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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