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How to Write Medical History Dr. Lu, Qinchi Dept. Neurology Ren Ji Hospital Shanghai Second Medical University 第一页，共二十三页。 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 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 第二页，共二十三页。 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 第三页，共二十三页。 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 第四页，共二十三页。 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 第五页，共二十三页。 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 第六页，共二十三页。 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 第七页，共二十三页。 Past Medical History 1. In intact medical histor