Course 3: History of Present Illness Flashcards
Subjective Information
Chief complaint, HPI, ROS
History of Present Illness (HPI)
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
Review of Systems (ROS)
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
HPI determines the entire visit
Every subjective complaint mentioned in the HPI is eventually followed up with an objective evaluation somewhere later in the chart
HPI Elements
Onset, Timing, Location, Quality, Severity, Modifying Factors, Associated Symptoms, Context
Chief Complaint
The primary reason(s) that brought the patient in
Onset
When did the complaint begin?
Timing
Has it been constant, intermittent, or waxing and waning?
Location
Where is the discomfort?
Quality
Does it feel sharp, dull, aching, cramping…?
Severity
How bad is it? (Mild/Moderate/Severe or 0-10)
Modifying Factors
What makes it better? What makes it worse?
Associated Symptoms
Do any other symptoms accompany the complaint?
Context
Is there anything else that is important?
HPI Context
- 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
HPI Structure
- Age and sex
- Complaint and onset
- Quality, severity, timing, location
- Modifying factors
- Positive associated symptoms
- Pertinent negatives
- Other important context
Patient says “It started Monday”
Scribe documents “Symptoms began 3 days ago”
Patient says “It got better”
Scribe documents “Symptoms improved” (avoid the word got)
Patient says “I took Tums and it didn’t help”
Scribe documents “The symptoms were unchanged by Tums”
Patient says “It hurts when I touch it”
Scribe documents “Pain is worsened by palpation of the area”
Patient says “I throw up when I eat or drink anything”
Scribe documents “The vomiting is exacerbated by PO intake”
Patient says “I have low back pain, but I always have that”
Scribe documents “Patient has chronic lower back pain, unchanged from baseline”
Patient says “My sister has the same cold”
Scribe documents “Positive sick contact with sister who has similar symptoms”
Patient says “It feels like a fizzing soda in my chest”
Scribe documents “Chest pain is described as a ‘fizzing soda’ sensation”
Patient says “I have the flu”
Scribe documents “Patient has a runny nose and cough” (do not document self-diagnoses)
ROS: Body Systems
Constitutional, Eyes, Ear/Nose/Throat, Cardiovascular, Respiratory, Gastrointestinal, Genitourinary, Musculoskeletal, Integumentary/Skin, Neurological, Psychiatric, Endocrine, Hematologic/Lymph, Immunologic
