Jonathan Poggi

1/24/13
Complete History Writeup
CC:
Patient presented with severe chest pain from the day before.
HPI:
Onset: Patient was chipping ice on her driveway when a sudden pain arose in her chest
Location: Where exactly is the pain? Try to describe it anatomically.
Duration: How many hours, days, or years has the problem been going on?
Characterization: What words did the patient use to describe the back pain? Where is the pain on
the pain scale?
Alleviating factors:
Radiation: Does the pain radiate? Describe where it radiates in anatomic terms. Repeat Episodes.
Has this ever happened before to the patient?
Timing: Does the pain or symptom come and go? Or is it constant? Does it vary based on time of
day?
PMH:
The past medical history is the next section, and I divide it up even further into the
following parts:
Childhood Illnesses:
Past Surgical History:
Psychiatric History:
Adult Illnesses:
Past Surgical History:
Psychiatric History:
Obstetric History (if your patient is female):
Immunizations:
Accidents/Injuries:
You should fill in each section with the relevant information.
Medications: List the patients current medications, doses, and what the patient is
taking the medication for. Remember to include a statement about over the counter
medications and herbal medications.
Allergies: List medications, foods, and environmental allergens the patient is allergic
too. Record what the allergic reaction is (e.g. rash, anaphylactic shock, etc.)
Social History: This section is written in paragraph form. You should include the
following sections in your social history:
who the patient lives with
the patients marital status
the patients occupation

 whether the patient currently smokes cigarettes

whether the patient has ever smoked cigarettes
whether the patient uses illicit drugs (and if they do, specify which drugs
they use, how frequently they use them, and when they last used them)
whether the patient drinks alcohol. If they do, what do they drink (beer,
wine, or liquor) and how frequently do they drink it?
Any of the patients hobbies or interests that youd like to record in their
chart.
Stressors in the patients life
Support System
Sexual History
o This can be asked in several different parts of the PE: with the HPI if
the sexual history is the problem or has an impact on the sexual
practices. For example if a person gets angina when he/she tries to
have sexual relations. In the SH when discussing support systems.
During the PMH it could be asked as part of the OB/GYN history for a
woman. Rarely should it be asked in the ROS. The ROS consists of
mainly closed ended questions and does not promote an open
dialogue about sexuality.
Health Practices: (as a separate section or often as part of the PMH)
This is the section where you will record your information about:
Diet(you can record the foods they eat in an average day) Exercise (discuss frequency of
exercise, what activities the patient does for
exercise, and how long the patient exercises each time they exercise)
Mammograms and other preventative tests
Family History:
For your family history, you should list each family member you asked about
followed by whether they are alive or deceased and a list of illnesses theyve been
diagnosed with. For example, a family history for a different patient might be:
Grandfather: deceased at age 84, no known health problems
Grandmother: aged 93, history of hypertension and myocardial infarction.
Father: aged 52, history of hypertension
Mother: aged 49, no known medical problems
Brother: age 24, no known medical problems
No children.
No grandchildren.
After you go through each family member, you need a sentence that shows you asked
the patient about common illnesses that run in families. The illnesses you can ask
about are: hypertension, diabetes mellitus, myocardial infarction, stroke, and cancer.
An example of this sentence at the end of your family history is: No family history of
cancer, diabetes, or stroke.
Review of Systems:
For a complete ROS, you should list out each system that you are reviewing and then
list the patients responses to each question you asked. You cannot write ROS

normal. You cant even write Skin: normal. You should write out each question you
asked the patient. For example: Cardiovascular: no chest pain, no palpitations.
The systems you should review in a complete ROS are:
General:
Skin:
Head:
Ears:
Eyes:
Nose:
Thorat:
Neck:
Cardiac:
Respiratory:
Gastrointestinal:
GenitoReproductive:
GenitoUrinary:
Endocrine:
Hematologic:
Peripheral Vascular:Musculoskeletal:
Neurologic: