Sample of History Taking

Chief complaint: chest pain

History of Present Illness

5 days PTA, patient experienced non-productive cough, colds with greenish

discharge and mild stabbing chest pain. He still went to work because his boss
insisted him to go.

3 days PTA, cough and colds persisted with moderate stabbing chest pain
that is relieved with rest. No associated fever, no medications taken. However, he
ignored it and he still went to his work.

15 hours PTA, chest pain persisted with sharp non-radiating headache located
at the temporal side with a pain scale of 6/10. It led him to have a check up and was
given co-amoxiclav and vitamin B complex as take home medicines but was not
able to take it and still went to work.

1 hour PTA, symptoms became worse. He experienced stabbing and pleuritic

chest pain upon inspiration with a pain score of 7/10. He had 1 episode of projectile
vomiting which consisted of a watery, clear vomitus with minimal phlegm and food
particles, amounting two cups. This was associated with mild dizziness.
Subsequently, he drove his self to Gabriela Silang General Hospital at Vigan City for
admission.

Allergies. No known allergies to food and medications.

Tobacco. 1-2 sticks ocassionally (usually after a meal)

Alcohol/drugs.Drinks 1-2 bottles of beer occasionally. No illicit drugs

Past History

Childhood Illness: Patient had chickenpox, measles. No scarlet fever or

rheumatic fever

Adult Illnesses:
 Hospitalization: This is the patients first hospitalization but had seldom
clinic check up.

Medical : Three years ago he was diagnosed of renal cyst and chose not to
undergo surgery. No follow-up check up done. There were no known
psychiatric problems.

Surgical: Sutures for laceration on the left temporal area, date unrecalled,
after vehicular accident

Health maintenance:

Immunizations: Bacillus Calmette-Guerin (BCG) was the only vaccine

recalled and evident by the vaccine scar on the right deltoid. Other
vaccinations received were not known by the patient.

Screening Test: None

Family History

Patients father and mother are still alive with no known medical problem. He
has 4 siblings. He has a brother who has asthma. No other known history of
herodofamilial dieases.

Personal History

He finished 1 year in mechanical engineering and decided to stop and

look for a job to sustain the need of his family . He has two children who live
together with him and his wife.. He typically wakes up at 6:00AM, sometimes even
earlier, works at around 8:00AM- 5:30 PM. He smokes 1-2 sticks per day usually
after a meal but not daily, and drinks alcohol occasionally like when his friends
invited him. He considers his family and friends as his support system whenever he
face emotional and financial problem.

He does not do any form of exercise. He eats regularly for about three times a
day. He drinks water not exceedingly 1 liter per day and sometimes less. Also drinks
coffee in the morning.