COLLEGE OF NURSING
AT ILLINOIS STATE UNIVERSITY
Diagnostic Reasoning for Advanced Nursing Practice 431
The interviewer first determines the patient’s chief complaint. Examples include:
After determination of the chief complaint, the interviewer then analyzes the problem
further using an analytical, organized approach.
HISTORY OF PRESENT ILLNESS OR PRESENT STATE OF HEALTH
This section of the history contains a thorough investigation of the chief complaint or a more detailed description of the well client’s health status. The components of the history of present illness (HPI) or present state of health are as follows:
1. Description of client
2. Usual health
B. Chronological investigation of symptoms
1. Course of symptomatology: incidence, duration and manner
2. Symptom analysis: aggravating, alleviating, and associated factors; location; quality; quantity; and setting
C. Pertinent negatives--what it is not
D. Relevant family history, psychological, social, cultural, spiritual data
E. Assessment of disability
F. Related medications including OTC.
Each of these components will now be discussed in further detail.
The introduction is a brief biographical section including age, sex, marital status, occupation, and employment status. It also includes the number of visits to the interviewer’s facility and the number of hospital admission for the problem identified in the chief complaint, or for any other problem. In addition, it contains information about the client’s usual health status and any previous or present health problems. Examples of an introduction are the following:
Chronological Investigation of Symptoms
For every problem or “chief complaint” the patient presents with, a symptom analysis is done. The following characteristics of a symptom are always analyzed.
In addition, pertinent (related to the system) past health history, personal/social/occupational history and family history are included in the symptom analysis. The meaning of some of the above-mentioned terms are:
Of course, for the well client, the chronological investigation of symptoms is usually omitted. If later in the interview, usually during the ROS, a symptom is uncovered, it would then be discussed. For example, when a client presents for a routine checkup and later mentions amenorrhea for two months, this symptom is fully investigated, and recorded in the present illness section, proceeding from the most remote to the most recent symptom as follows:
· Five years ago: Menarche-age 13, menses every 29-31 days, lasting 4-5 days with moderate blood flow (saturates 5-6 tampons/day). Mild cramping on second day that usually responds to aspirin, grains 10, bid. (NOTE: menstrual cramping usually not responsive to Tylenol.)
· Two years ago: Began having unprotected sexual relations with steady boyfriend about twice/month. Has never practiced contraception because it would ruin naturalness of sex.
· One week ago: Noticed breast tenderness and fullness and began to experience nausea every evening.
· The chief complaint is changed to say. “Desires routine check up and thinks she is pregnant.” LMP 12/4.
A negative response to certain questions about symptoms is just as important as a positive response in assessment. This is referred to as a pertinent negative. The items can be symptoms, as well as information, from any other section of history (family, psychosocial, socioeconomic, or nutritional history) that could have significance in the overall course of health or illness. Hence the descriptive word pertinent is used.
Some relationships are obvious; for example, persons with respiratory system symptoms are asked about their smoking history and persons with vascular changes such as cold extremities or intermittent claudication are asked about family history of angina, arrhythmias, arteriosclerosis, hypertension, and myocardial infarction. A good rule of thumb for beginning interviews is to ask all of the review of system questions for a given system or region when symptoms of that system or region are mentioned in the history of present illness.
An assessment of disability indicates what changes in lifestyle the client has made as a result of the symptoms discussed in the history of present illness. For example, a client who related recent difficulties in walking to work (a distance of 1 mile) due to shortness of breath and fatigue has made a quantitative statement about the effects of declining health on life style. Disability also includes financial constraints and physical limitations imposed by illness or injury.
All related medications taken by the client are recorded in this manner: drug’s name, dosage, frequency of administration, and description of the effect of the drug and any untoward reactions. Over-the-counter drugs including vitamins, aspirin, and cold remedies are also listed. Medications unrelated to the current problem are usually listed in a designated section of the patient’s record and verified for accuracy with each visit.
The following is an example of a completed history of present illness for a client with burning pains in the stomach:
Denies diarrhea, melena, belching, nausea, jaundice, dysphagia, bloating, constipation, and hemorrhoids. Paternal grandfather died of stomach hemorrhage at age 45. Father, age 64, three hospital admissions for bleeding peptic ulcers. Well since ulcer surgery 5 years ago. Smokes two packs of cigarettes/day for 15 years. Stopped drinking coffee and cola 2 yrs. ago. Drinks six pack beer with buddies q. Friday night. Fights with wife about 2x/wk. over children. Business slow. Maalox, 2 tabs, 30 mins. after meals and between meals up to 20/day, provides relief for only 30 mins. Uninsured. Worried about loss of income during hospitalization and about ability to pay for medical expenses.