(临床诊断学) 仁济临床医学院诊断学教研室 An Introduction to Clinical Diagnostics

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Chapter 14 Vertigo

Vertigo implies the illusory sensation of turning or spinning-either of the patient himself or his environment.Dizziness is less easily defined as lighthead. Although vertigo may be distinguished from dizziness by demanding that unmistakable whirling or turning be present, these two symptoms often are clinically indistinguishable and may be approached as one entity. Conditions that involve vestibular funtion can be separated into peripheral ( otological vertigo) and central subgroups. Patients with these syndromes present clinically with a combination of vertigo and ataxia. Practically, there are far more cases of otological vertigo than central vertigo, and for the reason in clinical practice, a detailed understanding of otological vertigo is essential.

[ Etiology and clinical manifestation ]


  1. Periphral Vertigo ( otological vertigo)

    1. Benign Paroxysmal Positional Vertigo: Benign Paroxysmal Positional Vertigo (BPPV) is the cause of half of all cases of otological vertigo; it accounts for about 20% of all patients with vertigo. BPPV is diagnosed by the history of positional vertigo with a typical nystagmus pattern ( a burst of upbeating/ torsional nystagmus) on positional testing. Symptoms are precipitated by movement or a poison change of the head or body. Getting out of bed or rolling over in bed are the most common” problem” motions.

    2. Vestibular neuritis : Vestibular neuritis is a self-limited otological condition. Patients present with vertigo, nausea, ataxia, and nystagmus. Mossst cases of vestibular neuritis are monophasic . Hearing is not impaired, and when there are similar symptoms with abnormal hearing, the symdrome is termed labyrinthitis. A strong nystagmus is seen acutely. Vestibular neuritis is thought to be caused by viral infections involveing the vestibular portion of the eight nerve. It usually happens with fever or after the infection of upper respiratory tract. In vestibular neuritis, severe distress associated with constant vertigo, nause, and malaise usually lasts 1 to 3 day, and less intense symptoms ordinarily persist for 2 weeks. Roughly 10% of patients may take as long as 2 months for the condition to improve substantially.

    3. Meniere’s Disease: Classic meniere’s disease presents as a quadrad of paroxysmal symptoms, including tinnitus, nausea and vomitting, fluctuating hearing, and episodic vertigo and nystagmus..
    4. Cerebellopontine Angle Syndrome: Acoustic neuromas and other tumors such as menigiomas, which can appear at the cerebellopontine angle, usually display asymmetrical sensorineural hearing loss, usually, patients in the fifth or greater decade present with mild vertigo or ataxia, accompanied by a significant asymmetrical hearing loss.


  2. Central Vertigo

In neurological practice, central vertigo typically makes up only 25% of diagnosis of patients

presenting with vertigo, because otololgical vertigo and vertigo of unknown cause are much more frequent. Stroke and TIAs account for one third of cause of central vertigo. Vertigo attributed to vertebrobasilar migraine accounts for another 15% cases. A large number of individual miscellaneous neurological disorders such as seizures, multiple sclerosis, and the Arnold-Chiari malformation make up the reminder




  1. Stroke and TIA

Cerebellum

AICA distribution

PICA distribution


  1. Vertebrobasilar migraine

Adult form

Childhood variant ( benign paroxysmal vertigo of childhood



  1. Others

Seizure ( temploral lobe)

Multiple Sclerosis, post-infectious demyelination

Arnold-Chiari malformation

Tumors of eight nerve, brain stem or cerebellum

Paraneoplastic cerebellar degeneration

Wernick’s syndrome


[Accompanying symptoms]

Ask about symptoms specific to brain stem, such as diplopia, dysarthria, and ataxia. Tinnitus may localize the problem to the inner ear. If there is posterior neck or head pain, consider vertebral dissection and stroke.



