(I) General Information
General information (general data) includes: name, gender, age, place of origin, birthplace, ethnicity, marital status, contact address, phone number, workplace, occupation, admission date, record date, history taker and reliability, etc. If the history taker is not the patient, the relationship to the patient should be noted. When recording age, the specific age should be filled in; terms like “child” or “adult” should not be used, as age itself has diagnostic significance. To avoid making the initial consultation too rigid, some general items such as occupation and marital status can be interspersed in the personal history questions.
(II) Chief Complaint
The chief complaint (chief complaint) is the main suffering or the most obvious symptom or sign that the patient feels, which is the primary reason for this visit and its duration. A precise chief complaint can initially reflect the severity and urgency of the condition and provide diagnostic clues for certain systemic diseases. The chief complaint should be summarized in one or two sentences, and the time from the onset of the complaint to the visit should also be noted. For example, “sore throat, high fever for 2 days,” “chills, fever, cough for 3 days, worsened with right chest pain for 2 days,” “palpitations and shortness of breath after activity for 2 years, worsened with bilateral lower limb edema for 2 weeks.” The chief complaint should be concise and should use the patient’s own description of symptoms as much as possible, such as “polydipsia, polyphagia, polyuria, weight loss for 1 year” or “palpitations and shortness of breath for 2 years,” rather than the physician’s diagnostic terms like “diabetes for 1 year” or “heart disease for 2 years.” However, in cases with a longer course of disease and more complex conditions, where symptoms and signs are numerous, or where the patient speaks too much, it may not be easy to simply summarize the main discomfort as the chief complaint. In such cases, the entire medical history should be analyzed comprehensively to summarize a chief complaint that better reflects the characteristics of the disease. Sometimes, for conditions without continuity, flexibility can be applied, such as “heart murmur discovered 20 years ago, palpitations and shortness of breath for 1 month.” For patients who are currently asymptomatic, with clear diagnostic data and admission purposes, the chief complaint can also be recorded in the following manner: “diagnosed with leukemia for 3 years, recurrence confirmed 10 days ago,” “gallstones discovered 2 weeks ago by ultrasound.”
(III) History of Present Illness
The history of present illness (history of present illness) is the main part of the medical history. It describes the entire process of the patient’s illness, including onset, development, evolution, and treatment. The following content and procedures can be used for inquiry:
1. Onset and Duration of Illness Each disease has its own characteristics regarding onset or attack. Detailed inquiry about the onset situation is crucial for differential diagnosis. Some diseases have a sudden onset, such as cerebral embolism, angina pectoris, aneurysm rupture, and acute gastrointestinal perforation; others have a gradual onset, such as pulmonary tuberculosis, tumors, and rheumatic heart valve disease. The onset of the disease is often related to certain factors, such as cerebral thrombosis often occurring during sleep; cerebral hemorrhage and hypertensive crises often occurring during excitement or tension. The duration of the illness refers to the time from onset to the visit or admission. If several symptoms appear sequentially, the time of the first symptom should be traced back, and the entire medical history should be inquired in chronological order and recorded separately. For example, palpitations for 3 months, recurrent nocturnal dyspnea for 2 weeks, bilateral lower limb edema for 4 days. From the above symptoms and their time sequence, it can be seen that the patient is gradually developing heart failure. The duration can be calculated in years, months, or days. For those with a sudden onset, hours or minutes can be used as the time unit.
2. Characteristics of Main Symptoms This includes the location, nature, duration, and severity of the main symptoms, as well as factors that relieve or exacerbate them. Understanding these characteristics is helpful for determining the affected system or organ and the location, extent, and nature of the lesions. For example, upper abdominal pain is often related to diseases of the stomach, duodenum, or pancreas; acute pain in the right lower abdomen is often due to appendicitis; if the patient is female, ovarian or fallopian tube diseases should also be considered; generalized abdominal pain suggests widespread lesions or peritoneal involvement. The nature of the symptoms should also be inquired with differential significance, such as burning pain, cramping pain, distending pain, dull pain, and whether the symptoms are persistent or paroxysmal, as well as the timing of onset and relief. Taking peptic ulcer as an example, its main symptom characteristics include abdominal pain, which can last for several hours or weeks, and may present as periodic attacks or have certain seasonal characteristics over the years.
3. Etiology and Triggers It is important to understand the causes (such as trauma, poisoning, infection, etc.) and triggers (such as climate changes, environmental changes, emotional disturbances, dietary irregularities, etc.) related to this episode of illness, as this helps clarify the diagnosis and formulate treatment measures. Patients can easily identify direct or recent causes, but when the causes are complex or the course of the disease is long, patients often cannot clearly articulate them and may mention some seemingly relevant or self-perceived factors. In such cases, the physician should conduct scientific induction and analysis and should not record them in the medical history thoughtlessly.
