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A Guide to History Taking and Medical Record Limei 李梅Endocrinology Department INTRODUCTION 1.How to take a medical record(1) 2. How to take a medical record(2) 3.A guide to history taking(1) 4. A guide to history taking(2) 5.Asthma Medical Record The structure of a record General data Chief complaints(CC) Present illness(PI) Past history(PH) Personal history Family history Physical examination Primary diagnosis 1. 年龄有5种写法(以15 岁为例) 15years old(of age); 15 year-old; The age of 15; Age 15; 15 years of age 2. 职业:Occupation 工人Worker 农民Peasant	 教师Teacher 学生Student	 工程师Engineer	 技术员Technician 医生Doctor 	 护士Nurse 	 战士Soldier 警察Police 	 营业员Assistant 	 服务员Attendant 职员Staff member 售票员Conductor	 家务Housework 退休Retired 3. marital status 婚姻状况已婚married		 未婚unmarried		 离婚divorced 寡妇widow 		 鳏夫widower 4.Source of History 病史提供者such as the patient, a relative ,a friend ,the patient’s medical record Patient himself Her husband His colleague Neighbor 5.reliability 病史可靠性可靠 reliable		 不完全可靠not entirely		 不太准确not clearly defined 混乱不清confused and uncertain 无法获得unobtainable The patient is consistently clear about her symptoms but vague on when they began 6. address 住址按从小到大的顺序写1.No 82 ,Jinzhai Road ,HEFEI ,ANHUI 2.XiaoLi Cun ,Sha ping Xiang ,Da Tong ,JIANGSU 3.No 808-4-3 Shidai Square,Anshan Road,Nankai District,TIANJIN II.Chief Complaints 列出主要症状及其存在的时间症状+for+ 时间cough with yellow sputum for 5 days 症状+of (时间)……duration Black tarry stools of three days duration 症状+时间+in duration Low fever 2-3 months in duration 时间+of+ 症状Two-day history of chest pain III.Present Illness 现病史This section is a clear, chronological account of the problems for which the patient is seeking care. The data come from the patient but the organization is yours. The narrative should include the onset of the problem, the setting in which it developed ,its manifestations, and any treatments. The principal symptoms should be described in terms of III.Present Illness 现病史1.location; 2.quality; 3.quantity or severity; 4.timing(i.e. onset,duration,and frequency); 5.the settting in which they occur; 6.factors that have aggravated or relieved them, 7.associated manifestations. Also note significant negatives(the absence of certain symptoms that will aid in differential diagnosis). 起病方式 The onset was fulminating with fever. 呈暴发性起病伴发热。The drug caused an explosive onset of pain. 这种药物骤然引起疼痛。The onset was sudden with the temperature rising to 40℃. 突然发病,体温达40℃。Attacks began and ended abruptly. 突然发作,突然停止。The attacks is often precipitated by a large or fatty meal. 常因过食或脂肪餐而突然发病。Coma occurred rapidly. 很快发生了昏迷Gradual onset of listlessness and anorexia. 逐渐出现无精打采和厌食。发作规律经常的、反复的Recurrent bouts of fever and joint pain 偶尔的Nocturnal attacks occur sporadically. 一过性Transitory attacks of dizziness. 一过性眩晕。时轻时重Symptoms waned and waxed from time to time. 时好时坏Her illness hangs in the balance. 持续的persistent fever 持续性发热间歇的intermittent fever 间歇性发热频繁的Patient had frequent episodes of vomiting. 持续的时间An attack lasted on the average 4 to 5 hours. 多在……时候发生Attacks occur usually between 2 and 4 AM. 有……时间未发作过The pain has been free of attacks for one month. 症状的发生和变化的影响因素 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. 常见症状的叙述 1.……感觉a sensation of fear(giddiness,nausea,chill) 恐惧(眩晕,恶心,寒战)感foreign body(oppressive, stranging or choking, burning, chilly)sensation(or feeling) 异物(压迫,窒息,烧灼,寒战)感2.其他全身不适感 无精力lack of energy 感到全身乏力to complain generalized weakness,feel weak all over 全身虚弱general debility 无法形容的眩晕nondescript dizziness 感觉气闷to feel suffocating 3. 疼痛pain 疼痛的性质酸痛aching pain 	 坠痛bearing-down pain 钻痛boring pain 烧灼痛burning pain 	 绞痛colic ,colicky (or cramp ;griping )pain 钝痛dull pain 束带样痛girdle pain 搏动性痛throbbing pain 痛的位置 Colicky pain is located in the right upper quadrant. Pain is localized to the right lower abdomen. Pain is confined to the epigastrium. Pain then shifts to the region of the gallbladder. Pain radiated to the left shoulder The pain radiates from the right upper abdomen to the right shoulder. 