Chapter 15 Tic and Seizures

Tics are patterned sequences of coordinated movements that appear suddenly and intermittently. The movements are occasionally simple and resemble a myoclonic jerk, but they are usually complex, ranging from head shaking, eye blinking, sniffing, and shoulder shrugging to complex facial distortions, arm waving, touching parts of the body, jumping movements, or making obscene gestures. Most often, tics are rapid and brief, but occasionally they can be sustained motor contractions.

One feature of tics is the compelling need felt by the patient to make the motor or phonic tic, with the result that the tic movement brings relief from unpleasant sensations that develop in the involved body part. Tics can be voluntarily controlled for brief intervals, but such a conscious effort is usually followed by more intense and frequent contractions.

A seizure is a transient disturbance of cerebral function caused by an abnormal neuronal discharge.


[Etiology]


    1. Cerebral Disease

  1. Infection: Encephalitis or encephalitis caused by bacterial, fungal, or parasitic infections can cause serzures.

  2. Trauma: Head trauma is a common cause, particularly when it occurs perinatally or is associated with a depressed skull fracture or intracerebral or subdural hematoma.

  3. Tumor: Both primary and metastatic brain tumor can be the cause.

  4. Vascular Disease: Cerebral hemorrhage, spontaneous subarachnoid hemorrhage, hypertensive encephalopathy, global cerebral ischemia, etc.

    1. Systemic Disease:

  1. Infection:

  2. Electrolyte Disorders: Hyponatremia and hypocalcemia can cause seizures.

  3. Hypoglycemia can produce seizures, especially with serum glucose levels of 20-30 mg/dL.

  4. Uremia can cause seizures, especially when it develops rapidly.

  5. Hyperthermia can result from infection, heat stroke, and hypothalamic lesions.

[Mechanism]

It’s mechanism is still not clear. Very probably it is related to abnormal discharge of neuron.



[Clinical Features]

Tics can be classified into 4 groups depending on whether they are simple, or multiple and transient or chronic.



  1. Transient simple tics are very common in children, usually terminate spontaneously within 1 year.

  2. Chronic simple tics can develop at any age but often begin in childhood. Treatment is unnecessary in most cases.

  3. Persistent simple or multiple tics of childhood or adolescence usually begin before

age 15.
  1. There is a specific syndrome called Chronic Multiple Motor and Vocal Tics.


Seizures can be classified as Generalized Seizures and Partial Seizures.

Tonic-Clonic (Grand Mal) and Absence (Petit Mal) are the most two regular types of generalized seizure. While Simple Partial, Complex Partial and Partial Seizure with secondary generalization are the most types of partial seizure.



[History Taking]

At what age did the tic or seizure first occurred, its clinical course, and its predisposing factors are all important. The tonic is generalized or partial. It is tonic or clonic. What is the conscious level during the attack?

A thorough neurological and systemic examination is important.

Chapter 16 Disturbances of the Level of Consciousness
Abnormalities of the level of consciousness are characterized by impaired arousal or wakefulness, and they result from lesions of the ascending reticular activating system or both cerebral hemispheres.

[Causes]

1. Brain Lesions:

(1) Supra-tentorial or infra-tentorial Subdural Hematoma: It is a consequence of trauma. Chronic subdural hematoma is more common in older patients. Sometimes the trauma is so slight, that the patient even has forgotten it.

(2) Epidural Hematoma: Epidural hematoma typically results from head trauma associated with a lateral skull fracture and tearing of the middle meningeal artery and vein.

(3) Cerebral Contusion: Cerebral contusion caused by head trauma is associated with initial unconsciousness from which the patient recovers. Edema surrounding the contusion may cause the level of consciousness to fluctuate, and focal neurological signs may develop.

(4) Intracerebral Hemorrhage: It can be a consequence of cerebral contusion or a result of chronic hypertension.

(5) Brain Abscess: Blood-borne metastasis from distant systemic infection, direct extension from parameningeal sites, infection associated with recent or remote head trauma or craniotomy, and infection associated with cyanotic congenital heart disease may all cause brain abscess.

