What are key considerations when evaluating a patient's History of Present Illness (HPI)?

Key Considerations When Evaluating a Patient's History of Present Illness

Begin with the patient's own narrative of their current symptoms, then systematically integrate relevant chart review information to establish a clear timeline and progression of illness. 1, 2

Essential Core Components to Document

Patient Demographics and Context

• Age, gender, and date of last visit to establish baseline context 1
• Living situation, self-care abilities, and functional status as these provide critical context for treatment planning 1, 3
• Social determinants of health including food security, housing stability, transportation access, financial security, and community safety 1
• Existing social supports and surrogate decision maker status 1

Symptom Characterization

• Document all major symptom domains systematically including onset, duration, severity, temporal patterns, and impact on daily functioning 4, 1
• For dyspnea: distinguish between rest dyspnea, exertional dyspnea (with specific activity level), orthopnea, and paroxysmal nocturnal dyspnea 4
• Include pertinent negatives—important symptoms that are absent—as failing to document these leads to incomplete assessment 1
• Subjective symptoms and their onset should be recorded, including cognitive and behavioral symptoms, gait problems, tremor, balance, swallowing, incontinence, and pseudobulbar affect 4

Medication and Treatment History

• Comprehensive medication regimen including prescription drugs, over-the-counter medications, supplements, and herbal remedies 1
• Medication adherence, side effects, and response to treatment documented in detail 1, 3
• Previous treatments attempted and their outcomes from chart review when relevant 1, 2
• For patients on antiretroviral or complex regimens: document drug combinations taken, response to each regimen including relevant lab values, duration of treatment, reasons for treatment changes, drug toxicities, and prior resistance test results 4

Medical and Family History

• Changes in medical and family history since last encounter, focusing on elements relevant to current presentation 1
• History of cardiovascular disease (myocardial infarction, arrhythmia, heart failure, angina, peripheral artery disease), cerebrovascular disease, or stroke 4, 1
• Family history of relevant conditions in first-degree relatives including strokes, vascular disease, dementia, and neurological diseases with age at death and age of event 4, 1

Lifestyle and Behavioral Factors

• Tobacco, alcohol, and substance use patterns documented thoroughly 4, 1
• Current and past use of illicit drugs, "alternative therapies," and chemotherapy drugs 4
• Physical activity levels and sleep behaviors, including screening for sleep apnea 1
• Sexual history and risk behaviors when relevant, including number of partners, condom use, and history of sexually transmitted diseases 4

Safety Assessment (When Clinically Indicated)

• Conduct a structured safety assessment with specific details about suicidal or homicidal ideation 1, 3
• Review safety plans with patients who have psychiatric concerns 1, 3
• Screen for depression and domestic violence using direct questions or validated screening tools 4

Organizational Structure and Documentation

Narrative Construction

• Begin with the patient's own narrative, then integrate relevant chart review information to establish clear timeline and progression 1, 2
• Chronologically sequence both relevant historical risks and known medical events to improve diagnostic reasoning 1, 5
• Synthesize information from patient interview, informant reports, and prior documentation into a coherent narrative 1, 2

Chart Review Integration

• Use chart review to fill gaps in patient's recollection, but clearly distinguish between information obtained directly from the patient versus from documentation 1, 2
• Focus on including chart review information that establishes previous diagnostic workup and results, prior treatments attempted and their outcomes 2
• Cross-reference information from multiple sources to verify key historical elements and avoid perpetuating previous diagnostic errors 1, 2
• Clearly document the source of each piece of information (patient report vs. chart review) 1, 2

Disease-Specific Considerations

Heart Failure Patients

• Assess volume status including weight gain or loss with timeframe, swelling in extremities or abdomen, orthopnea (number of pillows used), and paroxysmal nocturnal dyspnea 4
• Document history of renal disease, dialysis, chronic lung disease, dementia, depression, liver disease, and malignancy 4
• Record influenza and pneumococcal immunization status with dates 4

Vascular Cognitive Impairment

• Obtain thorough health history on cardiovascular disease, cerebrovascular disease, migraine, hypertension, hyperlipidemia, diabetes, sleep disorders, hypercoagulable states, autoimmune diseases, and depression 4
• Document environmental exposures such as second-hand smoke, pesticides, and medications 4

Hypersensitivity Pneumonitis

• Gather thorough clinical history of exposures focused on establishing type, extent, and temporal relationship of exposure(s) to symptoms 4
• Complete comprehensive environmental and occupational questionnaire tailored to geographic region 4
• Continue exposure history gathering until HP diagnosis or exclusion is more certain, as unrevealing exposure history does not exclude HP 4

Common Pitfalls to Avoid

• Avoid overreliance on chart review that may perpetuate diagnostic errors; always verify key elements directly with the patient 1, 2
• Do not allow patients to feel their narrative is being ignored; let them tell their story in their own words before integrating chart review information 1, 2
• Failing to address social determinants of health may miss critical factors affecting patient outcomes 1
• Avoid including excessive chart review details that make the HPI unwieldy; be selective and include only information relevant to current presentation 1, 2
• Document the rationale for treatment decisions to support clinical reasoning process 3

Initial Clinical Assessment Requirements

Physical Examination Elements

• Assessment of volume status, orthostatic blood pressure changes, weight, height, and body mass index calculation 4
• Vital signs including blood pressure (orthostatic), heart rate, vision, and hearing 4
• Ability to perform routine and desired activities of daily living 4

Initial Laboratory Evaluation

• Complete blood count, urinalysis, serum electrolytes (including calcium and magnesium), blood urea nitrogen, serum creatinine, fasting blood glucose (glycohemoglobin), lipid profile, liver function tests, and thyroid-stimulating hormone 4
• Twelve-lead electrocardiogram and chest radiograph (PA and lateral) 4