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大小:195.00 KB
页数:22页
时间:2019-09-22
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1、HowtoWriteMedicalHistoryDr.Lu,QinchiDept.NeurologyRenJiHospitalShanghaiSecondMedicalUniversityQinchilu@hotmail.comQinchil@hotmail.comChiefComplant(1).Symptom-for-Time:e.g.Coughwithyellowsputumfor5days(2).Symptom-of…..duration:e.g.Blacktarrystoolsofthreeday’sduration(
2、3).Symptom-Time-induration:e.g.Lowfever2-3monthsinduration(4).Time-of-Symptom:e.g.Two-dayhistoryofchestpainPresentHistory1.OnsetFulminant;explosiveTheonsetwasfulminatingwithfeverThedrugcausedanexplosiveonsetofpainSudden;abrupt;precipitateTheonsetwassuddenwiththetempe
3、raturerisingto40oCAttacksbeganandendedabruptlyTheattacksisoftenprecipitatedbyalargeorfattymealPresentHistoryRapidComaoccurredrapidlyGradualGradualonsetoflistlessnessandanorexiaOccasionally;accidentallyOccasionallyhenoticedamassintherightupperabomenHeperceivedaccident
4、allythathisstoolwasmixedwithbloodPresentHistory2.OccurrenceRecurrentboutsoffeverandjointpainAttacksoccurredoftenaftermealNocturnalattacksoccurssporadicallyTransitoryattacksofdizzinessSymptomswanedandwaxedfromtimetotime.HerillnesshangsinthebalancePresentHistoryPersist
5、entfeverIntermittentfeverPatienthadfrequentepisodesofvomitingAnattacklastedontheaverage4to5hoursTheentireattacklastedforlessthanaminuteTheattacklastedavariabletimefromafewminutestoseveralhoursAttacksoccureusuallybetween2and4AMThepainhasbeenfreeofattacksforonemonthPre
6、sentHistory3.FactorsaffecttheoccurrenceofthesymptomDyspneaoccurssoonafterlyingThepainbecamemoresevereaftermealsDyspneaisrelievedbysittingupThechestpainhadrelationtorespirationThepainhadnorelationtocoughingPastMedicalHistory1.Inintactmedicalhistory,itinclude:Infectiou
7、sdisease,allergy,surgeryHehadcontactwithpatientwhohadpulmonarytuberculosisfor3monthsbeforeoneyear.Hehad(ortherewas)nohistoryofallergytofoodordrugsHehadhistoryofPenicillinsensibilityAppendectomywasdoneinMay,1986becauseofacuteappendicitisPastMedicalHistorySystemReviewi
8、ncludes:Hadsymptom(Disease)inthepastNosymptom(Disease)2.InMedicalRecord,itonlyneedtomentiontherewereanydisease(orSymptom)therewasno
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