History taking

Week 1
At the beginning
• Name • Huangtingting
• Sex • Female
• Age • 47 Hours
• Medical history • Parent
• Time • Record time & Hospitalization time
• Day-Hour-Minute
Main complaint
• Main reason why the child came to the hospital
• Symptoms plus time
• If there are no symptoms, physical signs can be used instead.
Current History
• Details about the symptoms
• Location, duration or frequency, degree, etc.
• Medical history of newborns
✓Asked from birth
✓Begins with “ Patient is G1P1 ，40 weeks of, natural delivery".
✓Symptoms + how long after birth
✓Different from the medical history of non-newborns.
• Concomitant symptoms
• Negative differential symptoms,
• Process of diagnosis and treatment
• General situation in the course of the disease.
Past history
• Simple
• Mostly describing only jaundice.

• Nothing special, she's only 2 days old.

Birth history
• Gestational age and parity • G1P1, full-term
• Birth weight • birth weight 3.6kg
• Delivery • Natural birth
• Condition at birth • No asphyxia cyanosis, no
• Apgar score. malformation and bleeding.
• Apgar score 10/10
(1 minute /5 minutes after birth)
Feeding history
• Sugar feeding time
• Milk time
• Allergies
• Other medical histories

• Just breastfeeding after birth.

Family history
• Details of the parents
• Mother's pregnancy
• Brothers or sisters
• Jaundice children should ask the mother's blood type

• When I was pregnant, I didn't have any diseases. My blood type

was Rh (+) O, and the doctor asked the baby's father to check the
blood type, but he was too busy to do so.
• We are in good health and there is no family history of jaundice,
anemia, splenectomy, gallbladder or liver disease.
CASE
• Name • Huangtingting
• Sex • Female
• Age • 47 Hours
• Medical history • Parent
• Time • Record time & Hospitalization time
• Day-Hour-Minute
Physical examination
• T 37℃, P 110/min, R 38/min, BP 85/55mmHg
• Arterial oxygen saturation: 98%.
• Nondysmorphic
• Clinical exam was normal except he looked pale.
• Respiratory: No concerns, baby remained well in room air.
• Cardiovascular: No concerns.
• Abdomen: No abnormality detected. Baby fed well.
• CNS: Baby was neurologically appropriate for age. He had good suck and
grasp reflex. There was no concern with his tone. There was no
cephalohematoma.
Laboratory examination
• serum total bilirubin: 17mg/dl, indirect bilirubin 16mg/dl.

• Write other examination in your treatment plan.

Diagnosis and Treatment Plan
• Diagnosis
• Diagnostic basis
• Differential diagnosis
• Treatment plan
 In the process
Next week, we also need two students to role-play.
• Parent → ask the questions of concern
• Doctor → answer these questions
Week Doctor Parent

1 UAMPOOM SUPICHAYA UPARISATJAKUL CHAYANIT

3160300567 3160300557
2 TING MEI HUA KRISLUENON NATTANIT
3160300558 3160300559

• All students finish writing their medical records

• Send by DingTalk homework area
• Before next Monday (May 28).
The common problems in the writing of
medical histories are as follows:
• 1. The content of the chief complaint is too much. The chief
complaint is a summary of the current medical history, not a
diagnosis. The chief complaint is the main symptom + time.
The common problems in the writing of
medical histories are as follows:
2. In the writing of current history, it would be better to add some
negative symptoms with differential significance.
3. Don't add the word such as "they also mentioned".
4. Lack of general situation in the course of the disease in current
medical history.
The common problems in the writing of
medical histories are as follows:
• 6. Format error： Vital signs should be put in the physical examination.