as the efficiency of generating and communicating the most likely diagnosis 2

Key Components of an HPI

Some key components to include in an HPI are:

  • The patient's chief complaint (CC) and a clear description of the symptoms
  • The onset, duration, and severity of the symptoms
  • Any relevant historical risks and known medical events
  • A chronological sequence of events related to the patient's current illness
  • Any treatments or interventions the patient has received, as seen in the case of a patient treated with acetaminophen for fever 4

Organizing the HPI

To organize the HPI, consider using a structured format such as the AIHPI, which applies Bayesian statistical concepts to chronologically sequence relevant historical risks and known medical events, generating a series of pre-event probabilities of the most likely disease causing a patient's CC 2

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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