(6) Cerebral Infarction: Cerebral edema following massive hemispheric infarction can produce contralateral hemispheric compression or transtentorial herniation that will result in coma.

(7) Pontine Hemorrhage: The apoplectic onset of coma is the hallmark of this disease.

(8) Cerebellar Hemorrhage or Infarction: The clinical presentation of cerebellar hemorrhage or infarction ranges from sudden onset of coma, with rapid evolution to death, to a progressive syndrome developing over hours or even days.

(9) Brain Tumor: Usually coma occurs late in the clinical course of primary or metastatic tumors of the central nervous system. If there is hemorrhage into the tumor, the patient’s conscious level may deteriorate suddenly.

2. Diffuse Encephalopathies

(1) Meningitis and Encepahlitis: Meningitis and encephalitis may be manifested by an acute confusional state or coma, which is associated with fever and headache.

(2) Spontaneous Subarachnoid Hemorrhage: In spontaneous subarachnoid hemorrhage, symptoms are sudden in onset and include very severe headache. Consciousness is frequently lost at onset.

3. Systemic Disease:

(1) Hypoglycemia: In most cases, hypoglycemic encephalopathy is insulin overdose.

(2) Global Cerebral Ischemia: Global cerebral ischemia produces encephalopathy which culminates in coma; it most often occurs following cardiac arrest.

(3) Drug Intoxication: Sedative-hypnotic drug overdose may cause coma. Coma is preceded by a period of intoxication marked by prominent nystagmus in all directions of gaze, dysarthria and ataxia.

(4) Hepatic Encephalopathy: In patients with sever liver disease, hepatic encephalopathy can lead to coma.

(5) Electrolyte disorders: When serum sodium levels fall below 120 meq/L, the patient’s conscious level will be impaired.

(6) Hypothermia and Hyperthermia: When the temperature is below 26 degrees centigrade, or

above 42 degrees centigrade, the patient is comatose.



[Mechanism]

Consciousness, the awareness of self and environment, requires both arousal and mental

content; the anatomic substrate includes both reticular activating system and cerebral cortex.


[Clinical Features]

The level of consciousness is described in terms of the patient’s apparent state of wakefulness and response to stimuli.

Mild impairment of consciousness may be manifested by sleepiness from which the patient is

easily aroused when spoken to. As consciousness is further impaired, the intensity of stimulation required for arousal increases, the duration of arousal declines, and the responses elicited become less purposeful.

The most severe degree of depressed consciousness is coma, in which the patient is

unresponsive and unarousable. Less severe depression of consciousness results in an acute confusional state, or delirium, in which the patient responds to at least some stimuli in a purposeful manner but is sleepy, disoriented, and inattentive.

In patients with impaired conscious level, abnormalities during physical examination may suggest the underlying cause.

Papilledema suggests increased intracranial pressure. An intracranial mass should be considered.

Pupillary constriction suggests opiate ingestion.

Dilated pupils suggest anticholinergic intoxication.

Small, irregular pupils that react poorly to light---but better to accommodation---can be seen in neurosyphilis.

Systemic signs of liver disease and tremor may suggest hepatocerebral degeneration.

Abnormally high blood pressure may suggest hemorrhagic stroke.

Tachycardia, sweating, and papillary dilation are early signs of hypoglycemia.

Fever, neck stiffness and signs of systemic or parameningeal infection, such as otitis suggest meningitis or encephalitis.

Neck stiffness is also seen in spontaneous subarachnoid hemorrhage patient.



[History Taking]

    1. How is the consciousness impairment occurred and progressed.
    2. To see whether there are concomitant signs, such as fever, vomiting, change in blood pressure, etc.


    3. Past History: Diabetes Mellitus, Chronic Hepatitis, etc.

[Case]

A 57 yrs old woman experienced excruciating headache when she was rest at home and she lost her consciousness very soon.

