How to Write Medical History

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How to Write Medical History

• Dr. Lu, Qinchi
• Dept. Neurology
• Ren Ji Hospital
• Shanghai Second Medical University
  Qinchilu_at_hotmail.comQ
• inchil_at_hotmail.com

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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Past Medical History

• To have noexcept ( 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

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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

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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

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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

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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.

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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

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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

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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

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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

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Family History

• There 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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• THANKS!