History of Present Illness Exercise

Stalking the History of Present Illness

Signs and Symptoms

Define Sign:

Define Symptom:

Remember

• One Complaint at a time
• Start with an open-ended question
• Move from general to specific
• Move form qualitative to quantitative

What Do You Want to Know?

Where? Also known as:

Q?

Q?

Timing?

Timing?

What?

What?

Associated

Effect?

What?

The Case of the Dizzy Medical Student (Precision)

I'm Dizzy 1:

I'm Dizzy 2:

I'm Dizzy 3:

I'm Dizzy 4:

Common Mistakes

"You didn't cough up any blood did you?"

What's Wrong?

"Does anything make it better or worse?

What's Wrong?

Don't be afraid to use the patient's own words

Avoid?

Problem-Oriented Records

S - Subjective - What the patient tells you

O - Objective - What you observe

A - Assessment - What you think is going on

P - Plan - What you intend to do

Your Job

To be as objective as possible while you elicit and record the patient's subjective experience of their problem.