In this section you will practise reading and writing an HPI (history of present illness) report.
1. Common medical abbreviations.
There are many abbreviations used in medical records.
For example:
Abbreviation Meaning
EMR = Electronic Medical Record
Use the words to complete the table of common abbreviations.
3. Read an HPI.
Read the HPI (history of present illness) and choose the correct options to complete the summary.
Identifying Information
Three-month-old female accompanied by her mother. The mother is the primary historian and is a reliable source of information.
Chief Complaint
General irritability and restlessness, decreased feeding, and fever for one day.
HPI
This is a three-month-old infant who was taken to a local clinic with symptoms of fever and irritability. The mother explains that the patient normally takes 60 ml of formula every two to three hours. She also normally wakes up at night for feeding approximately every three hours. However, for the last 24 hours, she has not taken her feedings as frequently. She has taken three feedings of 60 ml in the last 24 hours. She did not wake during the night to feed. The mother also noted that the patient was increasingly restless during the day. She cried when left alone for any amount of time, which was a change from her normal behaviour. However, she stopped crying when she was held. She has had six nappy changes in the last 24 hours, and she normally has six to eight changes a day. She typically has stool in the nappy three times a day, and has had three normal stools in the last 24 hours.
The mother took the patient's tympanic membrane temperature, which was found to be 39.5ºC. The mother became worried about the infant's high temperature because she has an underlying heart condition, as well as a history of UTI, so she decided to take her to the clinic. There, the patient was observed as being feverish and lethargic, so they recommended her for admission to the hospital.
The mother says that the patient has not had a cough, diarrhoea, vomiting, rash or wheezing.
4. Vocabulary.
Can you remember? Use the words to complete the HPI. This exercise is in two parts.
Part 1.
Part 2.
6. Identifying verb forms.
Click on the underlined verbs and choose the correct form.
HPI
This is a three-month-old infant who was taken to a local clinic with symptoms of fever and irritability. The mother explains that the patient normally takes 60 ml of formula every two to three hours. She also normally wakes up at night for feeding approximately every three hours. However, for the last 24 hours, she has not taken her feedings as frequently. She has taken three feedings of 60 ml in the last 24 hours. She did not wake during the night to feed. The mother also noted that the patient was increasingly restless during the day. She cried when left alone for any amount of time, which was a change from her normal behaviour. However, she stopped crying when she was held. She has had six nappy changes in the last 24 hours, and she normally has six to eight changes a day. She typically has stool in the nappy three times a day, and has had three normal stools in the last 24 hours.
The mother took the patient's tympanic membrane temperature, which was found to be 39.5ºC. The mother became worried about the infant's high temperature because she has an underlying heart condition, as well as a history of UTI, so she decided to take her to the clinic. There, the patient was observed as being feverish and lethargic, so they recommended her for admission to the hospital.
The mother says that the patient has not had a cough, diarrhoea, vomiting, rash or wheezing.
For more information about the verbs and tenses see the Grammar Reference.
7. Practise verb forms.
Remember
We use the present perfect to describe actions in an unfinished period of time, from then until now.
Compare:
She has taken three feedings in the last 24 hours. Present perfect (referring to an unfinished period of time)
She took three feedings yesterday. Past simple: (referring to a completed action in a finished period of time)
We use passive verb forms when the agent (who did the action) is not important in the sentence.
Compare:
The infant was taken to a local clinic. Past passive (It’s not important to know who took the infant to the hospital.)
The father took the infant to the local clinic. Past simple (We say who did the action.)
Write the verbs in brackets () in the correct form to complete the patient history.
8. Linking information and ideas.
Different words are used to link and add to information in the patient history. Use the words to complete the text. This exercise is in two parts.
Part 1.
Part 2.
For more information about the linking and conjunctions see the Grammar Reference.
9. Practise linking information and ideas.
Read the explanations.
Linking information and ideas
She cries when she is left alone. However, she stops when she is held.
We can use however to link two ideas. It means the same as but.
This drug is effective but it has some side effects.
We can use but to add information that usually contrasts with what is said before.
I prescribed this treatment because the patient has a heart condition.
We can use because to explain a reason.
His fever was high, so his mother decided to take him to the hospital.
We can use so to explain the result or reason for doing of something.
He has been eating well and has had three feeds today.
We can use and to add extra information.
She cried, which was a change from her normal behaviour.
We can use which to add more information, referring back to something you just said.
She is restless. She also wakes up at night.
We can use also to add extra information.
She as a heart condition as well as a history of UTI.
She as a heart condition as well as having a history of UTI.
We can use as well as to add extra information. It means the same as and also. As well as is followed by a noun or the –ing form of a verb.
Choose the correct option.