4. Development and Evolution of the Condition This includes changes in the main symptoms during the course of the illness or the appearance of new symptoms. For example, in patients with pulmonary tuberculosis complicated by emphysema, if they suddenly experience severe chest pain and significant dyspnea on the basis of weakness, fatigue, and mild dyspnea, spontaneous pneumothorax should be considered. If a patient with a history of angina pectoris experiences worsening pain that lasts longer than usual, acute myocardial infarction should be considered. If a patient with liver cirrhosis presents with new symptoms such as changes in expression, mood, and behavior, this may indicate early hepatic encephalopathy.
5. Accompanying Symptoms A series of other symptoms often appear alongside the main symptoms. These accompanying symptoms are often the basis for differential diagnosis or indicate the occurrence of complications. For example, diarrhea can be a common symptom of various causes; relying solely on this symptom cannot diagnose a specific disease. However, if accompanying symptoms are clarified, the direction of diagnosis will be clearer. For instance, diarrhea accompanied by vomiting may indicate acute gastroenteritis caused by unclean food or poisoning; diarrhea with tenesmus, combined with seasonal and dietary factors, may suggest dysentery. Similarly, acute upper abdominal pain can have many causes; if the patient also has nausea, vomiting, fever, and especially jaundice and shock, acute pancreatitis or acute biliary infection should be considered. Conversely, if certain accompanying symptoms that should generally appear with a specific disease are absent, this should also be recorded in the history of present illness for further observation or as important reference material for diagnosis and differential diagnosis. Such negative manifestations are sometimes referred to as negative symptoms. A good medical history should not overlook any minor accompanying signs outside of the main symptoms, as they can sometimes play a crucial role in clarifying the diagnosis.
6. Treatment History If the patient has received treatment from other medical institutions prior to this visit, inquire about the diagnoses and treatment measures taken and their results. If treatment has been administered, ask about the names, dosages, timing, and efficacy of the medications used, as this provides reference for the current treatment of the disease. However, past diagnoses should not replace the physician’s own diagnosis.
7. General Condition During the Course of Illness At the end of the history of present illness, the patient’s mental and physical state after the onset of the illness, changes in appetite and food intake, sleep, and bowel and bladder habits should be recorded. This part of the content is very useful for a comprehensive assessment of the severity and prognosis of the patient’s condition and for determining what auxiliary treatment measures to take. Sometimes, it can also provide important reference material for differential diagnosis.
(IV) Past Medical History
The past medical history (past history) includes the patient’s previous health status and diseases (including various infectious diseases), trauma, surgical history, vaccinations, blood transfusions, allergies, etc., especially those closely related to the current disease. For example, in patients with rheumatic heart valve disease, inquire whether they have had recurrent sore throats or migratory joint pain in the past; for patients with liver enlargement, inquire about past jaundice; for patients with chronic coronary atherosclerotic heart disease and cerebrovascular accidents, inquire about past hypertension. When documenting the past medical history, care should be taken not to confuse it with the history of present illness. For instance, if the patient currently has pneumonia, previous instances of pneumonia should not be included in the history of present illness. However, for patients with peptic ulcers, the history of past episodes can be documented in the history of present illness. Additionally, the history of major infectious diseases and endemic diseases in the area where the patient lives, trauma, surgical history, vaccination history, and allergies to medications, foods, and other substances should also be recorded in the past medical history. The recording order is generally arranged chronologically.
(V) Review of Systems
The review of systems (review of systems) consists of a long series of direct questions, serving as a final sweep to collect medical history data and avoid any content that may have been overlooked by the patient or physician during the consultation. It helps the physician quickly understand whether other systems have any current or previously resolved diseases apart from the one currently being treated, and whether there is any causal relationship between these diseases and the current condition. The main situations should be recorded in the history of present illness or past medical history. The clinical diseases involved in the review of systems are numerous, and medical students must have a clear understanding of the pathological and physiological significance of symptoms and signs that may appear in each system before learning to collect medical history. In practical application, 2-4 symptoms can be inquired about in each system; if there are positive results, a more comprehensive inquiry into that system’s symptoms can be conducted; if negative, generally, one can transition to the next system. When addressing specific patients, some content can be flexibly adjusted based on the situation.
1. Respiratory System Nature, severity, frequency of cough, and its relationship with climate changes and position changes. The color, viscosity, and odor of sputum. The characteristics, color, and quantity of hemoptysis. The nature, severity, and timing of dyspnea, as well as the location, nature of chest pain, and its relationship with breathing, coughing, and position. Presence of chills, fever, night sweats, decreased appetite, etc.
