Past history refers to the patient's health and diseases before the onset, especially the diseases closely related to the current symptoms, which are recorded in chronological order. Personal history refers to personal experiences and personal records.
2, the content is different
The contents of past history include:
(1) General health in the past.
(2) whether you have infectious diseases, endemic diseases and other diseases, the date of onset and the diagnosis and treatment. For the diseases that patients have suffered before, you can use the name of the disease, but you should add quotation marks; If the diagnosis is uncertain, briefly describe its symptoms.
(3) whether there is a history of vaccination, trauma, surgery, and allergies to drugs and food.
Personal experience includes:
(1) Birth, growth, place and time of residence (with special attention to epidemic areas and epidemic areas), education level, hobbies, etc.
(2) Living habits, health habits, eating rules, tobacco and alcohol hobbies and their intake, whether there are other heterosexual and narcotic drug intake history, and whether there is a history of major mental trauma.
(3) Past and present occupation, labor protection and working environment, etc. Focus on understanding whether the patient has a history of frequent contact with toxic and harmful substances, and should indicate the time and degree of contact.
(4) whether there is a history of wandering, whether you have suffered from chancre, gonorrhea, etc.
(5) For children patients, in addition to understanding the mother's prenatal pregnancy and delivery process (natural delivery and dystocia), it is also necessary to understand the feeding history and growth history.
Extended data:
Other records of medical records-current medical history:
The present medical history is the main part of the medical history. Around the chief complaint, according to the order of symptoms, the occurrence, development, change, diagnosis and treatment of the disease from onset to treatment were recorded in detail.
Its contents mainly include:
(1) onset time, priority, possible causes and incentives (including some conditions before onset if necessary).
(2) Time, location, nature, degree and evolution of main symptoms (or signs).
(3) With the characteristics and changes of symptoms, important positive and negative symptoms (or signs) with differential diagnosis significance should also be explained.
(4) For patients with chronic diseases or relapse related to this disease, we should focus on the initial situation, major changes and recent recurrence.
(5) Where and what kind of diagnosis and treatment have been carried out since the onset (including the date of diagnosis and treatment, test results, drug name, dosage and usage, surgical method and curative effect, etc.). ).
(6) Other important injuries that have nothing to do with undergraduate diseases and still need to be diagnosed and treated should be described in another article.
(7) General conditions since the onset, such as changes in spirit, appetite, appetite, sleep, defecation, physical strength and weight.
Baidu Encyclopedia-Medical Records