After she was transferred to the hospital, a physical examination revealed neck stiffness. And a CT scan revealed acute subarachnoid hemorrhage. And later, angiography revealed the hemorrhage was caused by a ruptured intra-cranial aneurysm.

So when this aneurysm is ruptured, it cause severe subarachnoid hemorrhage. And this was the reason why the patient lost the consciousness and the neck was so stiff.


Chapter 17 Hematuria


  1. Definition

Hematuria is defined as more than three red blood cells per high-power field in a centrifuged specimen of urine. It may be gross or microscopic, according to the amount of red blood cells in the urine.


  1. Etiology

  1. Diseases of the urinary system:which is the most common cause. For example, glomerulonephritis, neoplasm, stone, tuberculosis, trauma, etc.

  2. System disorders:

  1. Hematological disorders:ITP, aplastic anemia

  2. Infection:infective endocarditis, septicemia

  3. Connective tissue diseases:SLE, polyarteritis nodosa

  4. Cardiovascular disorders:hypertensive nephropathy, chronic heart failure

  5. Endocrine and metabolism diseases:gout, diabetes mellitus

  1. Diseases of adjacent organs to urinary tract:prostatitis, appendicitis, etc.
  2. Drug and chemical agents:sulfanilamides, anticoagulant, etc.


  3. Miscellaneous:exercise, “idiopathic” hematuria




  1. Clinical Feature

The colour of the hematuria depends on the amount of red blood cells in the urine and the PH. When the urine is acidic, the colour may be more darker than it is alkalized. A single urinalysis with hematuria is common and can result from menstruation, drug, porphyrin, etc. Hematuria must be differentiated from hemoglobinuria, the latter is caused by hemolysis, soy-like, and has very few red blood cell under the microscope. It is very important to identify the origin of the hematuria . Gross hematuria with blood clots is almost never indicative of glomerular bleeding but rather suggests a postrenal source. Collecting the three stage of urine of a patient during micturition, if the initial specimen contains red blood cell, the origin may be urethra. If bleeding occurs mainly at the end of micturition, the bladder neck and triangular area or posturethra should be examined carefully. Total hematuria, which occurs throughout voiding, means that blood comes from the upper urinary tract or bladder. To evaluate the red blood cell is glomerular origin or not needs to make a phase-contrast microscopy examination. Due to press and PH, osmolarity changes in the distal tubule, the red blood cells of glomerular origin are often dysmorphic.


  1. Approach to the Patient



HEMATURIA


proteinuria(>500mg/24h)

dysmorphic RBCs or RBC casts


(-) (+)

(+)

pyuria, WBC casts urine culture serologic and

urine eosinophils hematologic

(-) evaluation: blood

culture, anti-GBM



hemoglobin electrophoresis antibody, ANCA

urine cytology complement level

UA of family numbers cryoglobulin,

24h urinary calcium/uric acid hepatitis B and C



(-) serology, VDRL

IVP +/- renal (+) as indicated: HIV, ASLO


ultrasound retrograde

pyelography or

arteriogram, renal biopsy

(-) or cyst aspiration

(+)


cystoscopy biopsy and

evaluation

(-)


(+)

renal CT scan open renal biopsy

(-)

follow periodic


urinalysis

RBC, red blood cell; WBC, white blood cell; GBM, glomerular basement membrane

ANCA,antineutrophil cytoplasmic antibody; VDRL, venereal disease research labora-

Tory; HIV,human immunodeficiency virus; ASLO,antistreptolysin O; UA,urinalysis;

IVP, intravenous pyelography; CT,computed tomography.

(Adapted from Harrison’s Principles of Internal Medicine, 14th edition)



Chapter 18 Incontinence of Urine
1. Definition

Incontinence, the inability to retain urine in the bladder, result from neurologic or mechanical disorders of the system that control normal micturition. Loss of urine through channels other than the urethra(ectopic ureter, fistulae) and severe tubercular cystitis(contracture of bladder) are rare but cause total or continuous incontinence.




