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Patient Medical History Example

This 65-year-old retired Ethiopian man presented with a 3-day history of chest pain. He has a history of stroke 4 years ago, diabetes for 20 years, and hypertension. He smokes cigarettes and drinks alcohol daily. His current chest pain is intermittent, squeezing, and radiates to his shoulders, accompanied by sweating, fatigue, shortness of breath, and palpitations. He has noticed worsening chest tightness over the past 6 months. He has a history of non-adherence to medications.

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Dagmawi Bahiru
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347 views2 pages

Patient Medical History Example

This 65-year-old retired Ethiopian man presented with a 3-day history of chest pain. He has a history of stroke 4 years ago, diabetes for 20 years, and hypertension. He smokes cigarettes and drinks alcohol daily. His current chest pain is intermittent, squeezing, and radiates to his shoulders, accompanied by sweating, fatigue, shortness of breath, and palpitations. He has noticed worsening chest tightness over the past 6 months. He has a history of non-adherence to medications.

Uploaded by

Dagmawi Bahiru
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

Sample Health history

Date -30/01/2014 EC Time -8:30 am

Identifying data

Name-Abebe Kebede Tesema(arbitrary)

Age-65

Sex-male

Religion-orthodox christian

Place of residence-bishoftu

Occupation-retired

Marital status-married

Source of the history-patient himself with no language barrier

Reliability –reliable

History of previous admission : 04 years back he was admitted at bishoftu hospital for stroke and
stayed for a weeks before he was discharged with improved with a blood thinner and cholesterol drug.

Chief complaint : anterior chest pain since 03 days back

History of present illness

This patient was apparently in good health until 03 days back when he began to experience sudden
onset anterior chest squeezing type of pain which radiates to his both shoulders associated with
profound sweating,easy fatigability, shortness of breath, feeling of impending doom, orthopnea of three
pillows, paroxysmal nocturnal dyspnea, palpitation, and bilateral leg swelling. The pain is intermittent
and stays for about 30min and exacerbated by exertion and relieved by rest.

He claims to notice progressive chest tightness and breathlessness for the past six months

He is a known diabetic and hypertension patient for the past twenty years on unspecified oral
medications and admits to have poor adherence to his medications and follow up

He discontinued his blood thiner and anti-cholesterol drugs since a year back

He is an active cigarette smoker (40 pack years) and binges 02 melekias of arake daily to help him sleep

He has intermittent claudication.


Otherwise no fever, chills, muscle or joint pain

No history of trauma

Has long standing productive cough associated with occasional wheezing but no recent weight loss, or
night sweating.

No recent surgery, immobilization or long haul travel

No history of abdominal swelling or yellowish discoloration of the eyes

Past History

Childhood illnesse : none.

Medical: none except those mentioned in the HPI

Surgical: prostate surgery at this hospital 10 years back

Psychiatric: he was told to have clinical depression related to his smoking and alcohol use which
requires drug treatment which he opted out.

Family history

He has four sibling (two sisters and two brothers),him being the eldest. All of them are healthy

Personal and social history

The patient was born and raised in bishoftu, he is educated to the level of diploma in education
and was teaching at a primary school in the vicinity until he retired 10 years back.

He is happily married for the past fourty years and has a daughter and forur sons who are in
good health and working.

Currently apart from his pension, his oldest son helps him financialy.

Despite his chronic illnesses he is not adherent to diatery allowances

He spends most of his time with his friends

He never exercised intentionally

He prefers to drink holy water for his ailments rather visiting a doctor.

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