局部的痛headache		 chest pain 		 backache; back pain lumbago		 abdominal pain;stomachache	 acrodynia; pain in limbs arthrodynia; arthralgia 4. 发热to have a temperature; to become feverish  高热hyperpyrexia ;hyperthermia; a high fever; ardent fever 低热hypothermia; low-grade fever; slight fever; The temperature rose to 40℃. The temperature went up from 38℃to 40℃yesterday. Fever dropped (was reduced) to normal. Fever disappeared 5 days after onset of illness. Temperature didn’t go up over 38℃. The temperature varied between 37.5℃and 38.5℃. His temperature showed perpetual fluctuation. 5. 食欲His appetite is undisturbed. The patient has appetite fair,eats two bowls of rice. He has no appetite, he took only some mouthfuls of rice gruel today. He becomes more anorexic, and he is indifferent even to his favorite food. 6. 喝水Recently he has felt very thirsty and he has had to get up in the night several times to refresh himself with water. He had marked thirst and drank approximately 3000ml of water a day. 7. 体重 He complains of a 5 kilograms weight gain in the past a month. His weight is constant(or maintained)at 55Kg. His weight lost 10Kg in the previous 3 months. 8. 睡眠 His sleep has been poor lately. Sleep was impossible if he didn’t take soporific. He falls into sleep easily and is also easily awakened. 9. 呼吸困难 He has difficulty in talking because of the urge to continue breathing . If he hurries up in walking, he gets short of breath. Expiration is felt to be more difficult than inspiraion. 10. 咳嗽 hacking cough 干咳wheezing cough 带哮鸣音的咳嗽irritable cough 刺激性咳嗽spasmodic cough 痉挛性咳嗽paroxysmal cough 发作性咳嗽loose cough; productive cough 痰咳咳嗽He coughs very often. Intermittent hacking cough started at 2 years old. He experienced a 6-day episod of dry paroxysmal cough. 11. 痰green expectoration; 绿色痰bloody sputum 血痰frothy sputum 泡沫状痰mucous sputum 粘液痰purulent sputum 脓痰	 rusty sputum; 铁锈色痰痰He suddenly coughed up large amounts of foul sputum. About 3 hundred milliliters of sputum are produced daily. 12. 大便bloody stool fatty stool formless stool mucous stool rice-water stool 米泔样便tarry stool 柏油样便watery(liquid)stool 大便to open the bowel, to have passage; to pass a stool to have a call of nature His stools numbered 4 to 6 daily. The stools became fewer in number. He has had watery stools containing mucus in the recent three days. 13. 便秘constipation The constipation was very obstinate(or stubborn)and he had to take cathartics. His constipation did not yield with mild laxatives. 14. 腹泻diarrhea Three was an onset with profuse bloody diarrhea. Various medicaments were tried ,but none seemed to help the diarrhea. He was watery stool and the volume of feces is as great as 2 liters in 24 hours. 15. 尿液to make water, to pass water, to urinate, micturiton frequency of micturition, Pollakiuria 尿频pain in urination, urodynia 尿痛difficulty in micturition, dysuria 排尿困难Three was no alteration in size and force of the urinary stream. His voiding was accompanied by severe burning. He has frequent desire to urinate, but doesn’t start immediately. 16. 出血Vomiting of blood was brown, resembling coffee grounds. From an early age the patient has had spontaneous and traumatic hemorrhages in the skin; once, after having cut his hand , bleeding continued for several hours. The patient notes often streaks of blood on the outside of stool. 四.既往史传染病史,过敏史和手术史He had contact with patient who had pulmonary tuberculosis for 3 months before one year. He had history of Penicillin sensibility. Appendectomy was done in May,1986 because of acute appendicitis. 既往史He had 



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