Course 3: History of Present Illness

Question 1

Subjective Information

Answer 1

Chief complaint, HPI, ROS

Question 2

History of Present Illness (HPI)

Answer 2

The story of symptoms and events that led to the clinic visit and summarizes the reason for the visit; the HPI is a vital component of the chart as it is the basis for the entire workup that follows

Question 3

Review of Systems (ROS)

Answer 3

A head-to-toe overview of the patient’s body-systems phrased in the form of positives and negatives; it includes symptoms that are not relevant to the chief complaint; it does not contain context

Question 4

HPI determines the entire visit

Answer 4

Every subjective complaint mentioned in the HPI is eventually followed up with an objective evaluation somewhere later in the chart

Question 5

HPI Elements

Answer 5

Onset, Timing, Location, Quality, Severity, Modifying Factors, Associated Symptoms, Context

Question 6

Chief Complaint

Answer 6

The primary reason(s) that brought the patient in

Question 7

Onset

Answer 7

When did the complaint begin?

Question 8

Timing

Answer 8

Has it been constant, intermittent, or waxing and waning?

Question 9

Location

Answer 9

Where is the discomfort?

Question 10

Quality

Answer 10

Does it feel sharp, dull, aching, cramping…?

Question 11

Severity

Answer 11

How bad is it? (Mild/Moderate/Severe or 0-10)

Question 12

Modifying Factors

Answer 12

What makes it better? What makes it worse?

Question 13

Associated Symptoms

Answer 13

Do any other symptoms accompany the complaint?

Question 14

Context

Answer 14

Is there anything else that is important?

Question 15

HPI Context

Answer 15

• Risk factors related to the complaint
• If a patient had similar symptoms in the past - when and if there was a diagnosis in the past
• If the patient has had any prior testing (and the results) related to their complaint
• Medical histories, surgeries, or social habits that are relevant to the current evaluation

Question 16

HPI Structure

Answer 16

1. Age and sex
2. Complaint and onset
3. Quality, severity, timing, location
4. Modifying factors
5. Positive associated symptoms
6. Pertinent negatives
7. Other important context

Question 17

Patient says “It started Monday”

Answer 17

Scribe documents “Symptoms began 3 days ago”

Question 18

Patient says “It got better”

Answer 18

Scribe documents “Symptoms improved” (avoid the word got)

Question 19

Patient says “I took Tums and it didn’t help”

Answer 19

Scribe documents “The symptoms were unchanged by Tums”

Question 20

Patient says “It hurts when I touch it”

Answer 20

Scribe documents “Pain is worsened by palpation of the area”

Question 21

Patient says “I throw up when I eat or drink anything”

Answer 21

Scribe documents “The vomiting is exacerbated by PO intake”

Question 22

Patient says “I have low back pain, but I always have that”

Answer 22

Scribe documents “Patient has chronic lower back pain, unchanged from baseline”

Question 23

Patient says “My sister has the same cold”

Answer 23

Scribe documents “Positive sick contact with sister who has similar symptoms”

Question 24

Patient says “It feels like a fizzing soda in my chest”

Answer 24

Scribe documents “Chest pain is described as a ‘fizzing soda’ sensation”

Question 25

Patient says “I have the flu”

Answer 25

Scribe documents “Patient has a runny nose and cough” (do not document self-diagnoses)

Question 26

ROS: Body Systems

Answer 26

Constitutional, Eyes, Ear/Nose/Throat, Cardiovascular, Respiratory, Gastrointestinal, Genitourinary, Musculoskeletal, Integumentary/Skin, Neurological, Psychiatric, Endocrine, Hematologic/Lymph, Immunologic