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1、How to Write Medical HistoryChief 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 pai
2、nPresent History1. Onset Fulminant; explosiveThe onset was fulminating with feverThe drug caused an explosive onset of pain Sudden; abrupt; precipitateThe onset was sudden with the temperature rising to 40oCAttacks began and ended abruptlyThe attacks is often precipitated by a large or fatty mealPre
3、sent History RapidComa occurred rapidly GradualGradual onset of listlessness and anorexia Occasionally; accidentallyOccasionally he noticed a mass in the right upper abomenHe perceived accidentally that his stool was mixed withbloodPresent History2.Occurrence Recurrent bouts of fever and joint pain
4、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 balancePresent History Persistent fever Intermittent fever Patient had frequent episodes of vomiting An attack lasted on the av
5、erage 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 History3. Factors affect the occurrence of the symptom Dyspnea oc
6、curs 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 coughingPast Medical History1. In intact medical history, it include: Infectious disease, allergy, surgeryHe had contact with patient
7、 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 appendicitisPast Medical History System Review includes:Had symptom(Disease) in the pas
8、tNo 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 untilPast Medical HistoryHe had been well until Sept.1983 at which time he was found to h
9、ave hypertensionHe was apparently healthy until his present illness Have 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
10、of breath no exertionPast Medical HistoryPast history was free from any suggestion of cerebritisNot pertinentNoncontribututory To 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
11、 has been a known hypertension since 35 years of agePast 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 toHe was liable to joint pain in his childhoodHe was apt to catch coldPersonal HistoryWorking and livi
12、ng 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 cle
13、ar-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 be
14、veragesHe drinks only occasionally and in moderationPersonal 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) foodPersonal H
15、istoryMarrage 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,
16、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 painfulPersonal HistoryPain of the left lower abdomen occurred before menstruationShe passed ( or underwent, went through) the menopause at a
