history of present illness (HPI)

Introduction

What brings you here... Anything else?

Attributes of a symptom:

• location, including radiation
• quality
• quantity or severity
• timing
  • when did/does it start?
  • how long has it last?
  • how often does it occur?
• setting in which it occurs
  • environmental factors
  • personal activities
  • emotional reactions
  • other contributing circumstances
• exacerbating or alleviating factors
• associated manifestations

amenorrhea:

• last menstrual period, sexual activity, possibility of pregnancy, menstrual pattern, dietary or exercise changes, history of dilatation & curettage, post-partum infection or hemorrhage, weight changes, headaches, head injury, hot flashes, night sweats, dyspareunia, galactorrhea

animal bite:

• regarding the animal: type of animal, relationship of animal to victim, circumstance of bite (provoked vs unprovoked), time & location of incidence, vaccination & health status of animal, current location of the animal
• regarding the victim: tetanus immunization status, first aid measures, history of immunocompromise, symptoms of musculoskeletal, neurologic or vascular compromise

cough:

• duration, rate of onset, fever/chills, sputum (quality), dyspnea, pleuritic chest pain, orthopnea, sore throat, rhinorrhea, headache, stiff neck, ear pain, nausea/vomiting, diarrhea, arthralgia, myalgia, smoking, recent antibiotics, exposure to tuberculosis or asbestos, travel, ill contacts, pneumococcal & influenza vaccination

diarrhea:

• onset, duration frequency, volume, timimg (daytime only with mucous stools suggests irritable bowel syndrome, fever, abdominal pain, cramping, tenesmus, nausea/vomiting, ability to keep foods down, bloating, light-headedness, myalgias, arthralgia, headache, buoyancy, blood or mucus, pus, oily?, odorspoiled, raw or undercooked poultry (Salmonella), milk, seafood, restaurants, travel, effect of fasting (fasting decreases osmotic diarrhea, but has no effect on secretory diarrhea), laxative abuse, ill contacts, diabetes, inflammatory bowel disease, alcoholism, hyperthyroidism, family history of celiac disease, risk factors for AIDS

dizziness:

• duration of symptoms, episodic nature, severity, positional effects, hearing loss, weakness, ataxia, paresthesias, diplopia, tinnitus, nausea/vomiting, head trauma, recent upper respiratory tract infection, ear infections

dyspnea:

• rate of onset, orthopnea, paroxysmal nocturnal dyspnea, effect of physical exertion, history of myocardial infarction, history of syncope, prior episodes of dyspnea, aggravating or relieving factors, edema, weight gain, cough, sputum, fever, nausea, HIV risk factors, history of asthma, occupational exposure

edema:

• duration, localized vs generalized, associated pain or redness, dyspnea, history of heart failure, liver disease, renal disease, thyroid disease, pregnancy, estrogens, steroids, vasodilators, exacerbation by menses or position, malnutrition

fever:

• onset, pattern, cough, sputum, sore throat, headache, neck stiffness, dysuria, frequency, night sweats, vaginal discharge, back pain, myalgia, nausea/vomiting, diarrhea, chest pain, abdominal pain, ear pain, arthralgias, bone pain, recent antipyretic use, diabetes, valvular heart disease, recent surgery, HIV risk factors, travel, exposure to tuberculosis, hepatitis, animals, ill contacts, recentantibiotic use

GI bleed:

• duration, quantity & color of bleeding, change in bowel habits or stool caliber, abdominal pain, fever, constipation, diarrhea, epistaxis, weight loss, nausea/vomiting, fecal mucus, fecal pus, tenesmus, lightheadedness, hematemesis, anorectal pain, easy bruising, recent antibiotics (pseudomembranous colitis), NSAID use, anticoagulants, diverticulosis, hemorrhoids, colitis, peptic ulcer disease, heartburn, bleeding disorder, colonic polyps, cirrhosis, alcoholism

hematuria:

• dysuria, frequency, pain, fever, bleeding between voidings, menstruation, renal stones & passage of stones, joint pain,color, timing,
  • pattern:
    • initial hematuria (anterior urethral lesion)
    • terminal hematuria (bladder neck or prostate lesion)
      • hematuria throughout voiding (bladder or upper urinary tract),
  • recent sore throat, streptococcal skin infection or upper respiratory tract infection, prior kidney infections, joint pain, travel, exposure to toxins

hemoptysis:

