Post on 28-Mar-2015
How to Write Medical History
Dr. Lu, Qinchi
Dept. Neurology
Ren Ji Hospital
Shanghai Second Medical University Qinchilu@hotmail.comQ
inchil@hotmail.com
Chief 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 day’s duration(3). Symptom-Time-in duration: e.g. Low fever 2-3 months in duration(4). Time-of-Symptom: e.g. Two-day history of chest pain
Present History 1. Onset
– Fulminant; explosive The onset was fulminating with fever The drug caused an explosive onset of pain
– Sudden; abrupt; precipitate The onset was sudden with the temperature rising to
40oC Attacks began and ended abruptly The attacks is often precipitated by a large or fatty
meal
Present History– Rapid
Coma occurred rapidly
– Gradual Gradual onset of listlessness and anorexia
– Occasionally; accidentally Occasionally he noticed a mass in the right
upper abomen He perceived accidentally that his stool was
mixed withblood
Present History 2.Occurrence
– Recurrent bouts of fever and joint pain– Attacks occurred often after meal– Nocturnal attacks occurs sporadically– Transitory attacks of dizziness– Symptoms waned and waxed from time
to time.– Her illness hangs in the balance
Present History– Persistent fever– Intermittent fever– Patient had frequent episodes of vomiting– An attack lasted on the average 4 to 5 hours– The entire attack lasted for less than a minute– The attack lasted a variable time from a few
minutes to several hours– Attacks occure usually between 2 and 4 AM– The pain has been free of attacks for one month
Present History 3. Factors affect the occurrence of the
symptom– Dyspnea occurs soon after lying– The pain became more severe after
meals– Dyspnea is relieved by sitting up– The chest pain had relation to respiration– The pain had no relation to coughing
Past Medical History 1. In intact medical history, it include:
– Infectious disease, allergy, surgery He 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 drugs
He had history of Penicillin sensibility Appendectomy was done in May, 1986
because of acute appendicitis
Past Medical History– System Review includes:
Had symptom(Disease) in the past No 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 past– Had been well ( or healthy ) until …; was
apparently healthy until…
Past Medical History He had been well until Sept.1983 at which time he was
found to have hypertension He was apparently healthy until his present illness
– Have never been sick He was barely ever sick He denied any history of prior heart and liver disease He denied experiencing ( or having) episode of
coughing before (There was ) no history of arthralgia in the past He has never been short of breath no exertion
Past Medical History Past history was free from any suggestion of cerebritis Not pertinent Noncontribututory
– To suffer from…, to have an attack of…, to have…, to catch…
He suffered from nephritis 10 years ago He had an attack of measles during the childhood He caught pneumonia at age 20 He has been a known hypertension since 35 years of
age
Past Medical History– To have no…except ( or apart from )…
He has had no other disease except bronchitis
– To be liable to…,to be subject to …, to be apt to…
He was liable to joint pain in his childhood He was apt to catch cold
Personal History Working and living environment ( according to…, it is
said to be…, he states that) According to his statement, he has worked as a driver for 15 years He was engaged in farming work for 30 years His occupation ( for 20 years ) necessitated his breathing
inhalation of dust He has had no contact with toxic chemicals nor clear-water
streams He has lived in Beijing since birth and denied travel to the south
Personal History Smoking
He was not a smoker He has smoked a package of cigarettes a day
for 35 years He smoked 3 or 5 cigarettes daily formely, but
he stopped smoking two months ago
Drink He denies the use of alcoholic beverages He drinks only occasionally and in moderation
Personal History He imbibes about 0.2 kilogram a day for 16
years He often drinks too much ( or heavily)
Eating habits He has no likes or dislikes in food He has a lifelong dislike for vegetables He liked acid ( sweets, pungent, hot, cold)
food
Personal History Marrage and childbearing history
She has been married for 6 years without conception
Childbearing history: 3-2-1-3 She has had two fullterm pregnancies and
has two living children, no history of abortion or premature births
Menstrual period She has regular periods every 28 days that
lasted 4 days, moderate menses.
Personal History Her menses began at the age of 14 and have
continued at normal intervals except during pregnancies
She had menstrual irregularities with intervals of 20 to 65 days
She experienced (or developed) menorrhagia with passage of clots
Profuse vaginal bleeding is present, she has no change her pads every hour
The menstrual periods were painful
Personal History Pain of the left lower abdomen occurred before
menstruation She passed ( or underwent, went through) the
menopause at age 38
Child history– Birth history
He was delivered normally and spontaneously The child was delivered by forceps He weighed 3.3 kilograms and was 46 cm in height at
birth
Personal History– Feeding history
He was fed at breast (-He took breast milk ) before he was 13 months old
– Developed history His 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 years
– Vaccination history The baby had a BCG vaccination when he
was three days old
Family History His parents, wife and 2 children are living and
well Her husband is well no evidence of illness The family history did not reveal any anemic
patient There was no family history of carcinoma There was no tuberculosis in his family Both parents had diabetes but were otherwise
well
Family History There was a familial tendency to obesity on
the maternal side( -on the mother’s side) His father died of heart disease attack His brother’s death was due to pneumonia at
the age of 15
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