  1. Etiology and Clinical Appearances

  1. True incontinence:In this condition, the sphincter of the bladder and urethra becomes prone to uncontrolled because normal neural pathways are damaged. It often arises from diseases of the central nervous system such as cerebrovascular accidents, Alzheimer’s disease, neoplasm, etc.

  2. Overflow or paradoxical incontinence :This form of incontinence arises from large residual volumes of urine secondary to obstruction at the bladder neck or the urethra(urethral stricture). Benign prostatic hyperplasia afflicts upward of 75 percent of old man.
  3. Stress incontinence:This condition is common in postmenopausal parous woman. Parturition may damage the pelvic support of the bladder so that the bladder and urethra can slip downward from their normal position above the pelvic diaphragm. As they do, the urethra shortens, and the normal urethrovesical angle, important in closing the urethral sphincter, is lost. Many women become unable to resist the passage of urine under the stress of increased intra-abdominal pressure during coughing, sneezing, climbing strains and other physical activity, so small amount of urine escape.


  4. Urge continence:It is an involuntary loss of urine associated with a strong desire to void. Bacterial cystitis or bladder cancer, bladder outlet obstruction and neurogenic bladder must be excluded.




  1. Approach to the Patient

The history should define the onset, duration, evolution and triggering events of leakage. Severity of incontinence is denoted by recording the type and number of pads used per day and how the incontinence affects daily activities. The amount and type of fluid consumed, sexual history(hormonal status, deliveries, venereal diseases), gastrointestinal function(fecal incontinence, constipation), and past urologic history(bed-wetting, surgeries) must also be documented. The physical examination should place special emphasis on the abdominal, genital, pelvic and neurologic system. Stress incontinence must be demonstrated by asking the patient to cough, strain , or even stand or squat. More complex testing is needed to determine whether the urethral anatomy is normal(evaluation of urethral mobility, lateral view of the urethra on the voiding cystourethrogram, cystoscopy), whether urethral function is normal with adequate closure(leak point pressure, urethral profilometry, videourodynamics) or whether bladder function is normal(bladder volume based on home diary, filling cystometrogram).
Chapter 19 Urinary Frequency, Urgency and Dysuria


  1. Definition

Urinary frequency means voiding at frequent intervals, due to a sense of bladder fullness. Urgency is an exaggerated sense of needing to urinate, due to an irritable or inflamed bladder. Dysuria refers to pain or a burning sensation during micturition.


  1. Etiology and Clinical Appearances

  1. Frequency

i. micturition increased but the volume each time is normal

such as diabetes mellitus, diabetes insipidus, polyuria period of acute renal failure



ii.micturition increased and the volume each time is decreased

  1. bladder and urethral irritation:inflammation, tuberculosis, stone

  2. diminished capacity of bladder:neoplasm, contracture of the bladder, pregnant uterus

  3. obstruction of the lower urinary tract:for example, prostatic hyperplasia, often seen in man after age 40 accompanied by force of the urinary stream, hesitancy in initiating voiding , postvoiding dribbling and the sensation of incomplete emptying.

  4. neurogenic bladder:history of neurologic disease

  5. psychogenic cause:nervous, worry, dread

  1. Urgency:acute cystitis, urethritis, prostatitis, stone, bladder cancer, neurogenic bladder, etc. Urgency is commonly associated with frequency and dysuria.

  2. Dysuria:urethritis, cystitis, prostatitis, bladder tuberculosis, stone, foreign body, end-stage bladder cancer, etc. Dysuria occurs at the beginning of micturition in urethritis. Cystitis can aggravate the pain at the end of micturition, and is often accompanied by fever and pyuria. Prostatitis in men can also cause discomfort in the lower abdomen, groin, perineum, rectum, testes, or penis. If patient is concomitant with evidence of TB infection and hematuria, it is necessary to consider bladder tuberculosis.




