History of Presenting Illness

It is important that you include the following in your presentation of history of presenting illness(HOPI) :

1) SEVERITY/FUNCTIONAL STATUS/ADL STATUS -- How has the presenting chief complain affected the patient's functional status/activities of daily living.

exp: Shortness of breath. How far can the patient walk before he stops to grasp for air? Can the patient speak in full sentence? How did it affect the ambulation. Conscious level?

2) Relevant Negatives

Template: There's no xxxx to suggest xxxx

exp: Fever. There's no photophobia, neck stiffness to suggest meningitis. There's no urinary symptoms or loin pain to suggest UTI.

To show to the examiners that you're THINKING!

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Relevant investigations.

Template: I would like to order xxxx to check for xxxx or to rule out xxxx.

exp: I would like to do a VBG to see if the patient is acidotic.

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Auscultation on lungs

Comment on:
1) Air entry(quality & intensity) 
2) Any additional breathing sounds
3) Any prolongation of phases


SOB: usually what are the things that you do(either at home/at work) that will cause you to develop sob?