HISTORY OF PRESENT ILLNESS (HPI)

 

 
HISTORY OF PRESENT ILLNESS (HPI) 

---

GENERAL FORMAT TO START HPI IN WARD ROUNDS

1. Open-ended Introduction:

• "Can you please describe what brings you here today?"
• "When did you first notice something was wrong?"
• "How has this affected your day-to-day activities?"

2. Symptom Timeline Clarification:

• "Was the onset sudden or gradual?"
  • Sudden
  • Gradual
• "Is it constant or intermittent?"
  • Constant
  • Intermittent: Hourly / Daily / Weekly / Monthly
• "Has the problem worsened, improved, or stayed the same?"
  • Worsening
  • Improving
  • No change

3. Severity:

• "How severe is the symptom on a scale from 0 to 10?"
  • 0–3: Mild
  • 4–6: Moderate
  • 7–10: Severe

4. Associated Symptoms:

• "Did anything else accompany this issue—pain, fever, swelling, or other complaints?"

5. Modifying Factors:

• "What makes it better or worse?"
  • Movement
  • Position change
  • Food intake
  • Medication
  • Time of day
  • Rest

6. Functional Impact:

• "Has this affected your ability to sleep, eat, walk, or work?"

7. Self-Treatment & Response:

• "Have you taken any treatment for this?"
  • Over-the-counter
  • Prescription
  • Home remedy
  • None
• "Did it help?"
  • Yes / No / Partially

---

SYSTEM-SPECIFIC QUESTIONS

MUSCULOSKELETAL

• Location of Pain/Swelling/Stiffness: Neck / Shoulder / Arm / Lower back / Hip / Knee / Foot
• Radiation? Yes / No → If yes, where?
• Character: Sharp / Dull / Burning / Cramping / Throbbing / Shooting
• Stiffness: Morning / After rest / Evening / Continuous
• Joint Deformity? Yes / No
• Redness/Heat? Yes / No
• Pain on Movement? Yes / No → Active / Passive / Both
• Any history of trauma or overuse?

GASTROINTESTINAL

• Abdominal pain? Yes / No → Site / Onset / Radiation / Character / Relation to food
• Appetite: Normal / Increased / Decreased
• Nausea/Vomiting: Frequency / Contents / Relation to food
• Bowel Changes: Constipation / Diarrhea / Alternating
• Stool Appearance: Normal / Pale / Blood / Black / Mucus
• Abdominal Distension / Flatulence? Yes / No

CENTRAL NERVOUS SYSTEM

• Headache: Location / Type / Duration / Frequency / Triggers
• Visual changes: Blurred / Double / Loss
• Speech problems: Slurring / Word-finding difficulty
• Weakness or Numbness: One-sided / Both-sided / Intermittent / Persistent
• Gait Abnormality / Imbalance? Yes / No
• Seizures or LOC? Yes / No → Description

CARDIOVASCULAR

• Chest Pain: Site / Character / Radiation / Duration / Aggravated by exertion?
• Palpitations: Rapid / Irregular / Awareness
• Shortness of breath: At rest / On exertion / Orthopnea / PND
• Leg Swelling: Unilateral / Bilateral / Pitting / Non-pitting
• Fainting or Dizziness? With exertion / Postural / Random

RESPIRATORY

• Cough: Productive / Dry / Hemoptysis
• Breathlessness: At rest / On exertion / Positional
• Wheezing / Noisy Breathing: Yes / No
• Chest Pain: Pleuritic / Constant / Localized
• Sputum: Color / Quantity / Odor

HORMONAL / ENDOCRINE

• Weight change: Gained / Lost / Stable
• Appetite: Increased / Decreased / Normal
• Thirst and Urine frequency: Increased / Normal
• Heat/Cold Intolerance?
• Fatigue/Weakness: Persistent / Intermittent
• Menstrual history (females): Regular / Irregular / Amenorrhea
• Skin/Hair Changes: Dryness / Hair loss / Excessive hair

---

SAMPLE HPI: PATIENT WITH SCIATICA

Chief Complaint: Pain in the lower back radiating to the right leg for 7 days.

History of Present Illness: Mr. Ramesh, a 45-year-old male, presented with complaints of low back pain that started 7 days ago after lifting a heavy bag. The pain was sudden in onset, initially localized to the lower back but gradually began radiating to the back of the right thigh and calf, reaching up to the foot over the next 2 days.

He describes the pain as a sharp, shooting sensation, rated 8/10 in severity. It worsens with walking, prolonged standing, and bending forward, and is relieved partially by lying on a hard surface. He reports associated numbness and tingling along the same pathway but denies any weakness or bowel/bladder incontinence.

He attempted home remedies and took ibuprofen with partial relief. He reports no recent fever, weight loss, or history of similar episodes. He has no known history of diabetes or trauma. On further questioning, he admits difficulty sleeping due to pain at night but continues attending work with difficulty.

