Sample Written History
Personal History
Presenting Complains
History of Present Illness
This is the first admission for this 56 year old woman who states she was in her usual state of good health until one week prior to admission. At that time she noticed the abrupt onset (over a few seconds to a minute) of chest pain which she describes as dull and aching in character. The pain began in the left para-sternal area and radiated up to her neck. The first episode of pain one week ago occurred when she was working in her garden in the middle of the day. She states she had been working for approximately 45 minutes and began to feel tired before the onset of the pain. Her discomfort was accompanied by shortness of breath, but no sweating, nausea, or vomiting. The pain lasted approximately 5 to 10 minutes and resolved when she went duration inside and rested in a cool area.
Past History / Comorbs:
Since that initial pain one week ago she has had 2 additional episodes of pain, similar in quality and location to the first episode. Three days ago she had a 15 minute episode of pain while walking her dog, which resolved with rest. This evening she had an episode of pain awaken her from sleep, lasting 30 minutes, which prompted her visit to the Emergency Department. At no time has she attempted any specific measures to relieve her pain, other than rest. She describes no other associated symptoms during these episodes of pain, including dizziness, or palpitations. She becomes short of breath during these episodes but describes no other exertional dyspnea, orthopnea, or paroxysmal nocturnal dyspnea. No change in the pain with movement, no association with food, no GERD sx, no palpable pain. She does not smoke nor does she have diabetes. She was diagnosed with hypertension 3 years ago and had a TAH with BSO 6 years ago. She is not on hormone replacement therapy. There is a family history of premature CAD. She does not know her cholesterol level.
Past Medical History
1998: Diagnosed with hypertension and began on unknown medication. Stopped after 6 months because of drowsiness.
1990: Diagnosed with peptic ulcer disease, which resolved after three months on cimetidine. She describes no history of cancer, lung disease or previous heart disease.
Allergy: Penicillin; experienced rash and hives in 1985.
Surgical History
1994: Total abdominal hysterectomy and bilateral oophorectomy for uterine fibroids.
1998: Bunionectomy
Family History
Mother: 79, alive and well.
Father: 54, deceased, heart attack. No brothers diseases or sisters. There is a positive family history of hypertension, but no diabetes, or cancer.
Occupation, Financial Status, Address and Contact Number
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