tags:
- type/patient/medical_history
mhid: 102
name: mh102
patient: pat102
patient_link: "[[pat102.patient]]"
banner: "![[_System/Banners/patient_medical_history_800x300.jpg]]"
created_at: 2024-07-28T19:17:41+03:00
updated_at: 2025-08-17T13:28:46+03:00
banner_y: 0.24248
social_history: |-
Marital Status:
The patient is married with two children, a son and a daughter. He lives with his family in a suburban home. He maintains close relationships with his parents and siblings, whom he sees regularly.
Occupational History:
The patient works as an engineer in a large industrial company for the past 15 years. He has prior experience in various positions within the same field and has progressed in the company due to his skills and professional performance. His work is demanding, involving both office tasks and on-site inspections at industrial facilities.
Habits:
Smoking: Approximately one pack per day for the past 20 years.
Alcohol: Social consumption, mainly on weekends, moderate intake of wine and beer.
Substances: No use of illicit drugs.
Sleep: Tries to maintain a consistent sleep schedule, although professional obligations sometimes disrupt his routine.
Pets:
The patient has one dog (Labrador Retriever) and two adopted stray cats. The care of the pets is mainly handled by the patient and his children.
Travel:
Enjoys travel and frequently goes on family vacations. Has visited several countries in Europe and Asia. Occasionally travels for work to inspect projects and meet clients, mainly domestically.
Diet:
Relatively balanced diet with emphasis on the Mediterranean diet—fruits, vegetables, fish, and olive oil. Occasionally consumes fast food due to work commitments.
Exercise:
Attempts to exercise at least three times per week, typically jogging or walking with his dog. Occasionally participates in team sports with friends, such as soccer or basketball. However, he often skips exercise due to work pressure.
family_history: |-
Parents:
Father: 72 years old, retired. History of hypertension and cardiovascular disease. Underwent angioplasty 5 years ago.
Mother: 70 years old, retired. History of type 2 diabetes and osteoarthritis. Underwent hip replacement surgery 3 years ago.
Siblings:
Brother: 45 years old, lawyer. History of childhood asthma, well managed with medication. Married with two children.
Sister: 40 years old, teacher. History of migraines, managed conservatively. Married with three children.
Children:
Son: 15 years old, student. History of pollen and certain food allergies, managed with antihistamines.
Daughter: 12 years old, student. Healthy, no significant medical issues to date.
Grandparents:
Paternal grandfather: Died at 78 from a heart attack. History of hypertension and hypercholesterolemia.
Paternal grandmother: Died at 80 from a stroke. History of type 2 diabetes.
Maternal grandfather: Died at 75 from lung cancer. Long-term smoker.
Maternal grandmother: Died at 82 from natural causes. History of osteoporosis and hypertension.
The patient’s family history indicates a predisposition to cardiovascular disease, diabetes, and hypertension, with additional history of lung cancer, asthma, and allergies.
personal_history: |-
Hypertension:
Diagnosis: January 2010
Description: The patient was diagnosed with hypertension following repeated measurements of high blood pressure. Managed with antihypertensive medication and lifestyle modifications, including a low-salt diet and regular exercise.
Hypercholesterolaemia:
Diagnosis: May 2020
Description: The patient was diagnosed with elevated cholesterol levels during a routine check-up. Initially managed with medication (atorvastatin) and subsequently with dietary and lifestyle changes.
surgical_ops:
- date: 2018-11-10
description: Severe injury to the right leg due to a traffic accident. The patient sustained multiple fractures of the tibia and fibula.
outcome: " The patient underwent an emergency osteosynthesis surgery to repair the fractures. Metal plates and screws were used to stabilise the bones. The postoperative course was stable, and the patient remained hospitalised for one week for monitoring and physiotherapy."
hospitalization:
- cause: Acute pneumonia. The patient was hospitalised for treatment with intravenous antibiotics and monitoring of respiratory function. Recovery was successful without complications, and the patient was discharged with instructions to continue oral antibiotic therapy and follow-up with a pulmonologist.
date: 2015-04-05
health_unit: GENERAL HOSPITAL OF ATHENS
- date: 2017-05-15
health_unit: EVANGELISMOS GENERAL HOSPITAL
cause: The patient was admitted urgently with severe chest pain and shortness of breath. He underwent emergency angioplasty with stent placement. The postoperative course was uneventful, and the patient was discharged with instructions for medication and regular cardiology follow-up.