No symptoms suggestive of cauda equina syndrome.

System Review:

• CNS: No headache, seizure, LOC, visual issues.
• CVS: No chest pain, palpitations, or syncope.
• Respiratory: No cough, dyspnea, or wheeze.
• GI: Normal appetite and bowel movements.
• Musculoskeletal: Right leg pain radiating from back, no joint swelling or stiffness.
• Endocrine: No recent weight change or abnormal thirst.

COMPREHENSIVE MEDICAL HISTORY TAKING

---

1. IDENTIFICATION DATA

• Name:
• Age:
• Sex:
• Occupation:
• Address:
• Marital Status:
• Date of Admission / Consultation:
• Informant (and reliability):

---

2. CHIEF COMPLAINT(S)

• Presenting symptom(s):
  • Nature of symptom:
    • Pain (burning, dull, throbbing, sharp, colicky, cramping)
    • Swelling (pitting/non-pitting, localized/generalized)
    • Fever (low-grade, high-grade, intermittent, continuous, remittent)
    • Cough (dry, productive, hemoptysis, barking)
    • Others (as per specific system)
• Duration of each complaint:
• Sequence of onset:
• Severity of each:
• Effect on activities of daily living:
• Day/night variation:

Associated Complaints

• Complaint:
• Duration:
• Temporal association with chief complaint:
• Significance or complications:

---

3. HISTORY OF PRESENT ILLNESS

A. Onset

• Sudden / Gradual
• Exact time/date of onset
• Initial symptom noticed

B. Progression

• Static / Progressive / Relapsing-remitting
• Episodic or continuous
• Speed of worsening (rapid/slow)

C. Characterization of Each Complaint

• Location: Precise anatomical site
• Radiation: Yes/No; if yes, where?
• Type of pain:
  • Dull, sharp, throbbing, burning, stabbing, colicky, constricting
• Severity: VAS scale (1-10)
• Frequency: Constant/intermittent
• Diurnal variation: Morning, night, throughout

D. Triggering Factors

• Activity related: Walking (e.g., claudication, sciatica)
• Position-related: Lying down (e.g., orthopnea), bending
• Meals: After fatty meals (e.g., biliary colic)
• Environmental: Cold air (e.g., asthma), dust, pollen
• Emotional stress
• Menstrual cycle

E. Relieving Factors

• Rest
• Medication
• Change in posture
• Food or fasting
• Home remedies

F. Similar Complaints in Past

• Yes / No
  • If yes:
    • Number of episodes:
    • Duration and frequency:
    • Similarity in severity and presentation:
    • Resolution and intervention used:

G. Treatment Taken

• Type of healthcare approached
• Investigations done:
• Medications used:
• Any improvement:

H. Functional Impact

• Impaired mobility
• Sleep disturbance
• Absenteeism from work/school
• Dependence on others

I. Systemic Correlation

• Respiratory: Cough, breathlessness, sputum (mucoid/purulent), hemoptysis, wheeze
• Cardiovascular: Chest pain (exertional/rest), palpitations, syncope, orthopnea, PND
• Gastrointestinal: Nausea, vomiting, appetite, heartburn, bloating, bowel habits
• Neurological: Headache, dizziness, weakness, numbness, seizures, vision/hearing issues
• Musculoskeletal: Joint pain/swelling, morning stiffness, muscle cramps, deformity
• Genitourinary: Burning micturition, urgency, hesitancy, frequency, nocturia, hematuria
• Skin: Rashes, itching, dryness, lesions, ulcers

---

4. PAST HISTORY

A. Medical History

• Hypertension
• Diabetes Mellitus
• Asthma / COPD
• Tuberculosis
• Epilepsy
• Liver disorders (Hepatitis, cirrhosis)
• Kidney disorders (stones, CKD)
• CAD / MI
• Stroke / TIA
• Psychiatric illness

B. Surgical History

• Past surgeries:
  • Type
  • Indication
  • Year
  • Complications (if any)

C. Hospitalizations

• Reason
• Duration
• Treatment given

D. Blood Transfusions

• Yes / No
  • If yes:
    • Date
    • Number of units
    • Reason
    • Reactions

E. Drug History

• Current medications:
• Past long-term medications:
• Self-medication habit:

F. Allergy History

• Drug allergies (e.g., penicillin, sulpha)
• Food allergies (e.g., nuts, seafood)
• Environmental (e.g., dust, pollen, latex)
• Type of reaction: rash, breathing difficulty, anaphylaxis

