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INTRODUCTION

The history of present illness (HPI) is also called the primary history. It is a detailed set of questions designed to elaborate on the patient’s chief complaint or presenting symptom. An accurate history is the first step in determining the etiology of the patient’s concern. In fact, frequently, the diagnosis can be made simply on the history and physical examination.

There are several general questions that are applicable to most symptoms. Many acronyms have been proposed for memorizing the elements of the HPI. The one we include here is the OLD CARTS method:

  • Onset

  • Location

  • Duration

  • Characteristics

  • Aggravating factors

  • Relieving Factors

  • Treatments tried

  • Symptoms associated

Remember that an accurate history is not only important in determining the diagnosis, but is essential for proper reimbursement. The Centers for Medicare and Medicaid Services has defined criteria for what qualifies as a “reimbursable” HPI. A brief HPI includes one to three of the following, whereas an extended HPI must include four or more elements.

  • Timing Onset

  • Location

  • Duration

  • Quality (Characteristics)

  • Severity (Characteristics)

  • Context (Onset)

  • Modifying factors (Aggravating/Relieving factors)

  • Associated signs and symptoms (Symptoms associated)

Included in this chapter are many of the acute symptoms most commonly encountered in clinical practice. The questions are designed to elicit a differential diagnosis for each complaint. Of course, not all the elements of the OLD CARTS questions can be applied to all symptoms; for example, insomnia has no location. But wherever possible, we attempted to incorporate as many questions as were appropriate to each symptom.

ABDOMINAL PAIN

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  • Do you have abdominal pain?

  • ¿Tiene usted dolor abdominal?

  • ¿Tiene usted dolor de barriga?

Show me where.

Enséñeme donde le duele.

Muéstreme donde le duele.

How long ago did it start (hours, days, weeks, months)?

¿Cuándo fue que le empezó (horas, días, semanas, meses)?

Did it start suddenly?

¿Le empezó de repente?

Did it start slowly?

¿Le empezó despacio?

Is the pain constant?

¿El dolor es constante?

Does it come and go?

¿Viene y se va?

Is it getting worse?

¿El dolor se le está empeorando?

  • Slowly?

  • ¿Despacio?

  • Rapidly?

  • ¿Rápido?

Does it feel …

¿Se siente …

  • crampy?

  • con retorcijones?

  • achy

  • adolorido?

Does it feel like

¿Se siente …

  • burning?

  • ardiente?

  • stabbing?

  • punzante?

  • ripping?

  • rasgado?

  • tearing?

  • desgarrado?

Does the pain radiate …

¿El dolor se irradia …

¿El dolor se riega hacia otros lugares como

  • to your back?

  • hacia su espalda?

  • to your jaw?

  • hacia su quijada?

  • to your groin?

  • hacia su ingle?

  • to your shoulder?

  • hacia sus hombros?

  • to your arm?

  • hacia sus brazos?

Do you have associated nausea or vomiting?

¿Tiene nausea o vómitos asociado con el dolor?

  • Do you vomit blood?

    ...

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