  1. Approach to the Patient

The history should focus on past as well as present urinary problems. A pelvic examination in woman and prostatic examination in men are necessary components of the physical examination. Urinalysis in all patients , leukorrhea in women and the prostatic fluid in men obtained by prostatic massage, should be examined by microscopy. Prostatic fluid is an important clue to prostatitis and may, when prostatitis is chronic, be the only detectable abnormality. Additional evaluation, when the cause is not evident, may include cultures of urine and prostatic fluid for aerobic and anaerobic bacteria, tubercle bacilli, and mycoplasmas; ultrasound, excretory urography, and voiding cystourethrography. If these examinations do not reveal the diagnosis but syndromes are troublesome, urologic evaluations, including cystoscopy, urethroscopy, endoscopic biopsy and dynamic urinary tract studies may be useful.

Chapter 20 Retention of Urine


  1. Definition

A variety of lesions can lead to interference with the normal ability to empty the bladder and to retain large amount of urine in the bladder, which is referred to the retention of urine. Overflow or paradoxical incontinence can occur with prolonged overdistention of the bladder. Retention of urine requires to be relieved as soon as possible to prevent progressive renal damage.


  1. Etiology and Clinical Appearances

  1. Acute retention of urine

  1. mechanical obstruction

caused by obstruction at the bladder neck or the urethra, such as prostatic hyperplasia, urethral injury and stricture, stone, neoplasm, foreign body, pelvic mass, etc.

  1. dynamic obstruction

caused by the dysfunction of micturition without obstruction of the urinary tract, such as anesthesia, neurologic disorders, excessive smooth muscle relaxation from drugs(anticholinergic medications), etc.

  1. miscellaneous

hypokalemia, fever, coma, stay in bed, etc.

  1. Chronic retention of urine

It develops slowly , also produces a dilated and palpable bladder, but the patients feel less painful, such as benign prostatic hyperplasia, prostatic carcinoma and bladder cancer.


  1. Approach to the Patient

A history of difficulty in voiding, pain, hematuria, operation, drug or coma is very important. Evaluation for distention of bladder often can be obtained by palpation and percussion of the abdomen. A careful rectal examination may reveal enlargement or nodularity of the prostate, abnormal rectal sphincter tone, or a rectal or pelvic mass. In the female, vaginal, uterine, and rectal lesions responsible for urinary tract obstruction are usually revealed by inspection and palpation. The nervous system examination should also be done if necessary. Laboratory testing needs the electrolyte analysis to exclude hypokalemia. If retention has been a long duration, abdominal ultrasound should be performed to evaluate bladder and ureter size, as well as pyelocalyceal contour. If urinary tract obstruction is suspected, intravenous pyelography, cystoscopy, urethrography, or computed tomography are indicated until the site of obstruction is determined.

Part II
Inquisition

Chapter 1 Importance of inquisition (asking histtory)


  1. Inquisition is an important part of diagnostic procedure through the conversation between the patient and doctor.

  2. It is useful to understand the actual history of an illness, no other diagnostic technology can take its place.

  3. For an experienced physician with profound knowledge, diagnosis or impression can be made simply by inquisition. As the diseased organ would give some clue by its pathophysiological changes.

  4. An inaccurate or rough history would lead you to make a wrong diagnosis.

Method of inquisition




  1. Physician should be patient and kind to the patient and treat him as one of his/her family member. The atmosphere should be invariably benevolent. Therefore, the patient can trust him/her.

  2. Inquisition usually begin with the patient’s chief complain. It is approached gradually and systematically.

  3. Ask questions in the most direct and simple language. After the patient has related in his own way the story of his illness, it will be necessary to ask more specific questions to elicit further information or to clarify the exact nature of his complaints.

  4. Never force the patient to related symptoms, which is difficult to answer. Ask some easy questions first, such as “how is your feeling when the illness starts? ”. And then, add some questions such as “ anything happened before the illness? ”.

  5. Hints to the patient such as “did you vomit during headache” are avoided. Instead, just ask “ anything happened during your headache?”. Questions should be objective.

