Sample Written History and Physical Examination History and Physical Examination Patient Name: Date: Referral Source: Data Source: Rogers, Pamela 6/2/04 Emergency Department Patient Define the reason for the patient’s visit as who has been specifically as possible. Comments

Chief Complaint & ID: Ms. Rogers is a 56 y/o WF having chest pains for the last week. 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 inside and rested in a cool area. 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 has never been told she has heart problems, never had any chest pains before, does not have claudication. She was diagnosed with HTN 3 years ago, 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 Surgical – 1994: 1998: Total abdominal hysterectomy and bilateral oophorectomy for uterine fibroids. Bunionectomy

Convey the acute or chronic nature of the problem and establish a chronology. onset character location radiation circumstances; exacerbating factors associated symptoms duration resolution; alleviating factors Describe the natural history of her problem since its onset Change or new circumstances to the problem New duration Reason she come in for visit What has patient tried for relief

Relevant positive and negative ROS for this complaint

Review of systems for the relevant organ system

Relevant risk factor/environmental conditions

This highly relevant, although it may seem like a trivial detail at first

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. 1 or 2 beers each weekend; 1 glass of wine once a week with dinner. None. No prescription or illegal drug use. Occasional OTC ibuprofen (Advil) for headache (QOD).

Always use generic names

Always list the type of reported reaction Quantity

Social History – Alcohol use: Tobacco use: Medications:

Include over-the-counter drugs

Family History Mother: Father: 79, alive and well. 54, deceased, heart attack. No brothers or sisters. There is a positive family history of