2. Circulatory System Timing and triggers of palpitations, nature, severity, and duration of precordial pain, presence of radiation and its location, triggers for pain episodes and relief methods. Triggers and severity of dyspnea, relationship with physical activity and position during episodes. Presence of cough, hemoptysis, etc. Location and timing of edema; urine output and changes between day and night; presence of ascites, liver area pain, headache, dizziness, syncope, etc. History of rheumatic fever, heart disease, hypertension, atherosclerosis, etc. For female patients, inquire about hypertension and heart failure during pregnancy and childbirth.
3. Digestive System Presence of abdominal pain, diarrhea, changes in appetite, belching, acid reflux, abdominal distension, oral diseases, and the urgency, severity, duration, and progression of these symptoms. The relationship of these symptoms with the type and nature of food and any influence from psychological factors. Triggers and frequency of vomiting; contents, quantity, color, and odor of vomit. Quantity and color of hematemesis. Location, severity, nature, and duration of abdominal pain, any regularity, whether it radiates to other areas, and its relationship with diet, climate, and psychological factors. Pain may lessen or worsen upon palpation. Frequency of bowel movements, color, consistency, quantity, and odor of stool. Presence of abdominal pain and tenesmus during defecation. Presence of fever and jaundice. Changes in physical strength and weight.
4. Urinary System Presence of dysuria, urgency, frequency, and difficulty in urination; urine output and nocturia; color (clear or dark brown), clarity of urine; presence of urinary retention and incontinence. Presence of abdominal pain, location of pain, and any radiation. Presence of pharyngitis, hypertension, edema, bleeding, etc.
5. Hematologic System Presence of pallor, jaundice, petechiae, ecchymosis, hematomas, and enlargement of lymph nodes, liver, and spleen; bone pain, etc. Presence of fatigue, dizziness, visual disturbances, tinnitus, irritability, memory loss, palpitations, tongue pain, difficulty swallowing, nausea. Nutritional, digestive, and absorption status.
6. Endocrine System and Metabolism Presence of heat intolerance, excessive sweating, fatigue, cold intolerance, headaches, visual disturbances, palpitations, abnormal appetite, thirst, polyuria, edema, etc.; presence of muscle tremors and spasms. Development of personality, intelligence, physique, sexual organ development, bones, thyroid, weight, skin, and hair changes. Presence of postpartum hemorrhage.
7. Nervous and Mental System Presence of headaches, insomnia, hypersomnia, memory loss, consciousness disturbances, syncope, seizures, paralysis, visual disturbances, sensory and motor abnormalities, personality changes, and disturbances in perception and orientation. If there are suspected changes in mental state, inquire about emotional state, thought processes, intelligence, abilities, and self-awareness.
8. Musculoskeletal System Presence of numbness, pain, spasms, atrophy, paralysis in limbs. Presence of joint swelling and pain, movement disorders, trauma, fractures, dislocations, congenital deformities, etc.
(VI) Personal History
1. Social History includes birthplace, residence area and duration (especially epidemic areas and areas with endemic diseases), education level, economic life, and hobbies. Different infectious diseases have different incubation periods, so inquire whether the patient has been to epidemic areas in the past.
2. Occupational and Working Conditions include type of work, labor environment, exposure to industrial toxins, and duration.
3. Habits and Preferences include daily routines and hygiene habits, dietary regularity and quality, smoking and drinking habits, duration and quantity of intake, as well as other substances and drug use.
4. History of Sexual Activity, including whether the patient has had gonococcal urethritis, condyloma acuminatum, or chancroid.
(VII) Marital History
Marital history (marital history) includes whether the patient is single or married, age at marriage, spouse’s health status, sexual life, and marital relationship.
(VIII) Menstrual and Reproductive History
Menstrual history (menstrual history) and reproductive history (childbearing history) include age at menarche, menstrual cycle and duration, amount and color of menstrual blood, menstrual symptoms, presence of dysmenorrhea and leukorrhea, date of last menstrual period, date of amenorrhea, and age at menopause. The recording format is as follows:
Number of pregnancies and births, number of induced or spontaneous abortions, presence of stillbirths, surgical births, perinatal infections, family planning, and contraceptive measures (safe period, contraceptive pills, IUDs, cervical caps, condoms, etc.). For male patients, inquire whether they have had diseases affecting fertility.
(IX) Family History
Family history (family history) includes inquiries about the health and diseases of parents, siblings, and children, especially whether there are diseases similar to the patient’s, and whether there are hereditary diseases such as hemophilia, albinism, hereditary spherocytosis, hereditary hemorrhagic telangiectasia, familial hypothyroidism, diabetes, mental illness, etc. For deceased direct relatives, inquire about the cause of death and age. Some hereditary diseases also involve both parents’ relatives, which should also be understood. If the same disease occurs in several members or generations, a family tree can be drawn to show the details.
| Internal Medicine | Symptoms and Signs |
| Pediatrics | Practical Skills |
| Surgery | Obstetrics and Gynecology |