G. Immunization Status

• Childhood immunizations
• Tetanus, Hepatitis B, COVID vaccine status

---

5. PERSONAL HISTORY

A. Dietary Pattern

• Vegetarian / Non-vegetarian / Mixed
• Appetite:
  • Normal / Increased / Decreased
  • Sudden changes
  • Cravings or aversions
• Recent weight changes:
  • Weight gain / Weight loss (intentional or unintentional)
• Fluid intake: adequate/inadequate

B. Bowel Habits

• Frequency: daily/alternate days/constipation/diarrhea
• Consistency:
  • Formed, hard, loose, watery, ribbon-like, greasy, clay-colored
• Blood/mucus: Yes/No
• Any incontinence or urgency

C. Bladder Habits

• Frequency: polyuria/oliguria
• Urgency, hesitancy, dribbling
• Nocturia: present/absent
• Burning micturition
• Hematuria

D. Sleep Pattern

• Duration: <4h / 4–6h / 6–8h / >8h
• Quality:
  • Restful, disturbed, difficulty initiating, early waking
• Sleep disorders: insomnia, hypersomnia, snoring, apnea

E. Addictions

• Smoking:
  • Type (bidi/cigarette), packs/day, years
• Alcohol:
  • Type, quantity, frequency, binge pattern
• Tobacco (chewing, gutka, pan): frequency and duration
• Others: cannabis, opioids

F. Sexual History

• Marital status
• Age at first intercourse
• Number of partners
• Contraceptive use
• Risk behavior or STDs

G. Menstrual History (Females)

• Age at menarche
• Cycle regularity, interval, duration
• Amount of bleeding (scanty/moderate/heavy)
• LMP
• Menopause (if applicable): age, symptoms

H. Obstetric History

• Gravida, Para, Abortion, Living children (G-P-A-L)
• Mode of deliveries
• Complications (e.g., PPH, eclampsia)

---

6. FAMILY HISTORY

• Similar illness in family
• History of hereditary diseases (e.g., hemophilia, thalassemia)
• Chronic illnesses (DM, HTN, TB, asthma, CAD, psychiatric illnesses)
• Consanguinity

---

7. SOCIOECONOMIC HISTORY

• Monthly income / family income bracket
• Type of housing (pucca/kachcha, overcrowding)
• Water and sanitation facilities
• Education level
• Occupation and occupational exposures
• Dependents and social support

---

8. GENERAL EXAMINATION

• General condition: Conscious/Oriented
• Build & nourishment: Ectomorphic/Mesomorphic/Endomorphic
• Pallor
• Icterus
• Cyanosis
• Clubbing (Grade I–IV)
• Lymphadenopathy: Site, size, tenderness, mobility
• Edema: Pitting/non-pitting, localized/generalized
• Height, Weight, BMI
• Vitals:
  • Pulse (rate, rhythm, volume, character)
  • Blood pressure (sitting, supine, standing)
  • Temperature
  • Respiratory rate
  • SpO2 (room air)

---

9. SYSTEMIC EXAMINATION (To follow history and general examination)

• Respiratory System
• Cardiovascular System
• Abdomen (Gastrointestinal)
• Central and Peripheral Nervous System
• Musculoskeletal System
• Genitourinary System

---

SOME COMMON DISEASES OF MUSCULO-SKELETAL SYSTEM

 

---

1. Osteoarthritis (OA)

Etiology:

• Age-related cartilage degeneration
• Obesity (weight-bearing joints)
• Previous joint trauma or surgery
• Genetic predisposition

Clinical Features:

• Pain that worsens with activity and improves with rest
• Morning stiffness lasting <30 minutes
• Crepitus, joint line tenderness, and bony swelling
• Restricted range of motion (ROM)
• Common sites: knees, hips, cervical/lumbar spine, DIP joints (Heberden’s nodes)

High-Yield Differentiating Feature:

• Asymmetrical joint involvement, especially weight-bearing joints
• Presence of bony outgrowths (osteophytes)
• Minimal systemic symptoms

Differential Diagnosis:

• Rheumatoid Arthritis (RA) – symmetrical joint involvement, prolonged morning stiffness, systemic symptoms
• Gout – acute onset, red and hot joint
• Psoriatic arthritis – associated skin lesions, nail pitting

Symptom Assessment:

• Joint pain character and duration
• Relation with activity/rest
• Functional limitations
• History of trauma or repetitive use

Diagnostics:

• X-ray: Joint space narrowing, osteophytes, subchondral sclerosis, cysts
• ESR/CRP: Usually normal
• Joint aspiration: Non-inflammatory fluid

---

2. Rheumatoid Arthritis (RA)

Etiology:

• Autoimmune disorder targeting synovial joints
• Female predominance (20-50 years)
• HLA-DR4 association

Clinical Features:

• Symmetrical polyarthritis – affects small joints first (MCP, PIP, wrists)
• Morning stiffness lasting >1 hour
• Joint deformities (ulnar deviation, swan-neck, boutonnière)
• Extra-articular features: nodules, anemia, scleritis, lung fibrosis

