HISTORY OF PRESENT ILLNESS (HPI)

 

 
HISTORY OF PRESENT ILLNESS (HPI) 

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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

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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

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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.