past_medication:
- date: 2019-01-10
cause: Treatment for a bacterial respiratory infection. The course lasted 10 days and was completed successfully without complications.
dosage: 500mg
drug: Amoxicillin
- drug: Atorvastatin
dosage: 20mg
date: 2020-05-15
cause: Management of hypercholesterolaemia. The treatment lasted six months and was discontinued following improvement in cholesterol levels and the physician’s recommendation for dietary and lifestyle changes.
alcohol: true
smoking: true
drugs: false
obesity: true
sleep_disorder: false
sleep_disorder_other:
diabetic: false
allergies: false
sexual_disfunction: false
sexual_disfunction_other:
hypertension: true
hyperlipidemia: false
infectious: false
infectious_other:
pulmo: false
pulmo_other: ""
cardio: false
cardio_other: ""
neuro: false
neuro_other:
ent: false
ent_other:
other_disorder: false
other_other: ""
allergies_content:
- description: Rhinitis, sneezing, and watery eyes during spring and summer. Managed with antihistamines.
date: 2005-05-10
type: Pollen
severity: 2
- date: 2010-09-15
type: Food Allergy (Nuts)
severity: 3
description: Skin rash, urticaria, and respiratory distress following the consumption of nuts. Managed by avoiding these foods and using epinephrine in emergency situations.
- date: 2015-03-20
type: Penicillin
severity: 3
description: An anaphylactic reaction with symptoms such as tachycardia, shortness of breath, and rash following administration of penicillin for infection treatment. Managed with epinephrine and antihistamines.
immunizations:
- date: 1980-02-15
description: Diphtheria-Tetanus-Pertussis (DTP)
- description: Poliomyelitis (IPV)
date: 1980-04-15
- description: Measles-Mumps-Rubella (MMR)
date: 1982-06-20
- description: Hepatitis B
date: 1991-03-10
- description: Meningococcus
date: 2010-11-05mh102.medhist
tags:
- type/patient/medical_history
mhid: 102
name: mh102
patient: pat102
patient_link: "[[pat102.patient]]"
banner: "![[_System/Banners/patient_medical_history_800x300.jpg]]"
created_at: 2024-07-28T19:17:41+03:00
updated_at: 2025-08-17T13:28:46+03:00
banner_y: 0.24248
social_history: |-
Marital Status:
The patient is married with two children, a son and a daughter. He lives with his family in a suburban home. He maintains close relationships with his parents and siblings, whom he sees regularly.
Occupational History:
The patient works as an engineer in a large industrial company for the past 15 years. He has prior experience in various positions within the same field and has progressed in the company due to his skills and professional performance. His work is demanding, involving both office tasks and on-site inspections at industrial facilities.
Habits:
Smoking: Approximately one pack per day for the past 20 years.
Alcohol: Social consumption, mainly on weekends, moderate intake of wine and beer.
Substances: No use of illicit drugs.
Sleep: Tries to maintain a consistent sleep schedule, although professional obligations sometimes disrupt his routine.
Pets:
The patient has one dog (Labrador Retriever) and two adopted stray cats. The care of the pets is mainly handled by the patient and his children.
Travel:
Enjoys travel and frequently goes on family vacations. Has visited several countries in Europe and Asia. Occasionally travels for work to inspect projects and meet clients, mainly domestically.
Diet:
Relatively balanced diet with emphasis on the Mediterranean diet—fruits, vegetables, fish, and olive oil. Occasionally consumes fast food due to work commitments.
Exercise:
Attempts to exercise at least three times per week, typically jogging or walking with his dog. Occasionally participates in team sports with friends, such as soccer or basketball. However, he often skips exercise due to work pressure.
family_history: |-
Parents:
Father: 72 years old, retired. History of hypertension and cardiovascular disease. Underwent angioplasty 5 years ago.
Mother: 70 years old, retired. History of type 2 diabetes and osteoarthritis. Underwent hip replacement surgery 3 years ago.
Siblings:
Brother: 45 years old, lawyer. History of childhood asthma, well managed with medication. Married with two children.
