Written History of Mr John

The preceding interview has revealed much about this 42-year-old lawyer. Superficially, he is a patient with coronary artery disease. Just as important as his physical illness is his emotional reaction to it. As the interview progressed, the interviewer recognized that the patient is frightened and anxious. What will happen ''after tomorrow''? Will he be a candidate for balloon angioplasty? Can it be performed? Is he a good candidate for bypass surgery? Will he live? The anxiety from these questions has resulted in his depression, which must be dealt with as well.

The written history is a summary of the information obtained during the interview. It is usually written after the interview and the physical examination have been completed. The following is an example of the written history of Mr. Doe, based on the preceding interview.

Chief Complaint: ''Chest pain for the past 6 months.''

History of Current Illness: This is the first St. Catherine's Hospital admission for Mr. John Doe, a 42-year-old lawyer with coronary artery disease. His history dates back to approximately 4 years before admission, when he started to experience a vague discomfort in his chest. He describes it as ''a dull ache,'' provoked by emotional upsets at work. He suffered his first heart attack on July 15, 2008, while playing tennis. He was hospitalized for 3 weeks in Kings Hospital. After 3 weeks at home, he returned to work. Six months later, he suffered his second heart attack, again while playing tennis. He was again hospitalized at Kings Hospital and was told that he had ''irregularity'' of his heart. He was started on some medications for this irregularity. The patient denies any palpitations since then.

Over the past 6 months, the patient has had increasing chest pain with radiation down his left arm despite atenolol, 50 mg daily, and isosorbide dinitrate, 10 mg qid.{ The patient's chest pain is produced by exercise, emotion, and sexual intercourse. The patient takes nitroglycerin as needed, with relief within 5 minutes. One-block dyspnea on exertion is also present. This has worsened in the past 6 months, before which he could walk two to three blocks. The patient's risk factors for coronary artery disease include a history of untreated hypertension, a 40-pack-year history of smoking (2 packs per day for 20 years), and a brother with a myocardial infarction at the age of 40 years. The patient's brother is now 45 years of age. The patient denies any history of diabetes or hyperlipidemia. At his physician's and wife's request, he has entered the hospital for elective cardiac catheterization. The patient has a significant denial of his illness and a secondary depression.{ Although cardiac catheterization was suggested after the patient's first heart attack, he refused to accept it until this admission.

Past Medical History: The patient was hospitalized at age 15 years for an appendectomy in Booth Memorial Hospital in Rochester, New York. The surgery was performed by a Dr. Meyers. The only other hospitalizations were for the patient's two heart attacks, as indicated previously. The patient is predominantly a red meat eater with little fish in his diet. Recently, presumably owing to depression, there has been a loss of appetite with a 10-pound weight loss. The patient admits to a sleeping problem. He falls asleep normally but awakens early and cannot go back to sleep. His only medications are indicated in the history of current illness. There is no history of renal, hepatic, pulmonary, or gastrointestinal disease. There is no history of allergy.

Family History: The patient's father is 75 years of age and has a history of diabetes. He apparently has some ocular problem related to diabetes. The patient's mother died at age 64 years from stomach cancer. The patient's older brother, as mentioned previously, is

*By indicating to the patient that the interviewer and her preceptor will be back, the patient is less likely to press the interviewer for her opinion at this time. The interviewer should never provide an answer at this point. False reassurances can be dangerous. {The abbreviation qid means four times a day.

{Notice that the history of the current illness summarizes all the information related to the current illness chronologically, regardless of when the information was obtained during the interview.

45 years of age and has coronary artery disease. The patient has a younger sister who is 37 years of age and is well. There is no history of congenital disease. The patient is married and has a 15-year-old son, who is well.

Psychosocial History: The patient is a ''type A'' personality. He admits to having a need to drink alcohol occasionally after work. He drinks coffee about three times a day. He has used only marijuana on rare occasions, and he denies the use of other recreational drugs.

Review of Systems: There is a 20- to 25-year history of headaches without any recent change in their pattern or severity. The patient denies any head injury. There is. . . .* There is no history of claudication.{ The remainder of the review of systems is noncontributory.1

*The review of systems would then indicate any of the other symptoms that may be present. {Notice that the positive symptoms are indicated first. The important, or pertinent, negative symptoms are then listed. A pertinent negative symptom in this patient is the lack of claudication. Coronary artery disease is often associated with peripheral vascular disease. The absence of a major symptom of peripheral vascular disease, claudication, makes claudication in this patient a pertinent negative symptom. Chapter 15, The Peripheral Vascular System, provides a further discussion of pertinent positives and negatives.

{This statement indicates that none of the other symptoms is either present or contributes to the patient's current illness.

CHAPTER 7

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