• rate of onset, quantity of blood, color, character of sputum (clots, food), dyspnea, pleuritic chest pain, smoking, fever/chills, exposure to tuberculosis or asbestos, hematuria, weight loss, farm exposure, foreign body aspiration, nasal or sinus pain, HIV risk factors, leg pain or swelling (PE), valvular heart disease, anticoagulants, NSAIDs, family history of bleeding disorder

hypertension:

• duration, baseline blood pressure, chest or back pain, headaches, dyspnea, orthopnea, dizziness, blurred vision, nausea/vomiting, tremor, palpitations, diaphoresis, diarrhea, edema, hematuria, dysuria, polyuria, flank pain, thyroid disease, heart failure, alcohol withdrawal, non-compliance with antihypertensive agents (esp clonidine or beta-blocker)

PAIN:

abdominal pain:

• duration, pattern of progression, location at onset, present location, character of pain (burning, cramping, dull, sharp, constant or intermittent), rate of onset, fever/chills, nausea/vomiting, hematemesis, temporal relationship of vomiting to abdominal pain, chest pain, constipation, change in bowel habits, obstipation, diarrhea, dysuria, hematuria, hematochezia, melena, anorexia, weight loss, dysphagia, trauma

chest pain:

• duration, location, radiation, character, intensity, rate of onset, relationship to activity, relief by nitroglycerin, rest, or antiacids, changes in frequency or severity of chest pain, occurrence during rest or sleeping, diaphoresis, nausea/vomiting, dyspnea at rest or on exertion, orthopnea, edema, palpitation, hemoptysis, dysphagia, cough, sputum, paresthesia, syncope, fever/chills, effect of: inspiration, cough, position, arm, chest or neck movement, eating, NSAIDs, alcohol, exertion

pelvic pain

• character, intensity, location, radiation, onset, duration, frequency, remissions, exacerbations, aggravating factors, ameliorating factors, vaginal discharge, vaginal bleeding, dysuria, frequency, hesitancy, nausea/vomiting, diarrhea, constipation, hematochezia, melena, fever, last menstrual period, sexual activity, sexual partner(s), dysparunia, sexual trauma, IUD, birth control, vaginal douching

palpitation:

• dizziness, nausea, dyspnea, edema, chest pain, pleuritic chest pain, syncope, weakness, fatigue, diaphoresis

seizure:

• timing of onset, duration, description of seizure, past seizures, compliance with medications, aura, incontinence, salivation, vomiting, aspiration, post-ictal weakness, prodrome, history of TIA, stroke or migraine, fever/chills, diabetes, family history

syncope: time & location where unconsciousness occurred, duration of unconsciousness, onset, witnesses, seizure activity, post-ictal state, activity when it occurred, precipitants: cough, micturition, defecation, exertion, Valsalva, hyperventilation, chest pain, trauma, palpitations, prodrome, hemoptysis

stroke/TIA

• onset, improvement or progression of symptoms, anatomic location of deficit, activity prior to onset, headache, nausea/vomiting, loss of consciousness, brisk neck movement, visual aura, scotoma, vertigo, seizure, trauma, confusion, dysarthria, incontinence, dysphagia, palpitations, prior TIAs or strokes, amaurosis fugax, HTN, diabetes, CAD, hyperlipidemia, IVDA, cocaine, valvular heart disease, migraine, anticoagulants, oral contraceptives, tobacco, alcohol

urinary incontinence:

• malignancies, neuroendocrine disorder, pelvic surgery or irradiation, parity, frequency, dysuria, hematuria, fever, polydipsia, weight gain, change in bowel habits, sexual function, sensory or motor symptoms

vaginal bleeding:

• pattern of bleeding: onset, duration, intensity, clots, pads/day, last menstrual period, contraceptives, sexual history, sexual abuse, drug history, vasomotor flushing, pain, fever/chills, lightheadedness, coagulopathy, thyroid disease, renal disease or hepatic disease

vertigo (see dizziness)

More general terms

• medical history

Additional terms

• family history
• past medical history (PMHx)

Components

• chief complaint (CC)