How to Write Medical History

1. How to Write Medical History Dr. Lu, Qinchi Dept. Neurology Ren Ji Hospital Shanghai Second Medical University Qinchilu@hotmail.comQ inchil@hotmail.com

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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…

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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.

17. 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

18. 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

19. 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

20. 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

21. 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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