The Improving Doctor

A Good HPI

You might have heard that 90% of the diagnosis is in the patient history…It seems easy, when you read a good HPI, you know the diagnosis, it’s laid out for you.  A good HPI starts with a brief introduction to the patient, ex: “A 25 year old previously healthy female”, or “A 65 year old male with multiple cardiac risk factors”…and then we transition into why they are seeking medical care, what happened, when did it happen, for how long, what made it better/worse, what other symptoms occurred/different occur. This last part is why the first two years of medical school are important. You can train a 12 year old to do a good history of one symptom, but it takes clinical knowledge to take a symptom and create a differential diagnosis for what the cause might be, and then ask questions to rule in, rule out different hypotheses. For example, take a case of someone who felt lightheaded and passed out. It’s not too difficult to get the history of what happened when they passed out, but thinking of the differential (vasovagal syncope, structural syncope, seizure, neurogenic syncope, orthostatic hypotension, etc) -that takes some clinical expertise! You really don’t want to misdiagnose tonic clonic seizures as vasovagal syncope, and it takes some questioning to differentiate the two, thus the name “differential diagnosis”.

HPI basics: patient intro + story of pertinent illness  (PQRST) + pertinent positives + pertinent negatives.

I recommend the Lange review book  ”The Patient History”, for a beginners course on understanding important questions to ask to piece together your differential diagnosis for common medical conditions.