Clinical Presentation Skills: History of Present Illness
By: Stephen Geller, DPM
Have you ever stepped in a hole and twisted your ankle? Well I recently had a 27-year-old female who was otherwise healthy accept for right ankle pain 3-weeks after a similar inversion injury. No other part of her foot or leg hurts. Her pain is sharp, graded 6/10, localized to the anterolateral ankle without radiation. Standing and walking aggravates the pain and there is still residual swelling and bruising in the area. Improvement has been noted with ice, rest, and ace wrap. She has no prior history of ankle injuries.
Presenting a case is no different than telling a story. Granted, storytelling is an artform itself, but if you can become a good story teller, your attendings will remember you and your medical records will stand out from the rest. In medicine it has become acceptable to use poor grammar, run-on sentences, and be plain old boring. It doesn’t have to be that way. I bring up documentation here because your presentation should reflect your note.
‘A 27-year-old female presents for right ankle pain. The patient states that she stepped in a hole 3-weeks-ago suffering inversion injury. The patient states that her pain is sharp. The patient grades her pain as 6/10. The patient states that her pain is localized to the anterolateral ankle. The patient states that walking and standing aggravate her pain. The patient notes that swelling and bruising remain. The patient denies prior ankle injuries or pain in other areas of her foot or leg. The patient has attempted self-treatment using ice, rest, compression in ace wrap without relief.’
Compare the two presentations. Which one do you think would catch your attention and keep you attentive for the rest of the complaint?
Story telling begins with a hook. You need something to grab your attending’s attention so that they will remain attentive throughout the rest of your presentation. One sentence that conveys the story that is to follow.
“Excuse me Dr. Jones, but my patient has a severely infected diabetic foot ulcer that will need admitting”. Ok, that one is easy. Everyone is going to pay attention as soon as you say severely infected and need admitting. Still you have cleared a path to tell the rest of the medical history.
“Mr. Smith returns for a noninfected venous leg ulcer fifty percent improved from last week”. Here is a rather mundane medical issue. The patient is doing fine and just returning for follow up care. It’s the 50% improvement that will grab the listener’s attention, so you can go on with the rather routine presentation.
Once you have your audience hooked, you must tell the story. If it were a real story you would want to demonstrate a personal tie to the problem or evoke an emotional response. Let’s face it, in medicine that is frowned upon. What your audience is listening for in medicine is the information needed to make the diagnosis. This is where you will demonstrate your medical knowledge. Regardless of which pneumonic you prefer, NLDOCAT or OPQRST, you can still make it more interesting. Success at this level will require a thorough understanding of the differential diagnosis, end-organ effects of systemic illnesses, and complications of prior treatments.
‘You know how you say that heel pain isn’t always plantar fasciitis? Well Ms. Johnson is here for left heel pain, but it’s not typical. One-week ago she began a new exercise program and developed 8/10 sharp shooting pain in the plantar left heel. No known injury is reported. This pain radiates posterior to the medial malleolus, up her calf, thigh and to the hip. She doesn’t have to be active to experience pain and there is no relation to time of day or shoe gear. Ms. Johnson has a history of low back pain but has never been worked up for this complaint. No history of joint swelling or stiffness anywhere in her body is reported. Since the heel pain began there has been no progression and slight improvement treating with ice, stretching, ibuprofen, and cessation of exercise.’
Heel pain is one of the most common complaints we see. The differential includes plantar fasciitis, nerve entrapment in the foot, tarsal tunnel, radiculopathy, systemic arthropathy, stress fracture, etc. The above history takes the listener through the differential diagnosis as told by somewhat of a story. There is enough information to have a pretty good idea of what you will find in the exam.
This is presentation of a history of present illness. If you become good at telling the patient’s story everything will flow. Apply this practice to your notes as well. Obviously, there is less leeway for a casual introduction to hook the reader but convey the information in full sentences. Try to start each sentence with a new subject such as pain, onset, treatment. It is not acceptable to begin each sentence with “the patient states…” This is the history, so it is assumed that anything in quotations is exactly what the patient states.