History of present illness

History of present illness (HPI)

History of patient’s compliant/illness is essential and the most important aspect of the information gathering process. First and most important step towards a correct diagnosis.

To obtain good history:
1) Put patient at ease
1) Interpersonal skills in communication – a good listener
2) Always introduce self – often helpful to shake hands
2) Having the patient volunteering as much as is needed
3) Giving the patient the opportunity to describe the complaint/illness
4) Questioning by the clinician
5) Sufficient time

Need:
• Description
• Location
• Onset
• Evolution/chronology
• Traumatic events
• Course
• Duration
• Severity
• Factors influencing (precipitating, aggravating and relieving factors)
• Prior treatment

Has been a tendency to rely too heavily on more sophisticated investigative techniques at the expense of a good history.

Source of the history should be noted – especially if elements of it were given by a parent, relative or caregiver.

If some elements of the history are uncertain, it should be noted especially if English is not the patients first language.

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Page last updated: @ 11:55 pm