Before we get into how to take a history of present illness, let’s first review the components of a medical evaluation. Information from a medical evaluation (written medical documentation and verbal patient presentations) is typically relayed in a structured way. Although the format may vary slightly from region to region, most clinicians follow a similar template.
One such template lists four components of a medical evaluation and uses the acronym SOAP:
The SOAP evaluation is a basic form of communication that can be expressed verbally and in written form. Each part of the SOAP builds on the previous section. It starts with the healthcare provider recording observations of a subjective nature. This is followed by the measurement of objective information so that an assessment of the problem can be made, and a plan can be created for it.
The subjective portion of the SOAP is based on observations from the patient. It contains the history of present illness (HPI) as well as the patient’s chief complaint and associated symptoms. The chief complaint is the primary reason for the patient presenting to a healthcare professional.
The objective portion contains measured information and is therefore not subjective. This portion contains vital signs, lab tests, diagnostic imaging, and a physical exam (including the abdominal exam).
The assessment portion is a summative section that provides the diagnosis, or at least the differential diagnosis. Based on the information from both the subjective and objective sections, this portion notes what the disease or condition might be.
The plan section refers to how the patient’s problem or condition will be addressed. For example, the plan for a patient assessed to have acute appendicitis is to perform an appendectomy, give pain medications, and prescribe antibiotics.
How to gather a history of present illness
The history of present illness, or HPI, is part of the subjective portion of the patient interview and provides detailed information on the patient’s chief complaint. For example, if someone presents with a cough, the HPI would record details about the cough from the patient in their own words.
The HPI can be organized into the acronym OLD CARTS that contains eight sections:
- Alleviating factors
- Temporal patterns
Question: When did the pain start?
When asking about the onset, you should determine exactly when the pain started. Be very specific with your questions to the patient. Did it start one week ago or two days ago? Did it start today? If so, when—in the morning or the afternoon?
Question: Where is the pain located?
Next, determine the location of the pain. Again, be very specific with your questions. It is important to localize the pain as best you can during the subjective portion. Localization will set you up for success during the physical exam portion.
Ask the patient about specific regions such as the right upper quadrant, right lower quadrant, left upper quadrant, left lower quadrant, epigastrium, and suprapubic regions. As well, ask the patient to point to the area where the pain hurts the most using a single finger. Where they point may surprise you because it forces the patient to really think about the location. Keep in mind, the location may not line up with what they initially said!
Question: How long have you had the pain?
Next, determine how long the patient has had the pain. Again, be specific and ask how many hours, days, weeks, or months they have had the pain. The onset of pain is important to help determine if it has an acute or chronic nature.
Question: Can you describe the pain?
Pain always has a character to it; you just have to ask and be specific with the patient. The character of the pain is also known as the type of pain. There are several ways we can characterize pain:
Question: What helps the pain, and what makes it worse?
Ask your patient if certain things alleviate or worsen the pain. This might include different positions such as sitting, standing, laying down, moving, or not moving. Inquire about the use of medications such as nonsteroidal anti-inflammatory drugs.
Ask what happens if they consume certain foods such as fatty, greasy, spicy, acidic, or milk-containing foods. Also, ask about the consumption of caffeinated beverages and alcohol.
Radiation of the pain
Question: Does the pain radiate anywhere?
As part of the HPI, ask the patient if the pain radiates to other locations of the body such as the back, neck, shoulders, or arms.
Question: Does the pain show any patterns as to when it recurs?
Ask the patient if their pain has a specific pattern of recurrence. Does it appear every morning or night? Is it happening after a fatty meal, after consuming dairy products, drinking a cup of coffee, or eating spicy, acidic food?
Question: Are any other symptoms associated with the pain?
Lastly, you’ll want to ask if there are any other symptoms associated with the pain. Ask whether these symptoms occur before, after, or during the pain. Ask if there is any associated nausea, vomiting, or diarrhea.
Remember that the pain could be stemming from several different organ systems, including the gastrointestinal (GI), urinary, and reproductive systems. So, make sure to include questions about each of these systems when inquiring about associated symptoms.
What associated symptoms should you ask about?
As mentioned previously, there are several organ systems in the abdomen. The patient may not realize that other symptoms are associated with the pain. You must guide them by asking them direct questions.
Associated GI symptoms
Start by asking about GI symptoms such as heartburn, constipation, nausea, vomiting, anorexia, reflux, and diarrhea. However, you will want to think through these symptoms to determine which may be related to the chief complaint. Some symptoms may fit with the chief complaint and some may not. So, you have to ask about a large variety of symptoms.
Asking broad questions allows you to initially understand which symptoms the patient has and which they don’t have. Then, you can begin to narrow down what the source of their pain may be based on their answers.
Associated gynecological symptoms
In women experiencing abdominal pain, you also need to inquire about associated gynecological symptoms. Ask about symptoms such as pelvic pain, abnormal vaginal discharge, pain with intercourse (e.g., dyspareunia), and painful periods (e.g., dysmenorrhea).
Associated urological symptoms
Bladder and kidney infections are just two of the many urological issues that present as abdominal pain. So, you also need to ask about urologic symptoms in men and women. Ask the patient if they have flank pain (pain in the lower back or side), pain with urination (e.g., dysuria), incomplete micturition (where they are unable to completely void), blood in their urine (e.g., hematuria), or frequent urination.
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