History of the Present Illness: Duration of chest pain. Location, radiation (to arm, jaw, back), character (squeezing, sharp, dull), intensity, rate of onset (gradual or sudden); relationship of pain to activity (at rest, during sleep, during exercise); relief by nitroglycerine; increase in frequency or severity of baseline anginal pattern. Improvement or worsening of pain. Past episodes of chest pain. Age of onset of angina. | Current Clinical Strategies History and Physical Examination Tenth Edition Paul D. Chan . Peter J. Winkle . Current Clinical Strategies Publishing ccs Digital Book and Updates Purchasers of this book may download the digital book and updates for Palm Pocket PC Windows and Macintosh. The digital books can be downloaded at the Current Clinical Strategies Publishing Internet site ccs Copyright 2005 Current Clinical Strategies Publishing. All rights reserved. This book or any parts thereof may not be reproduced or stored in an information retrieval network without the permission of the publisher. No warranty exists expressed or implied for errors or omissions in this text. Current Clinical Strategies Publishing 27071 Cabot Road Laguna Hills California 92653-7012 Phone 800-331-8227 Fax 800-965-9420 E-mail info@ Internet ccs Printed in USA ISBN 1-929622-28-7 Medical Documentation History and Physical Examination Identifying Data Patient s name age race sex. List the patient s significant medical problems. Name of informant patient relative . Chief Compliant Reason given by patient for seeking medical care and the duration of the symptom. List all of the patients medical problems. History of Present Illness HPI Describe the course of the patient s illness including when it began character of the symptoms location where the symptoms began aggravating or alleviating factors pertinent positives and negatives. Describe past illnesses or surgeries and past diagnostic testing. Past Medical History PMH Past diseases surgeries hospitalizations medical problems history of diabetes hypertension peptic ulcer disease asthma myocardial infarction cancer. In children include birth history prenatal history immunizations and type of feedings. Medications Allergies Penicillin codeine Family History Medical problems in family including the patient s disorder. Asthma coronary artery disease heart .
