History Present Illness Explained for Students (Easy Guide)

This type of question evaluates analytical and critical thinking skills.

What This Question Is About

This question relates to history present illness and requires a structured academic response.

How to Approach This Question

Use appropriate theories and support your answer with clear reasoning.

Key Explanation

This topic involves history present illness. A strong answer should include explanation, application, and examples.

Original Question

HPI (History of Present Illness) – describe the chief complaint in a chronologic manner and include symptom dimensions. Use PQRST or OLDCARTS mnemonic to guide you in obtaining pertinent information. First sentence should include patient’s identifying data, including age, gender, (and race if clinically relevant),and pertinent past medical history. If the information is obtained from other sources, always identify source. Incorporate elements of the PMHx, FHx, and SHx relevant to the patient’s chief complaint. Include pertinent positives and negatives based on relevant portions of the R.O.S. HPI should present the context for the differential diagnoses. PMH (past medical history) – major illnesses and conditions, hospitalizations, blood transfusions Describe medical conditions in details such as date of onset, treatment, hospitalizations, and possible complications Surgical Hx Dates and types of operations Health Maintenance – immunization and screening exams Age – appropriate health maintenance (ex. Pap smears, mammograms, lipid testing, hgbA1C, colon cancer screening, eye and dental exams, skin cancer screening, use of sunscreen, etc…) and immunizations Family History – major illness and health status, genetic defects (comment on the age and health status of living family members or cause of death and age of deceased members) Social History – social aspects (e.g., occupation, socioeconomic status, quantify any tobacco, alcohol, or drug use etc.) of the patient’s life that might be pertinent to the patient’s health. Include relevant sexual history. Note any safety concerns. Assess patient’s functional status and ability to complete ADLs. Medications – Current medications (list with daily dosages). Allergies – describe the nature of the adverse reaction ROS (review of systems) – head to toe system-based list of questions that help uncover symptoms not otherwise mentioned by the patient. Follow the proper order of the different systems. Review each system in details. “Refer to HPI” if question responses are documented in the HPI. OBJECTIVE (25 points) Vital signs PE – Head to toe physical exam. Follow the proper order of the different systems of PE and provide a detailed description of each system based on observation. “Normal exam” terminology not accepted for the purpose of this assignment. Laboratory or diagnostic data obtained prior to this visit and dated, if applicable. Laboratory or diagnostic data obtained during this visit and are part of the work-up to confirm or exclude a diagnosis belong under Plan ASSESSMENT (Problem List) with ICD-10 Codes (15 points) This section documents the synthesis of “subjective” and “objective” evidence to arrive at a diagnosis. This is the assessment of the patient’s status through analysis of the problem, possible interaction of the problems, and changes or progress in the status of the problems. List the problem list (diagnosis/es) in order of importance. The assessment could also contain the possible causes of the patient’s problem, especially if the patient is experiencing an illness. If the patient had made a visit before, it should also contain the progress which had been made since the last visit as well as the overall progress towards fully treating the symptoms, based on the perspective of the main physician. Assessment should also address chronic illnesses, which should be listed after the primary diagnosis. For ex. in case of HTN, assess how well the patient’s BP is controlled based on patient’s reports and on PE. If uncontrolled, how do you think this patient’s BP should be better managed (by interventions during this visit or referral to other specialists). Same applies to other patient’s chronic conditions. PLAN (25 points) This has to be evidence-based using the latest clinical guideline. For the comprehensive SOAP, this should also include health promotion recommendations and disease prevention screening and chronic conditions, based on clinical guidelines. Pharmacologic, non-pharmacologic, Lab/diagnostics, education, referrals and follow-up – when applicable. The plan should be personalized and appropriate for the patient. The plan should address all the problems in Assessment. DIFFERENTIAL DIAGNOSES EVIDENCE-BASED RATIONALE (10 points) Briefly discuss the rationale of the plan. Include clinical guidelines used, cite. Identify 3 differential diagnoses related to the chief complaint. Include the most LIKELY diagnosis/diagnoses in your differential. Order your differentials to reflect the most likely or more serious first. For each diagnosis, include a brief rationale for each differential diagnosis (3-4 sentences) – rationale should provide physiologic data that support your differential diagnoses and elements from the patient’s history, physical, lab results, diagnostic test results, that help you confirm or refute the diagnosis. Explain what makes it likely and what makes it less likely. Cite. Briefly discuss the rationale of the plan. Provide clinical guidelines used to support the plan, cite. does a comprehensive soap note include a physical plus a new complaint in order to cover these requirements?

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