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
• Traumatic events
• 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.