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The Presentation Series (The HPI)

July 11, 2021

Hi everyone,

Humans are storytelling animals.* Random facts bore us; they’re lifeless and forgettable. By contrast, stories brim with characters, plots, and emotion. They stick in our memories, and they move us to act.

The History of Present Illness (HPI) tells the medical story, transforming critical details into narratives that flow towards diagnoses and treatments. Effective HPIs follow these rules:

Start with the beginning: You can’t go wrong with a first sentence like “The patient was in his/her usual state of health until…” Some problems are new, some are superimposed on chronic disorders, and some represent the latest episode in a patient’s saga. Your job is to decide how much backstory, if any, to tell up front:
New problems: “Mr. Smith was in his usual state of good health until the day of admission, when he developed nausea, vomiting, and diarrhea.”
Superimposed problems: “Mr. Smith has a long history of well-controlled ulcerative colitis and was in his usual state of health until the day of admission, when he developed nausea, vomiting, and diarrhea.” Mr. Smith’s chronic UC bears mention in the first sentence, but if his acute illness is unrelated (e.g., his whole family has norovirus), then put the IBD details in the Past Medical History (PMH).
Sagas: “Mr. Smith was diagnosed with ulcerative colitis two years previously, and he’s been admitted to the hospital six times for flares treated with corticosteroids, most recently one month earlier. At baseline, he has three loose stools per day. On the day of admission, he developed nausea and vomiting, accompanied by 10 episodes of diarrhea.”

Create a reverse timeline: To avoid confusing people with dates, position the history relative to the day of admission:
“Ms. Jones was in her usual state of health until one week before admission when she developed a temperature of 103oF, dry cough, and anosmia. Three days before admission, she developed shortness of breath climbing a flight of stairs. On the day of admission, she felt short of breath lying in bed, and her husband drove her to the ER.”

Include pertinent positives: Share essential clues, including severity, time course, exacerbating and relieving factors, and related symptoms. Don’t confuse pertinent positives (and negatives) with the Review of Systems (ROS), which is a structured inventory of symptoms asked of all patients when you do a comprehensive workup. It’s up to you to decide what’s pertinent, but a good rule to follow is that pertinent details should contribute to your subsequent assessment. Note the pertinent details in these chest pain narratives:
Myocardial Ischemia: “The chest pain came on while the patient was watching the Mets lose to the Pirates. He described the pain as ‘squeezing’ and said it increased in intensity over five minutes. The pain was substernal and radiated to the left jaw and was associated with diaphoresis and shortness of breath. It subsided gradually over fifteen minutes.”
PE: “The chest pain began suddenly while the patient was getting off a plane after a flight from Malaysia. The pain was located on the right side and increased with inspiration. He also experienced dyspnea while walking through the airport terminal and had to stop several times to catch his breath. He also reported that his left leg was swollen, painful, and red.”
List pertinent negatives: Show that you’ve asked all the key questions and consider it a win if no one asks clarifying questions when you’re done. For the chest pain patient, you could report that “the patient denied previous episodes and said the symptoms were unrelieved by ibuprofen,” and that “he also denied fever, cough, nausea, vomiting, heartburn, palpitations, lightheadedness, and recent trauma.” Show that you’ve taken a thorough history and anticipate what your audience wants to know when you share these details.

Include prior exam and test results: You’ll report your own workup later, but prior clinic visits and hospitalizations belong in the history. For example: “She saw her PMD, who found mild suprapubic tenderness on exam. A U/A was positive for leukocyte esterase and nitrates and she was started on trimethoprim-sulfamethoxazole, which provided no relief.” These data will provide context for your workup, for example if you think the patient has a UTI caused by a resistant organism.

Explain how the patient came to you: Was she admitted from clinic? From the ER? From another hospital? Why did she come to your team (floor, SDU, ICU)? For example, “When the patient arrived in the ER, she was speaking in two word sentences, using accessory muscles, and wheezing diffusely. She was given 125 mg of methylprednisolone and three albuterol nebulizers with partial relief. An ABG showed no CO2 retention and she was admitted to the Step-down Unit for further management.” Don’t flood the audience with needless detail, but don’t leave them wondering about critical exam findings and test results either. For example, you could say “an abdominal CT showed an SBO, an NGT was placed, and the patient was admitted to Smilow for further management.”

Modify your HPI for transfers: Highlight the earlier hospital course. For example, when you accept a transfer from the ICU, describe how the patient’s shock and respiratory failure were treated with vasopressors and mechanical ventilation before they stabilized and came to your team.

Decide what to include and what to leave out: If you leave out too much, you’ll be bombarded with questions; if you tell too much, you’ll lose your audience. Share just enough detail to construct succinct, coherent, memorable HPIs, which are the mark of the master internist.

Enjoy your Sunday, everyone. Francesca and I are going sailing on Penobscot Bay.

*Check out The Storytelling Animal by Jonathan Gottschall.

Yesterday on top of Mount Battie:

Submitted by Mark David Siegel on July 11, 2021