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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.
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:
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Obstetric/Gynecologic history (if female): include total number of pregnancies, whether they are full term, preterm, miscarriages, abortions, living, as well as any complications. Include menopause and date. Include sexual history and any history of sexually transmitted infection.
The parts of the mnemonic are: Onset of the event What the patient was doing when it started (active, inactive, stressed, etc.), whether the patient believes that activity prompted the pain, [2] and whether the onset was sudden, gradual or part of an ongoing chronic problem.