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History

History of Present Illness (HPI)

• Taking a history is the first step in the diagnostic reasoning process.

• Understanding the patient’s lived experience is essential for diagnosis.

• If the patient’s visit is for episodic care or a new complaint, the history begins with HPI.

• The “OLD CART” mnemonic helps clinicians remember essential data elements.

  • Onset:
  • When did the problem start?
  • How did it start?
  • Has it changed over time?
  • For an injury, describe the mechanism of injury.
  • Location:
  • Where are the symptoms located?
  • Is it a specific location or generalized?
  • Has the symptom moved?

• Clinicians begin sorting diagnostic possibilities upon hearing the chief complaint.

• Generating questions based on the possibilities aids in distinguishing between competing hypotheses, e.g., "Do you feel the pain more often on an empty stomach or several hours after eating?" (distinguishing between an ulcer and gallbladder disease).

• Open-ended questions are encouraged to allow patients to present their perspectives.

  • An open-ended question cannot be answered with a yes or no.

• Eliciting the patient’s story leads to a clearer understanding of the illness experience from their perspective.

• Frequent interruptions can distract from the patient’s narrative and place it within the context of the clinician.

• Clarification of the patient’s story may be necessary to paint a clearer picture of the illness (requires patience).

• Patients may confuse chronological order or not recall exact onset of issues.

• Sometimes multiple problems can complicate the narrative of symptoms.

• Clinician can periodically restate the emerging understanding of the patient’s story to clarify and summarize.

• It is important to address what the patient thinks may be wrong (patients know their bodies best).

  • Addressing fears about possible serious diagnoses can lead to explanations about common concerns (e.g., a recurring headache does not necessarily indicate a brain tumor).

• For periodic health screenings or establishing a new patient-provider relationship, the HPI does not follow the same form unless a new problem is identified.

• Questions like "What do you want to accomplish today?" or "What matters most to you today?" can help guide these visits.

Past Medical History (PMH)

• PMH refines the hypothesis list by providing explanations for symptoms or ruling out other options.

• PMH can suggest risk factors for problems under consideration.

  • Example: Gallbladder removal history rules out cholecystitis as a hypothesis but may suggest abdominal adhesions.

• PMH is frequently divided into:

  • Childhood and other illnesses
  • Surgical history
  • Other hospital admissions
  • History of trauma
  • Pregnancies
  • Psychiatric diagnoses

• Travel history for possible exposure to infectious or toxic agents should be explored.

• Past cancer treatment has implications for future risks.

  • Example: Certain chemotherapy agents can lead to heart failure later in life.

• PMH includes current medications (both prescribed and over-the-counter, vitamins, herbal remedies).

  • Confirming current medications helps clinicians understand patient awareness and adherence.
  • The “brown bag” method can facilitate reviewing medications with patients (asking them to bring in all taken medications).

• This review determines if prescribed medications are being taken correctly and identifies understanding or difficulties with the regimen.

• Immunization status is also part of PMH.

  • Parents may bring vaccination cards.
  • Verification of adult vaccinations (tetanus, influenza, pneumonia, COVID-19) is critical.

• Allergies should be discussed, including the kind of reaction caused by medications/food:

  • True allergies characterized by rash, hives, wheezing, or other hypersensitivity reactions.

• Health maintenance practices (risk reduction techniques such as seat-belt use and exercise habits) should be questioned.

Family History

• Family history provides insight into risk factors for the patient.

• The genogram is an effective way to represent family history:

  • Records family birth patterns, ages at death, causes of death.
  • Shows family members living with the patient.

• Aim for at least two generations back, including children and their health status.

• Record patterns of behaviors like alcohol use and the quality of family relationships (e.g., support vs. troubled).

• If space is limited, simply list major familial diseases (diabetes, heart disease, arthritis, psychiatric problems, cancer).

Social History

• Social history includes work patterns, even if retired, to identify risk factors from past employment.
• Work background provides clues about handling information and available resources.
• Medical model histories include alcohol, tobacco, and street drug use.
• Nursing histories should expand on leisure activities, risk exposures, and patient resources.

Review of Systems (ROS)

• Often completed by patients before a physical examination.
• Organized by body systems and can remind patients of forgotten conditions, refining hypotheses further.
• Introduce body systems with general questions, then specific items.
• Remember that this data is considered subjective, reported from the patient’s perspective.

Functional Health Patterns

• Established by Marjory Gordon in 1987 to determine nursing diagnoses.

• NPs sometimes make medical diagnoses but always operate from a nursing perspective focusing on patient lifestyles and illness coping.

• Openness and thoroughness in NP care stem from broader and more personal databases than the traditional medical model.

• Important patterns will vary depending on the visit type (episodic visits may prioritize different data).

• Example: For a sore throat, data related to nutrition, sleep/rest, activity levels, and role relationships are critical.

• Inability to perform daily functions is a red flag indicating potential serious conditions.

• The functional health pattern aims to determine how illness affects normal living.

  • Questions about necessary accommodations for self-limiting issues are central to this.

