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
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)
– Rapid
Coma occurred rapidly
– Gradual
Gradual onset of listlessness and anorexia
– Occasionally; accidentally
Occasionally he noticed a mass in the right upper abomen
How to Write Medical History
Dr. Lu, Qinchi Dept. Neurology Ren Ji Hospital
Shanghai Second Medical University Qinchilu@Q inchil@
Chief Complant
– 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
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
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
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
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…
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
(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
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
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)
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
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
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
Pnt; explosive
The onset was fulminating with fever The drug caused an explosive onset of pain
– Sudden; abrupt; precipitate
– 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
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
– 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
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.
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.
breathing inhalation of dust He has had no contact with toxic chemicals nor clear-