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 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

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 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

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 mothers side)
His father died of heart disease attack
His brothers death was due to pneumonia at
the age of 15

THANKS!