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Following the chief complaint in medical history taking, a history of the present illness (abbreviated HPI) [1] (termed history of presenting complaint (HPC) in the UK) refers to a detailed interview prompted by the chief complaint or presenting symptom (for example, pain).
The chief complaint, formally known as CC in the medical field, or termed presenting complaint (PC) in Europe and Canada, forms the second step of medical history taking. It is sometimes also referred to as reason for encounter ( RFE ), presenting problem , problem on admission or reason for presenting .
For example, an ambulance paramedic would typically limit their history to important details, such as name, history of presenting complaint, allergies, etc. In contrast, a psychiatric history is frequently lengthy and in depth, as many details about the patient's life are relevant to formulating a management plan for a psychiatric illness.
For example, an "OB/GYN" section may be included, including language such as "G3P2, menarche at age 14, LMP 2 weeks ago, regular". family history (FH) "noncontributory" Including health of siblings, parents, spouse, and children, living and dead. Age of diagnosis may also be included (for example, in conditions such as colon cancer). A phrase ...
This is divided into the psychiatric history, which looks at any previous episodes of the presenting complaint as well as any other past or ongoing psychiatric problems. [2] The substance (drug) history includes data about patterns of use (mode of administration, age of onset, frequency, amount, last use, medical or psychological complications ...
A case presentation is a formal communication between health care professionals such as doctors and nurses regarding a patient's clinical information. [ 1 ] [ 2 ] [ 3 ] Essential parts of a case presentation include:
Where available, ICD-10 codes are listed. When codes are available both as a sign/symptom (R code) and as an underlying condition, the code for the sign is used. When there is no symptoms for a disease that a patient has, the patient is said to be asymptomatic.
In a medical encounter, a past medical history (abbreviated PMH) [1] is the total sum of a patient's health status prior to the presenting problem. Questions to include [ edit ]