Sister: 40 years old, teacher. History of migraines, managed conservatively. Married with three children.
Children:
Son: 15 years old, student. History of pollen and certain food allergies, managed with antihistamines.
Daughter: 12 years old, student. Healthy, no significant medical issues to date.
Grandparents:
Paternal grandfather: Died at 78 from a heart attack. History of hypertension and hypercholesterolemia.
Paternal grandmother: Died at 80 from a stroke. History of type 2 diabetes.
Maternal grandfather: Died at 75 from lung cancer. Long-term smoker.
Maternal grandmother: Died at 82 from natural causes. History of osteoporosis and hypertension.
The patient’s family history indicates a predisposition to cardiovascular disease, diabetes, and hypertension, with additional history of lung cancer, asthma, and allergies.
personal_history: |-
Hypertension:
Diagnosis: January 2010
Description: The patient was diagnosed with hypertension following repeated measurements of high blood pressure. Managed with antihypertensive medication and lifestyle modifications, including a low-salt diet and regular exercise.
Hypercholesterolaemia:
Diagnosis: May 2020
Description: The patient was diagnosed with elevated cholesterol levels during a routine check-up. Initially managed with medication (atorvastatin) and subsequently with dietary and lifestyle changes.
surgical_ops:
- date: 2018-11-10
description: Severe injury to the right leg due to a traffic accident. The patient sustained multiple fractures of the tibia and fibula.
outcome: " The patient underwent an emergency osteosynthesis surgery to repair the fractures. Metal plates and screws were used to stabilise the bones. The postoperative course was stable, and the patient remained hospitalised for one week for monitoring and physiotherapy."
hospitalization:
- cause: Acute pneumonia. The patient was hospitalised for treatment with intravenous antibiotics and monitoring of respiratory function. Recovery was successful without complications, and the patient was discharged with instructions to continue oral antibiotic therapy and follow-up with a pulmonologist.
date: 2015-04-05
health_unit: GENERAL HOSPITAL OF ATHENS
- date: 2017-05-15
health_unit: EVANGELISMOS GENERAL HOSPITAL
cause: The patient was admitted urgently with severe chest pain and shortness of breath. He underwent emergency angioplasty with stent placement. The postoperative course was uneventful, and the patient was discharged with instructions for medication and regular cardiology follow-up.
past_medication:
- date: 2019-01-10
cause: Treatment for a bacterial respiratory infection. The course lasted 10 days and was completed successfully without complications.
dosage: 500mg
drug: Amoxicillin
- drug: Atorvastatin
dosage: 20mg
date: 2020-05-15
cause: Management of hypercholesterolaemia. The treatment lasted six months and was discontinued following improvement in cholesterol levels and the physician’s recommendation for dietary and lifestyle changes.
alcohol: true
smoking: true
drugs: false
obesity: true
sleep_disorder: false
sleep_disorder_other:
diabetic: false
allergies: false
sexual_disfunction: false
sexual_disfunction_other:
hypertension: true
hyperlipidemia: false
infectious: false
infectious_other:
pulmo: false
pulmo_other: ""
cardio: false
cardio_other: ""
neuro: false
neuro_other:
ent: false
ent_other:
other_disorder: false
other_other: ""
allergies_content:
- description: Rhinitis, sneezing, and watery eyes during spring and summer. Managed with antihistamines.
date: 2005-05-10
type: Pollen
severity: 2
- date: 2010-09-15
type: Food Allergy (Nuts)
severity: 3
description: Skin rash, urticaria, and respiratory distress following the consumption of nuts. Managed by avoiding these foods and using epinephrine in emergency situations.
- date: 2015-03-20
type: Penicillin
severity: 3
description: An anaphylactic reaction with symptoms such as tachycardia, shortness of breath, and rash following administration of penicillin for infection treatment. Managed with epinephrine and antihistamines.
immunizations:
- date: 1980-02-15
description: Diphtheria-Tetanus-Pertussis (DTP)
- description: Poliomyelitis (IPV)
date: 1980-04-15
- description: Measles-Mumps-Rubella (MMR)
date: 1982-06-20
- description: Hepatitis B
date: 1991-03-10
- description: Meningococcus
date: 2010-11-05$= await dv.view("js_scripts/display_patient_full_name", {fname: "prf102.profile", folder: "People/Patient/102"})
MEDICAL HISTORY - Patient Summary
Personal History - General / Notes
Hypertension:
Diagnosis: January 2010
Description: The patient was diagnosed with hypertension following repeated measurements of high blood pressure. Managed with antihypertensive medication and lifestyle modifications, including a low-salt diet and regular exercise.
