TheAbridgedGuidetoWritingaHistory

1、Jeffrey L. Greenwald, MD1.Source2. Chief complaint (CC)3. History of the present illness (HPI)4. Past medical history (PMH)5. Medications (Meds)6. Allergies (All) allergyallergy / lrdi /7. Family history (FHx)8. Social history (SHx)9. Review of Systems (ROS)10. Physical Exam (PE)11. Laboratory and D

2、ata (Lab/Data)12. Assessment/Impression/Summary13. PlanExample: Information obtained from the patient and his spouse /spas/, who seemed clear and coherent /kohrnt/.Example: Information obtained from 5-year-old son who acted as interpreter for the patient, who doesnt speak English. Son seemed to unde

3、rstand only part of questions.Example: Information obtained from drowsy /drazi/, intoxicated patient and the police officer who brought her in, and it was supplemented /splmnt/ by old medical records.Example: 34-year-old male with advanced AIDS complains of a “bad cough” and fevers developing over t

4、he last 8 days.Example:81-year-old African-American female with a history of hypertension and diabetes complains of “pain in my chest” while walking up the stairs yesterday.Example:56-year-old male with a history of ulcerative colitis complains of 3months of worsening back stiffness, 2 weeks of “a s

5、ore on my leg,” and 3 days of fevers and bloody, painless diarrhea.例：1.病史资料来自患者本人和其配偶，二人均神志清晰，思路连贯。例：2.患者不会讲英语，由其5岁的儿子充当翻译提供病史，这个孩子看起来只能理解部分问题。例：3.病史资料源自昏昏欲睡的酗酒女患者、送她入院的警察以及既往病历资料。例：34岁男性进展期AIDS患者，诉“剧烈咳嗽”伴发热8天。例：81岁美国黑人妇女有高血压和糖尿病病史，诉昨天上楼梯时出现“胸痛”。例：56岁男性患者，曾患溃疡性结肠炎，诉背部僵直逐渐加重3个月，“肢体疼痛”2周，发热、无痛性血便3天。Ex

6、ample: M.T. is a 45-year-old homeless male who was in his usual state of health until approximately 5weeks prior to admission when he began noting drenching night sweats occurring initially about 2 times weekly. The night sweats then increased in frequency, and about 3 weeks prior to admission, he a

7、lso began having a cough. It was initially dry but progressed being productive of small amounts yellow sputum tinged with blood. He also thinks he had fevers but had no access to a thermometer. He has been staying at various shelters around Boston. He noted that hed been losing about 5Ibs/months wit

8、hout trying to diet and there had been no change in his activity level. This had been going on for about 3 month. He had no history of injection drug use, blood transfusion, or cigarette use and does not know his PPD status. He has had multiple sexual partners over the last few years he has been on

9、the streets, including two experiences of trading unprotected sex with another male for alcohol. The patient admits to only sporadic condom use and says he forgets when he gets drunk, which happens a few times a week. He has not received either a flu or pneumococcal vaccine in the past though he had

10、 an uncomplicated admission in 2/97 to St. Elsewhere for community-acquired pneumonia. He stated that there were a lot of people at the shelters who had “colds” but didnt know any specifics about those illnesses. M.T. came to the USA about 10 years ago and has lived in Boston the entire time with no

11、 travel outside the city. At this time, he denies dyspnea, chest pain, nausea, vomiting, diarrhea, swollen lymph nodes, myalgias, arthralgias decreased appetite, and rash.例：M.T.是一位45岁的无家可归的越南籍男性，既往健康情况一般，约入院前5周出现夜间大汗淋漓，最初平均每周2次。夜间大汗淋漓出现次数逐渐增多，并在入院前3周出现咳嗽。最初为干咳，以后逐渐出现少量黄痰伴血丝。或者自觉发热，但没有用体温计测量。患者曾在波士顿不同的避难所居住过。在没有刻意减肥和改变运动量的情况下，体重以约5磅的速度递减。这种情况持续了大约3个月。患者没有毒品注射史、输血史和吸烟史，PPD检查不详。在过去的数年中，患者在所居住的街区有多个性伴，曾有两次因酒精而进行的无保护措施的同性性交易。患者只偶尔使用安全套，在每周数次的性行为中，经常因