The following information is recorded in the health history: “The patient has had abdominal pain for 1 week. The pain lasts for 30 minutes at a time; it comes and goes. The severity is 7 to 9 on a scale of 1 to 10. It is accompanied by nausea and vomiting. It is located in the mid-epigastric area.” Which of these categories does it belong to?
A) Chief complaint
B) Present illness
C) Personal and social history
D) Review of systems
B) Present illness
This information describes the problem of abdominal pain, which is the present illness. The
interviewer has obtained the location, timing, severity, and associated manifestations of the pain. The
interviewer will still need to obtain information concerning the quality of the pain, the setting in which it
occurred, and the factors that aggravate and alleviate the pain. You will notice that it does include
portions of the pertinent review of systems, but because it relates directly to the complaint, it is included
in the history of present illness.
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