  6. The following aspects should be noted:

(1). For a critical case, the inquiry should be short and emergency treatment started as early as possible.

(2). Words used during inquiry should be understood by the patient. Try not to use medical terms such as occult bleeding, tonesmus, opistaxis.

(3). History should be taken from the patient himself, from his relatives or friends only when patient is in critical status and/or unable to talk.



Chapter 2 Contents of inquisition


  1. General data: such as name, sex, age,native, birth place, profession, marital status, source of history and estimate of reliability etc.

  2. Chief complaints: It should constitute in a few simple words the main reasons why the patient consulted his physician, which usually includes symptoms or sign the patient is suffering.

  3. History of present illness: It should be a well-organized, sequentially developed elaboration of patient’s chief complaint or complaints. A good history will reflect the facts that your diagnosis or impression is going to be made.

It includes the following aspects:

(1). Onset and duration of the disease.

(2). Main symptoms, location and their character.

(3). Etiology and provoking factors.

(4). Evolution of disease

(5). Associated symptoms.

(6). Treatment and its effects.

(7). General condition, especially the dietary habit.


4. Past history: Health condition and disease which the patient suffered before the present illness. Infectious disease, surgery, allergy are essential part of the case history.
5. Systems review:

The purpose of this review is twofold:

(1): A thorough evaluation of the past and present status of each body system.

(2): A double check to prevent omission of significant data relative to the present illness.


6. Personal history: It includes those relating to smoking and alcoholic beverages (duration and amount), sedatives, social history, profession and working condition.


  1. Marital history: This review includes data concerning the health of the mate, the number of children and their physical status.

  2. Menstrual history

  3. Childbearing history

  4. Family history: Inquire the disease of patient’s first relative which might be hereditary, such as heart disease, hypertension, diabetes etc.




Chapter 3 History Writting
History writing is the most important part of diagnosis of a disease. It is the systematic record of the onset, progression, diagnosis and treatment of disease. It includes symptoms, signs, laboratory, instrumental studies, impression of the disease, changes of the clinical manifestations, response to the treatment and prognosis. Not only it is the true record of the state of an illness, but also it reflects the quality of medical treatment and scientific level. A doctor should always write a good history through his incessant study of medicine.
Basic requirement


  1. The content of history should be genuine.

  2. The history should be written according to the form described in the textbook.

  3. The description of the history should be refine. The words used should be appropriate.

  4. The history should be written in a systemic, complete and clear way.

Forms and contents of the history




  1. Outpatient history: Brief, main points of disease, including main symptoms and signs, laboratory tests, initial diagnosis and treatment.

Emergency and critical patients: Their history should be further recorded with BP, Temp, mental status, methods, processes and precise time of the treatment.


  1. Admission history:

Two types of admission history: complete history and admission note.

1). Complete history: written by intern and/or junior resident

2). Admission note: written by senior resident

3). Progressive note: It is very important. For severe patient, it should be written according to the progression of the disease at any time of the day. For mild patient, it may be written every 2~3 days. It includes the following:

a: Change of main symptoms and signs

b: Lab findings --- analysis of the result.

c: Noninvasive and invasive findings.

d: Reason of treatment.

e: diagnosis and plain of treatment

f: Patient’s and his/her relative’s idea and suggestion.

The first progressive note should be written at the same day of patient’s admission.

4). Consultation note.

5). Transfer note.

6). Preoperative, operative and postoperative notes

7). Discharge note.

8). Death note.

9). Readmission note. A: Past history and history detailed after last discharge

B: Previous history should be put in the chart

General steps in history writing


  1. An accurate and comprehensive description of patient’s complaint.

  2. List the possible diagnosis from the description.

  3. Ask the questions to patient which are designed to confirm or exclude the tentative diagnosis.

  4. A thorough physical examination.

  5. Reassemble the history and findings into a well organized record according to the principles mentioned above.



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