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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 physician will take a history of present illness, or HPI, of the CC. [1] This describes the patient's current condition in narrative form, from the time of initial sign/symptom to the present. [10] It begins with the patient's age, sex, and reason for visit, and then the history and state of experienced symptoms are recorded. [1]
History of the present illness (HPI) – details about the complaints, enumerated in the CC (also often called history of presenting complaint or HPC). Past medical history (PMH) (including major illnesses, any previous surgery/operations (sometimes distinguished as past surgical history or PSH), any current ongoing illness, e.g. diabetes).
An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care.
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.
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.
History of present illness (HPI) - circumstances relating to chief complaints. Past medical history (PMHx) Past surgical history; Current medications; Allergies; Family history (FHx) Social history (SocHx) Physical examination (PE) Laboratory results (Lab) Other investigations (imaging, biopsy etc.) Case summary and impression; Management plans
The term chief complaint, also "presenting problem", is used to describe the initial concern of an individual when seeking medical help, and once this is clearly noted a history of the present illness may be taken. The symptom that ultimately leads to a diagnosis is called a cardinal symptom.