History of Present Illness Answers

Stalking the History of Present Illness

Signs and Symptoms

Define Sign: What you observe - the Objective

Define Symptom: What the patient tells you - the Subjective

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: Location

Q? Quality

Q? Quantity

Timing? How Long? - Duration

Timing? How Often? - Frequency

What? What makes it better?

What? What makes it worse?

Associated? Other Symptoms

Effect? Impact on the Patient

What? What Does the Patient Think?

The Case of the Dizzy Medical Student (Precision)

I'm Dizzy 1: Room Spinning - Vertigo

I'm Dizzy 2: Almost Blacked Out - Syncope

I'm Dizzy 3: Hard to Walk - Instability

I'm Dizzy 4: Light Headedness

Common Mistakes

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

What's Wrong? Leading Question

"Does anything make it better or worse?

What's Wrong? Multi-Part Question

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

Avoid? Jargon

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.