Advanced Assessment 4.1: Functional Health Patterns Questions

Physical Examination

• Physical examination clarifies diagnostic hypotheses and reveals unanticipated problems.

• Techniques vary but generally follow a head-to-toe progression.

  • An initial visit may take longer due to the comprehensive nature.

• Focused examinations are necessary based on the patient’s complaints and history.

  • Example: For headache, examine head/eyes/ears/nose/throat and neurological functions.

• Each body system examined should align with the hypothesis list generated from the history.

• Positive/negative findings must be recorded to refine hypotheses.

• A diagnosis may evolve over time; thus, data gathered, even from unclear visits, can improve future accuracy.

• Full documentation protects both patient and provider.

Diagnostic Tests

• Diagnostic tests confirm or rule out hypotheses, functioning as screening devices for subtle presenting conditions (e.g., lead poisoning).

• Their usefulness varies by sensitivity, specificity, and predictive value.

• Prevalence of a condition refers to the number of existing cases; incidence reflects new cases during a specified time.

  • Example: The annual incidence of flu differs from daily prevalence cases.

• Understanding laboratory and imaging is important for diagnosis, especially for chronic conditions which need ongoing monitoring.

• False-positive and false-negative results can mislead patients about their health.

  • Sensitivity: True positives divided by all actual disease cases.
  • Specificity: True negatives divided by all non-disease cases.
  • Positive predictive value (PPV) and negative predictive value (NPV) are key to understanding test reliability affected by prevalence.

• Cost, convenience, test reliability, and patient impact must be evaluated before ordering tests.

• Life-altering screenings and guidelines from authoritative organizations guide appropriate testing (e.g., U.S. Preventive Services Task Force).

Genetic Influences

• Genomic discoveries are improving predictions of disease susceptibility and treatment specificity.
• Consider genetic testing to assist in definitive diagnoses based on patient histories (e.g., prenatal patients).
• Understanding pharmacogenomic drugs enhances symptom management.

Differential Diagnosis

• Differential diagnosis is a prioritized list of possible conditions.
• Consider the problem from a holistic viewpoint (e.g., "skin in" approach).
  • Example: For chest pain, assess from skin level downward, examining various structures (ribs, lungs, esophagus, heart).
• Prevent definitive conclusions too quickly but maintain expansive hypothesis lists.

Management Plan Development

• Clarifying the problem list assists with effective clinical management.
• NPs integrate medical and nursing responsibilities, billing for medical services and maintaining nursing focus.
• Presenting patient data effectively to preceptors enables treatment planning.

Interventions

• Interventions range from symptom relief to comprehensive life-pattern approaches, including:
  • Immediate relief approaches (ice/heat)
  • Functional patterns (stress coping)
  • Life patterns (rehabilitation after a cardiac event)
  • Spiritual support for terminal conditions.
• Management plans should include evaluations of patient motivations and capabilities (e.g., weight loss goals).

Current Diagnostic Process Trends

Evidence-Based Practice (EBP)

• EBP emphasizes informed treatment selection based on updated research demonstrating patient benefit.
• Clinicians should not solely rely on clinical trials; they also have to integrate individual patient values/preferences into practice.
• Look for guidelines from health organizations to inform practice decisions.

Shared Decision Making

• Shared decision making fosters patient and family involvement in treatment choices.
• Utilize evidence-based decision aids to inform and engage patients in healthcare options.
• Focus on improving patient satisfaction and outcomes through collaborative treatment planning.

Documentation

• Proper documentation enhances communication and continuity of care:
  • Capture the patient's report of symptoms, PMH, lifestyle factors, physical findings, and clinician decisions.
  • Accurate records inform future care and can serve legal protection.

SOAP Format of Documentation

• Subjective: Patient reports (HPI, PMH, history, allergies).
• Objective: Objective examination data, vital signs, and laboratory results (no diagnostic judgments).
• Assessment: Active problems requiring management and their implications for treatment.
• Plan: Treatment plans detailed for interventions, education, and follow-up.

Clinician Processes

Documentation Systems

• Documentation systems differ significantly; EMR software is essential for tracking and continuing care.
• Familiarity with documentation systems streamlines patient and billing management processes in primary care.

Reduction of Medical Errors

• Efforts exist to minimize medical errors through better systems and practices.
• Address the factors that contribute to errors, including miscommunication and misdiagnoses.

Digital Future and Telehealth

• EMRs are required for compliance and improved patient record management.
• Telehealth gained prominence during COVID-19, influencing primary care practices.

Artificial Intelligence (AI) and Precision Health Care

• AI aids diagnosis and patient management by simulating human intelligence in data analysis.
• Precision healthcare focuses on individualized treatment based on genetic and environmental factors, driven by technological and scientific advancements.

Ethics

• All clinical judgments are ethical, impacting patient autonomy and care outcomes.

  • Balancing beneficence with respect for patient preferences is crucial.
  • NPs play a key role in advocating for patient rights and ensuring ethical practice.

• The Circle of Caring emphasizes the relational aspect of healthcare, nurturing both clinician and patient during their journeys.