History of Present Illness
Doctors arrive at most diagnoses based on the patient’s history, even in the modern era. Studies comparing final diagnoses with physicians’ leading diagnoses after the history, after the physical, and after testing, show that most correct diagnoses are suggested by the history.
Because the history of present illness is the highest yield part of the encounter, you should plan to spend the most time on it. Take at least twenty minutes to practice this with your hospital patients, using both data gathering and relationship building skills.
Diagnoses suggested by each part of patient encounter1,2
History 
Physical exam 
Labs and imaging
Eliciting the HPI
Start with open-ended questions
After greeting the patient, establishing the chief concern, and discussing the agenda, start the patient’s narrative with an open-ended question or request.
Guide the story and explore the details
Next, draw out more of the patient’s illness narrative, guiding them with more open questions, gentle directives, and reflections. Your goals are to:
- elicit a complete and precise description of the symptoms
- clarify the time course
- understand the patient’s perspective and impact of the illness
Summarize what you’ve heard to check for accuracy and encourage the patient to share any details they may have left out.
Follow up with closed-ended questions
Switch to closed-ended questions about symptoms or risks that might differentiate between the diseases you’re considering. As a first-year student, you can simply ask about other symptoms from the organ system that you think is causing your patient’s problem. The Review of Systems section will help.
Explore patient perspective and attribution
The patient’s perspective is an important – and often overlooked – element of the history, including their feelings, ideas and concerns about their illness and its impact on their daily lives.
Attribution refers to your patient’s ideas about the reason for their symptoms – ask “what do you think might be causing this?” The answer to this question is sometimes diagnostically helpful – your patient might be right! Attribution also provides insight into their underlying concerns and cultural context that could impact care.
You can also explore the impact of the illness on your patient’s life, with questions like:
- How has this affected your life?
- How are you coping with all of this?
- How has this affected your ability to do what you need to do?
- How has this impacted you emotionally?
Example HPI
Eliciting the HPI: Helpful tools
Although there are over 10,000 known human diseases, patients present with fewer than 200 symptoms. A careful, complete and detailed description of the presenting concern will help differentiate among the many possible causes.
Communication techniques
| Technique | Purpose | Example |
|---|---|---|
| Open-ended Qs | Encourage the patient to share their concerns | “What brings you in today?” |
| Gentle directives | Encourage patient to share their concerns | “Tell me about your headaches.” |
| Continuers | Encourage patient to keep talking | Head nodding, facial expressions, “Uh-huh” |
| Reflection or echoing | Encourage patient to expand | Patient: “And then I lost vision in one eye.” Physician: “You lost your vision” |
| Focused Qs | Fill in details about symptoms and time course | “Did anything make your headache better or worse?” |
| Summary | Check for accuracy & elicit last details | “It sounds like this headache is in both temples. It started all of a sudden yesterday, after a stressful meeting and it’s gotten worse and worse.” |
| Closed-ended questions | Clarify details & test diagnostic hypotheses | “Any weakness in your legs?” |
OPQRSTAAA
Consider a patient presenting with abdominal pain – a careful history can limit the possibilities substantially. Severe pain that came on suddenly would lead you to consider different diagnoses than mild, intermittent pain. The list of diseases that cause pain in the upper right abdomen is different from those that cause pain on the left. Relief with antacids would suggest heartburn or ulcers. Each of these details can be diagnostically useful – and you can gather them even before learning about causes of this chief concern.
| OPQRSTAAA: A mnemonic for defining symptoms | |
|---|---|
| O nset | How did this start? What was the first thing you noticed? |
| P osition | Where in the body did you feel it? |
| Q uality | Tell me what the pain was like. Was it sharp, throbbing, dull? |
| R adiation | Did you feel it anywhere else in your body? |
| S everity | How bad was it? Were there things it kept you from doing? |
| T iming | Did it get better or worse? Come and go? |
| A ggravating factors | Is there anything that made it worse? |
| A lleviating factors | Is there anything that made it better? What did you try? |
| A ssociated symptoms | Was there anything else you noticed? |
Establish a clear chronology
The diseases that cause acute and chronic presentations of the same symptom are often different. In general, a symptom with a “sudden” onset came on over minutes; an acute symptom over hours to days; subacute over weeks to a few months; and a chronic symptom has been present for longer than several months.
Understanding the acuity of symptoms both helps with diagnosis and determines the urgency of the workup. A patient who has had similar headaches for years is unlikely to have a severe problem, but new onset headache could be something serious.
The temporal relationship between different symptoms and treatments can also be diagnostically useful. For example, patients with infectious gastroenteritis usually develop nausea or diarrhea first, before they have any abdominal pain. Those with surgical problems usually develop pain first. Be sure you understand which symptom came first and how others followed.
If the time course of your patient’s illness is unclear, clarify it by asking questions like:
- When did you last feel well?
- What was the first thing you noticed?
- What happened next?
- How have things changed since (start of symptoms)?
Transition to the past medical history
Once you have a complete picture of the HPI, summarize one more time and check to see if there is anything else that your patient would like to add. Then transition explicitly to the next stage of the interview, with a phrase like “Next I’d like to ask about other health problems you may have.”
References & resources
- Peterson, MC, Holbrook, JH, Von Hales, D, Smith, NL, Staker, LV. Contributions of the history, physical examination, and laboratory investigation in making medical diagnoses. West J Med. 1992;156:163–165.
- Hampton, JR, Harrison, JM, Mitchell, JR, Prichard, JS, Seymour, C. Relative contributions of history-taking, physical examination, and laboratory investigation to diagnosis and management of medical outpatients. Br Med J. 1975;2:486–489