High-Yield Differentiating Feature:

• Symmetrical small joint involvement + prolonged morning stiffness
• Positive Rheumatoid Factor (RF) and Anti-CCP antibodies

Differential Diagnosis:

• OA – larger joints, asymmetrical, less morning stiffness
• SLE arthritis – no erosions, reversible joint symptoms
• Viral arthritis – self-limited, short duration

Symptom Assessment:

• Joint pattern, stiffness duration, constitutional symptoms
• Family history, systemic signs

Diagnostics:

• Blood tests: RF (70%), Anti-CCP (high specificity)
• Elevated ESR/CRP
• X-ray: Marginal erosions, periarticular osteopenia, joint space narrowing

---

3. Gout

Etiology:

• Hyperuricemia (diet rich in purines, alcohol, CKD, diuretics)
• Male predominance
• Metabolic syndrome association

Clinical Features:

• Sudden onset of severe joint pain, swelling, and redness
• Classically affects 1st MTP joint (podagra)
• Pain at night, triggered by alcohol/food
• Tophi in chronic gout

High-Yield Differentiating Feature:

• Monoarticular arthritis of 1st toe, rapid onset, and tophus formation
• Crystal identification: Needle-shaped, negatively birefringent under polarized light

Differential Diagnosis:

• Septic arthritis – fever + systemic illness + purulent aspirate
• Pseudogout – affects knee, rhomboid crystals, positively birefringent
• RA – symmetrical, chronic, systemic features

Symptom Assessment:

• Alcohol/diet history, sudden pain, location, recurrence

Diagnostics:

• Serum uric acid: Often elevated, may be normal during attack
• Joint aspiration: Monosodium urate crystals
• X-ray: Erosions with overhanging edges in chronic cases

---

4. Ankylosing Spondylitis (AS)

Etiology:

• Chronic inflammatory disease of axial skeleton
• Young males (teens to 30s), HLA-B27 positive

Clinical Features:

• Chronic low back pain, better with exercise, worse at rest
• Morning stiffness >30 minutes
• Reduced spine mobility – positive Schober test
• Sacroiliac joint tenderness
• Extra-articular: anterior uveitis, aortic regurgitation

High-Yield Differentiating Feature:

• Insidious onset back pain in young male + improvement with activity + sacroiliitis
• Bamboo spine in late stage

Differential Diagnosis:

• Mechanical back pain – no stiffness, worsens with activity
• Disc herniation – radicular pain, neuro signs
• Psoriatic arthritis – similar axial involvement but with skin lesions

Symptom Assessment:

• Age at onset, activity relationship, stiffness duration
• History of uveitis or psoriasis

Diagnostics:

• X-ray pelvis: Sacroiliitis, syndesmophytes, bamboo spine
• MRI: Early changes
• HLA-B27: Positive
• ESR/CRP: Elevated

---

5. Septic Arthritis

Etiology:

• Hematogenous spread or direct inoculation (trauma, surgery)
• Common organisms: Staphylococcus aureus, Neisseria gonorrhoeae

Clinical Features:

• Acute monoarthritis, intense pain, fever, and swelling
• Joint held in semi-flexed position
• Reduced ROM, tender, warm joint

High-Yield Differentiating Feature:

• Hot, swollen, tender joint with fever and systemic toxicity
• Requires emergency management

Differential Diagnosis:

• Gout – no fever, crystals in aspirate
• RA flare – no acute systemic signs
• Reactive arthritis – post-infectious, usually polyarthritis

Symptom Assessment:

• Fever, trauma, immunocompromised state, joint involved

Diagnostics:

• Joint aspiration: Purulent, WBC >50,000/mm³, Gram stain & culture
• Blood culture: Positive in 50%
• X-ray: May show joint space narrowing or destruction in late stages

---

6. Osteoporosis

Etiology:

• Postmenopausal estrogen deficiency
• Age-related, sedentary lifestyle
• Long-term corticosteroids, thyroid disorders

Clinical Features:

• Silent disease until fracture occurs
• Common fractures: vertebral compression, Colles’ fracture, hip fracture
• Loss of height, kyphosis

High-Yield Differentiating Feature:

• Fragility fractures with normal calcium/phosphate levels
• T-score ≤ -2.5 on DEXA

Differential Diagnosis:

• Osteomalacia – bone pain, proximal myopathy, low Vitamin D
• Multiple myeloma – pathological fractures, anemia, hypercalcemia

Symptom Assessment:

• Fracture history, risk factor evaluation, lifestyle

Diagnostics:

• DEXA scan: Gold standard
• Serum calcium, phosphate: Normal
• ALP: Normal or mildly elevated
• X-ray: Vertebral collapse, increased radiolucency

---