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1、How to Write Medical History Dr. Lu, Qinchi Dept. Neurology Ren Ji Hospital Shanghai Second Medical University QQ2021/9/101Chief Complant(1). Symptom-for-Time: e.g. Cough with yellow sputum for 5 days(2). Symptom-of.duration: e.g. Black tarry stools of three days duration(3). Symptom-Time-in duratio
2、n: e.g. Low fever 2-3 months in duration(4). Time-of-Symptom: e.g. Two-day history of chest pain2021/9/102Present History1. OnsetFulminant; explosiveThe onset was fulminating with feverThe drug caused an explosive onset of painSudden; abrupt; precipitateThe onset was sudden with the temperature risi
3、ng to 40oCAttacks began and ended abruptlyThe attacks is often precipitated by a large or fatty meal2021/9/103Present HistoryRapidComa occurred rapidlyGradualGradual onset of listlessness and anorexiaOccasionally; accidentallyOccasionally he noticed a mass in the right upper abomenHe perceived accid
4、entally that his stool was mixed withblood2021/9/104Present History2.OccurrenceRecurrent bouts of fever and joint painAttacks occurred often after mealNocturnal attacks occurs sporadicallyTransitory attacks of dizzinessSymptoms waned and waxed from time to time.Her illness hangs in the balance2021/9
5、/105Present HistoryPersistent feverIntermittent feverPatient had frequent episodes of vomitingAn attack lasted on the average 4 to 5 hoursThe entire attack lasted for less than a minuteThe attack lasted a variable time from a few minutes to several hoursAttacks occure usually between 2 and 4 AMThe p
6、ain has been free of attacks for one month 2021/9/106Present History3. Factors affect the occurrence of the symptomDyspnea occurs soon after lyingThe pain became more severe after mealsDyspnea is relieved by sitting upThe chest pain had relation to respirationThe pain had no relation to coughing2021
7、/9/107Past Medical History1. In intact medical history, it include:Infectious disease, allergy, surgeryHe had contact with patient who had pulmonary tuberculosis for 3 months before one year.He had (or there was) no history of allergy to food or drugsHe had history of Penicillin sensibilityAppendect
8、omy was done in May, 1986 because of acute appendicitis2021/9/108Past Medical History System Review includes:Had symptom(Disease) in the pastNo symptom (Disease)2. In Medical Record, it only need to mention there were any disease ( or Symptom) there was no disease ( or Symptom) in the pastHad been w
9、ell ( or healthy ) until ; was apparently healthy until2021/9/109Past Medical HistoryHe had been well until Sept.1983 at which time he was found to have hypertensionHe was apparently healthy until his present illnessHave never been sickHe was barely ever sickHe denied any history of prior heart and
10、liver diseaseHe denied experiencing ( or having) episode of coughing before(There was ) no history of arthralgia in the pastHe has never been short of breath no exertion2021/9/1010Past Medical HistoryPast history was free from any suggestion of cerebritisNot pertinentNoncontribututoryTo suffer from,
11、 to have an attack of, to have, to catchHe suffered from nephritis 10 years agoHe had an attack of measles during the childhoodHe caught pneumonia at age 20He has been a known hypertension since 35 years of age2021/9/1011Past Medical HistoryTo have noexcept ( or apart from )He has had no other disea
12、se except bronchitisTo be liable to,to be subject to , to be apt toHe was liable to joint pain in his childhoodHe was apt to catch cold2021/9/1012Personal HistoryWorking and living environment ( according to, it is said to be, he states that)According to his statement, he has worked as a driver for
13、15 yearsHe was engaged in farming work for 30 yearsHis occupation ( for 20 years ) necessitated his breathing inhalation of dustHe has had no contact with toxic chemicals nor clear-water streamsHe has lived in Beijing since birth and denied travel to the south 2021/9/1013Personal HistorySmokingHe wa
14、s not a smokerHe has smoked a package of cigarettes a day for 35 yearsHe smoked 3 or 5 cigarettes daily formely, but he stopped smoking two months agoDrink He denies the use of alcoholic beveragesHe drinks only occasionally and in moderation2021/9/1014Personal HistoryHe imbibes about 0.2 kilogram a
15、day for 16 yearsHe often drinks too much ( or heavily)Eating habitsHe has no likes or dislikes in foodHe has a lifelong dislike for vegetablesHe liked acid ( sweets, pungent, hot, cold) food2021/9/1015Personal HistoryMarrage and childbearing historyShe has been married for 6 years without conception
16、Childbearing history: 3-2-1-3She has had two fullterm pregnancies and has two living children, no history of abortion or premature birthsMenstrual periodShe has regular periods every 28 days that lasted 4 days, moderate menses.2021/9/1016Personal HistoryHer menses began at the age of 14 and have con
17、tinued at normal intervals except during pregnanciesShe had menstrual irregularities with intervals of 20 to 65 daysShe experienced (or developed) menorrhagia with passage of clotsProfuse vaginal bleeding is present, she has no change her pads every hourThe menstrual periods were painful2021/9/1017P
18、ersonal HistoryPain of the left lower abdomen occurred before menstruationShe passed ( or underwent, went through) the menopause at age 38Child historyBirth historyHe was delivered normally and spontaneouslyThe child was delivered by forcepsHe weighed 3.3 kilograms and was 46 cm in height at birth20
19、21/9/1018Personal HistoryFeeding historyHe was fed at breast (-He took breast milk ) before he was 13 months oldDeveloped historyHis weight was 8.6 kg and he was 70 cm high at a year, but his weight and height increased slowly in the past 2 yearsVaccination historyThe baby had a BCG vaccination when
20、 he was three days old2021/9/1019Family HistoryHis parents, wife and 2 children are living and wellHer husband is well no evidence of illnessThe family history did not reveal any anemic patientThere was no family history of carcinomaThere was no tuberculosis in his familyBoth parents had diabetes but were otherwise well2021/9/1020Family HistoryThere was a familial tendency to obesity on the maternal side( -on the mothers side)His father died of heart disease attack His brothers death was due to pneumonia at the age of 152021/9/1021 THANKS!THANKS!2021/9/1022
