Sample Medical History Registry

This sample medical history registry, which would be stored on the Medical Edge Web site, is for a patient named Rosa DelRosario. (For more information about the Web site, see story, p. 36.)

Patient Information:

Most recently updated: 5/19/98 at 3:45 p.m.
DOB: 2/14/41
Name: Rosa P. DelRosario
Address: 555 Main Street, Anywhere, USA 11221
Home Phone: (123) 555-1212
Work Phone: (123) 534-1212
Emergency Contact: Jose DelRosario (husband) — also at above home phone number — husband’s work number: (123) 432-1212

History of Present Illness:

Rosa is a 56 year-old Hispanic female with a past medical history of hypertension for the last 20 years under fair control with medication, angina for the last five years, and arthritis that bothers her on an intermittent basis for which she sees a rheumatologist. Rosa’s angina has been self-limited, and a stress thallium test done on 7/4/97 revealed an ejected fraction of some 54% with no ST or T wave changes having achieved 75% of maximal heart rate. At baseline she has no shortness of breath or chest pain with exertion. She can perform age-appropriate activities of daily living without any restriction and with ease. She sees cardiologist John Roseman, MD, of Edgemont Hospital in Edgemont, RI, at (123) 434-1212 for her angina and her internist is Paul Rhoades, MD, at (123) 343-1212.

Past Medical History:

Hypertension x 20 years
Angina x five years
Arthritis — intermittent over last three years

Past Surgical History:

Tonsillectomy age 8
Appendectomy age 23
Cesarean x 2 age 34, 36
Tubal ligation age 36
Medical allergies: None known
Tobacco: None
Alcohol: Only socially
Street drugs: None
HIV risk factors: None, tested negative in past for life insurance purposes

Medications:

Norvasc 5mg po qD, Tiazac 180mg CD qD, Ecotrin 325mg qD, Naprosyn 375 qID prn joint pain, Sublingual Nitroglycerin 1-2 tablets SL prn angina pain

Social History:

Married, two grown children who live outside the home, works part-time as cashier in local hardware store

Family History:

Mother died of lung cancer age 64 (+ smoking history). Father died of myocardial infarction, age 56. One sister with high blood pressure, other siblings without medical problems. Children alive and well.

Relevant Diagnostic Testing/Procedures/Labs:

SMA20 done 2/3/97 with outstanding values of SGOT of 64, Alkaline phosphates of 212, and cholesterol of 232. CBC on 2/3/97 with outstanding values of 11 basophils and MCV of 93.

EKG from 3/23/97 with normal sinus rhythm, nl axis with nonspecific ST/T wave changes but no q waves, normal QRS and PR intervals.

Stress thalium done 7/4/97 revealed an ejected fraction of some 54% with no ST or T wave changes having achieved 75% of maximal heart rate. All areas were well perused on thallium infusion.