How to Write Medical History

Dr. Lu, Qinchi Dept. Neurology Ren Ji Hospital Shanghai Second Medical University Qinchilu@hotmail.comQinchil@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 days 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 History1. OnsetFulminant; explosiveThe onset was fulminating with feverThe drug caused an explosive onset of painSudden; abrupt; precipitateThe onset was sudden with the temperature rising to 40oCAttacks began and ended abruptlyThe attacks is often precipitated by a large or fatty meal

Present HistoryRapidComa occurred rapidlyGradualGradual onset of listlessness and anorexiaOccasionally; accidentallyOccasionally he noticed a mass in the right upper abomenHe perceived accidentally that his stool was mixed withblood

Present 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 balance

Present 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 pain has been free of attacks for one month

Present 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 coughing

Past 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 sensibilityAppendectomy was done in May, 1986 because of acute appendicitis

Past 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 well ( or healthy ) until ; was apparently healthy until

Past 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 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 exertion

Past Medical HistoryPast history was free from any suggestion of cerebritisNot pertinentNoncontribututoryTo suffer from, 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 age

Past Medical HistoryTo have noexcept ( or apart from )He has had no other disease 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 cold

Personal 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 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

Personal HistorySmokingHe was 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 moderation

Personal HistoryHe imbibes about 0.2 kilogram a 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) food

Personal HistoryMarrage and childbearing historyShe has been married for 6 years without conceptionChildbearing 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.

Personal HistoryHer menses began at the age of 14 and have continued 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 painful

Personal 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 birth

Personal 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 he was three days old

Family 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 well

Family 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 15

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