The difference between past history and personal history in cases

1. Different definitions:

Past history refers to the patient’s health and disease conditions before the onset of the disease, especially diseases closely related to the current disease, which are recorded in chronological order. Personal history refers to a personal record of personal experience.

2. Different contents

The content of past history includes:

(1) Past general health status.

(2) Whether you have suffered from infectious diseases, endemic diseases and other diseases, the date of onset and diagnosis and treatment status. For diseases that the patient has suffered from before, if the diagnosis is certain, the name of the disease can be used, but it should be in quotation marks; if the diagnosis is not certain, the symptoms should be briefly described.

(3) Whether there is a history of vaccination, trauma, surgery, and allergies to drugs, food, and other contact objects.

The content of personal history includes:

(1) Place and time of birth, growth and residence (especially attention should be paid to epidemic foci and endemic areas), education level and leisure time Hobbies etc.

(2) Daily habits, hygiene habits, eating habits, tobacco and alcohol habits and their intake, whether there is a history of intake of other heterophilic substances and narcotic drugs, and whether there is a history of major mental trauma.

(3) Past and current occupation, labor protection situation and working environment, etc. Focus on understanding whether the patient has a history of frequent contact with toxic and harmful substances, and the time and extent of exposure should be noted.

(4) Do you have a history of travel, and have you ever suffered from chancre and gonorrhea?

(5) For child patients, in addition to understanding the mother’s pregnancy and birth process (natural delivery, dystocia) before birth, the feeding history, growth and development history must also be understood.

Extended information:

Other records of medical records - history of current illness:

The history of current illness is the main part of the medical history. Focusing on the chief complaint, the occurrence, development and changes of the disease, as well as the diagnosis and treatment from the onset of illness to the time of treatment, are recorded in detail according to the order of symptoms.

The content mainly includes:

(1) Time of onset, urgency, possible causes and incentives (including some conditions before the onset of illness if necessary).

(2) The time, location, nature, degree and evolution of the main symptoms (or signs).

(3) Along with the characteristics and changes of symptoms, important positive and negative symptoms (or signs) with differential diagnostic significance should also be explained.

(4) For those who suffer from chronic diseases related to this disease or those who have relapsed from old diseases, we should focus on understanding their initial conditions and major changes, as well as recent relapses.

(5) Where and what kind of diagnosis and treatment has been done since the onset of the disease (including date of diagnosis and treatment, examination results, name of medication and its dosage and usage, surgical method, efficacy, etc.).

(6) Important injuries and illnesses in other departments that are not related to the main disease and still need to be diagnosed and treated should be described in a separate paragraph.

(7) General conditions since the onset of the disease, such as changes in spirit, appetite, food intake, sleep, defecation, physical strength and weight, etc.

Baidu Encyclopedia-Medical Records