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Sample Written History and Physical Examination History and Physical Examination Patient Name: Date: Rogers, Pamela 6/2/04 Referral Source: Emergency Department Data Source: Patient Chief Complaint & ID: Ms. Rogers is a 56 y/o WF having chest pains for the last week. Comments Define the reason for the patient’s visit as who has been specifically as possible. 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. Convey the acute or chronic nature of the problem and establish a chronology. 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. Thi ...
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