医学专业英语课件_14

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.
– Rapid
Coma occurred rapidly
– Gradual
Gradual onset of listlessness and anorexia
– Occasionally; accidentally
Occasionally he noticed a mass in the right upper abomenPa来自t 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…
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
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
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
– 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
(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
Present History
1. Onset
– Fulminant; explosive
The onset was fulminating with fever The drug caused an explosive onset of pain
– Sudden; abrupt; precipitate
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
How to Write Medical History
Dr. Lu, Qinchi Dept. Neurology Ren Ji Hospital
Shanghai Second Medical University Qinchilu@Q inchil@
Chief Complant
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