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LAB SESSION #1

MEDICAL INTERVIEW:  THE HISTORY OF PRESENT ILLNESS

“The physician enjoys a wonderful opportunity actually to witness the words being born.  Their actual colors and shapes are laid before him carrying their tiny burdens, which he is privileged to take into his care with their unspoiled newness.  He may see the difficulty with which they have been born and what they are destined to do.  No one else is present but the speaker and ourselves; we have been the words’ very parents.  Nothing is more moving.”
- William Carlos Williams, MD, 1883 - 1963

Learning Objectives

1.         Take a chief complaint and history of present illness from your small group instructor or MS4 teaching assistant.

2.         Record the history briefly during the interview. 

3.         Write the HPI narrative and submit to your small group faculty instructor electronically. You must also submit a copy to the course coordinator, Kristin Hilty.

        

Resources

Bates textbook: Chapter 1, pg 3 – 20, Chapter 2, pg 23 – 53
Bates videotape:  Approach to the Patient; Head-To-Toe Assessment

General Information

  • Spend a few minutes at the beginning of lab to introduce yourself to your group and briefly tell the students a little bit about you, your specialty, and practice setting.  Please allow some time for your MS4 teaching assistant for an introduction also.

  • The goal is to gain experience in taking a history of present illness. This is the first history that many of these students have ever taken.

  • Each student should be given 10-15 minutes to take your history.  Each student should listen to his/her classmates perform their history.

  • Students are expected to pretend that this is a “real session with a patient” and to practice introducing themselves in an appropriate manner before taking the history.

  • Students should take brief notes as they take the history so they will have the information to write up the history later.

  • Give brief feedback to each student.  Some examples might include the need for more open-ended questions, any information they didn’t obtain due to the type of questions used, amount of eye contact, etc.

In this lab, you will be acting as a patient giving each student a history of present illness.  We have recruited MS4 teaching assistants to assist you in this lab.  Divide your students so that six to seven students will work with each instructor.  We only have enough rooms available for each group to have one room, so please split into two groups and go to separate sides of the room.  The students will obtain the history from you and are then expected to write it out and turn in the write up electronically to the faculty small group preceptor by August 29, 5:00 pm. The lab will begin at 9:00 am and you will have until 11:50 am to complete the exercise.

The students will each practice taking a history of the chief complaint of “pain”.  The goal is to learn to characterize the seven characteristics of this primary symptom (see below).

We will provide written histories (one for each student) for you to “act out.”  They are written in two different formats – paragraph form and outline form categorized by symptoms.  Use the form that is more comfortable for you.  You do not need to stick to this script – it is merely a guideline.  If you do deviate, be sure to annotate it for yourself so that you will know if the student write-up is accurate.  If the student asks a question that we don’t have answered on the script, just make it up.  We have included some Past Medical or Social history on some scripts when pertinent, but the goal is only to obtain an HPI – it is not necessary that they ask Past Medical History, Medications, Review of Systems or other information. A template is provided to the students to organize, perform, and document the HPI.

Performing a medical interview – Chief Complaint / History of Present Illness

  1. Identifying Data:  Age, gender, ethnicity, marital status, occupation

  2. Source of History:  Patient, spouse, partner, family member, friend, medical record

  3. Chief Complaint (CC): Record the patient’s primary symptom(s) causing him/her to seek medical care.  The chief complaint should be recorded as a brief phrase or sentence, preferably in his/her own words.

  4. History of Present Illness (HPI): Chronological account of the patient’s problem from the time the patient was last well to the present.

    1. 7 characteristics of the primary symptom – especially for complaint of pain.

      1. Location Where is it?  Does it radiate?

      2. QualityWhat does it feel like?  (i.e., dull, sharp, aching, throbbing, pressure, burning).

      3. Quantity or severityHow bad is it? (Rate on a scale from 1 to 10.

      4. Timing
        • Onset When did (does) it start?  What was the patient doing when the symptom(s) first began?

        • DurationHow long has the patient had the symptom(s)?

        • FrequencyHow often does the symptom(s) occur?  Is it constant or episodic?

      5. Setting Is there an association with home, work, personal activities, emotional reactions?

      6. Relieving or exacerbating factorsWhat makes it better or worse?

      7. Associated manifestationsAre there other symptoms associated with the chief complaint?

  5. Treatment/medicationsWhat has been the therapeutic response of treatment already tried?

  6. Relevant past medical or surgical historyAre there previous episodes of the problem that have been evaluated?  Does the patient have a relevant related diagnosis?

  7. Pertinent positive and negative findingsIs there a relevant finding from any other part of the history (PMH, FH, Personal and social, ROS) that is important in the evaluation of this problem?

  8. Patient’s perspective about the illnessWhat are the patient’s thoughts about the cause, the effect on his/her life, concerns or fears?


Template for The History of Present Illness

Identifying Data:
            Name of patient
            Age
            Occupation
            Marital status

Chief Complaint:

History of Present Illness: 7 characteristics of the major symptom

            Location
            Quality
            Quantity or Severity
            Timing
                        Onset
                        Duration
                        Frequency

            Setting in which symptoms occur
            Relieving factors
            Exacerbating factors
            Associated symptoms
                                                                                                                                             
Effect of the illness on the patient’s life:

 

Other relevant / important information from:
Past medical history
Medications
Personal / Social History
Family History