Hypercholesterolaemia:
Diagnosis: May 2020
Description: The patient was diagnosed with elevated cholesterol levels during a routine check-up. Initially managed with medication (atorvastatin) and subsequently with dietary and lifestyle changes.
Previous (Chronic) Conditions
Diabetes Mellitus
Arterial Hypertension
Hyperlipidemia
Asthma – Other Pulmonary Disease
Coronary Disease, Myocardial Infarction, Angina – Other Cardiac Disease
Stroke, Epilepsy – Other Neurological Disease
ENT Disorders
Infectious / Communicable Diseases
Other Condition
Other Issue / Particularity
Alcohol
Drugs
Smoking
Obesity
Sleep Disorders
Sexual Disfunction
Surgical Procedures or Serious Injuries
| DATE | DESCRIPTION | TREATMENT/OUTCOME | |
|---|---|---|---|
Previous Hospitalizations
| DATE | HOSPITAL | REASON | |
|---|---|---|---|
Past Medication History
| DRUG | DOSAGE | DATE | REASON | |
|---|---|---|---|---|
Allergies - Drug Reactions
| DATE | TYPE | SEVERITY | DESCRIPTION | |
|---|---|---|---|---|
Vaccination Record
| DATE | DESCRIPTION | |
|---|---|---|
Family History
Parents:
Father: 72 years old, retired. History of hypertension and cardiovascular disease. Underwent angioplasty 5 years ago.
Mother: 70 years old, retired. History of type 2 diabetes and osteoarthritis. Underwent hip replacement surgery 3 years ago.
Siblings:
Brother: 45 years old, lawyer. History of childhood asthma, well managed with medication. Married with two children.
Sister: 40 years old, teacher. History of migraines, managed conservatively. Married with three children.
Children:
Son: 15 years old, student. History of pollen and certain food allergies, managed with antihistamines.
Daughter: 12 years old, student. Healthy, no significant medical issues to date.
Grandparents:
Paternal grandfather: Died at 78 from a heart attack. History of hypertension and hypercholesterolemia.
Paternal grandmother: Died at 80 from a stroke. History of type 2 diabetes.
Maternal grandfather: Died at 75 from lung cancer. Long-term smoker.
Maternal grandmother: Died at 82 from natural causes. History of osteoporosis and hypertension.
The patient’s family history indicates a predisposition to cardiovascular disease, diabetes, and hypertension, with additional history of lung cancer, asthma, and allergies.
Social History
Marital Status:
The patient is married with two children, a son and a daughter. He lives with his family in a suburban home. He maintains close relationships with his parents and siblings, whom he sees regularly.
Occupational History:
The patient works as an engineer in a large industrial company for the past 15 years. He has prior experience in various positions within the same field and has progressed in the company due to his skills and professional performance. His work is demanding, involving both office tasks and on-site inspections at industrial facilities.
Habits:
Smoking: Approximately one pack per day for the past 20 years.
Alcohol: Social consumption, mainly on weekends, moderate intake of wine and beer.
Substances: No use of illicit drugs.
Sleep: Tries to maintain a consistent sleep schedule, although professional obligations sometimes disrupt his routine.
Pets:
The patient has one dog (Labrador Retriever) and two adopted stray cats. The care of the pets is mainly handled by the patient and his children.
Travel:
Enjoys travel and frequently goes on family vacations. Has visited several countries in Europe and Asia. Occasionally travels for work to inspect projects and meet clients, mainly domestically.
Diet:
Relatively balanced diet with emphasis on the Mediterranean diet—fruits, vegetables, fish, and olive oil. Occasionally consumes fast food due to work commitments.
Exercise:
Attempts to exercise at least three times per week, typically jogging or walking with his dog. Occasionally participates in team sports with friends, such as soccer or basketball. However, he often skips exercise due to work pressure.