病历书写(英文).ppt

HISTORYRECORD Whatishistoryrecord Theclinicalrecorddocumentsthepatient shistoryandphysicalfindings Itshowshowcliniciansassessthepatient whatplanstheymakeonthepatient sbehave whatactionstheytake andhowthepatientrespondstotheirefforts Importanceofhistoryrecord 1 DiagnosisandtreatmentpurposeAnaccurate clear wellorganizedrecordreflectsandfacilitatessoundclinicalthinking Itleadstogoodcommunicationamongthemanyprofessionalswhoparticipateincaringforthepatient2 Teachingandresearchpurpose3 Medicolegalpurposes Howtomakeagoodhistoryrecord Whencreatingarecord youdomorethansimplymakealistofwhatthepatienthastoldyouandwhatyouhavefoundonexamination Youmustreviewyourdata organizethem evaluatetheimportanceandrelevanceofeachitem andconstructaclear concise yetcomprehensivereport Howtomakeagoodhistoryrecord 1 Orderisimperative2 Keepitemsofhistoryinthehistory3 Describespecificallyanypertinentnegativeinformation4 Datanotrecordedaredatalost5 Useshortwordsinsteadoflongandprobablyfancieroneswhentheymeanthesamething6 Beobjective7 Youshouldwritetherecordassoonaspossible Basicrequirementforthehistoryrecord 1 Tobewellorganizedandcanonical2 Nomucherasionandgridecouldbedoneinthehistoryrecord3 Tobeobjectiveandaccurate4 Usingprofessionaltermtorecordinsteadoffolksay5 Remembertohaveyoursignature A Outlineofcaserecord 1 BiographicaldataBiographicalinformationofpatientshouldincludehisfullname age dateofbirth sex race occupation nationality maritalstatusandpermanenthomeaddress Also thedateofadmission thetimeatwhichyoutookthehistory thesourceofhistoryandestimateofreliabilityshouldbeinvolved 2 chiefcomplaintThechiefcomplaintconsistsofmainsymptom s andduration Itshouldconstituteinafewsimplewordsthemainreasonswhythepatientconsulteddoctorandshouldbestateasnearlyaspossibleinthepatient sownwards Ingeneral thechiefcomplaintshouldincludeage sex complaint anddurationofthecomplaint Itshouldnoincludeddiagnostictermsordiseaseentities Forexample This70 yearoldmanhashadshortbreathforaweek 3 Historyofpresentillness HPI Thehistoryofpresentillnessshouldbeawell organized sequentiallydevelopedelaborationofhischiefcomplaint s onitsvariouscharacteristics dateofonset characterofcomplaint modeofonset courseandduration location relationshiptoothersymptoms bodilyfunctionandactivities exacerbationandremissions and effectoftreatment 4 Pasthistory PH Itshouldincludeareviewofallpastillnesses surgicalprocedures andinjuries andallergyhistory medicine food whichareparticularlyrelatedtothepresentillness 5 Reviewofsystem ROS Thepurposeofsystemreviewistwofold athoroughevaluationandadoublecheckpreventomissionofsignificantdatarelativetothepresentillness Thereviewisacomprehensiveaccountofallcomplaintsreferabletoeachbodysystemprogressinginalogicalmannerfromtheheadtowardthefeet includingrespiratorysystem cardiovascularsystem digestivesystem Urinarysystem hemopoieticsystem endocrinesystem nervoussystemandskeletalsystem 6 Personalhistory socialandoccupationalhistory Itincludespersonalhabits smoking alcoholdrinking businesslife sexlife occupation exposuretocertainirritatingagents conditionofwork 7 MaritalhistoryItincludesdataconcerningthehealthofmate sexualadjustment thenumberofchildrenandtheirPhysicalstatus andthegeneralsocialadjustmentwithinthefamily 8 Menstrualhistory forfemalepatients Ageofonset intervalbetweenperiods duration amountandcharacterofflow concomitantsymptoms dateoflastmenstruation ageofmenopause 9 Childbearing reproductive historyAgeanddateofpregnancy ies andchildbirth s Dateofartificialornaturalabortions stillbirths operativedelivery puerperalfever Methodoffamilyplanning thepossiblefactorsofinfertility alsoformalepatients 10 Familyhistory FH Thehealthstatusofthepatient sfamily mother father siblingsandchildren andifdied theageandcauseofdeathshouldberecorded suchasdiabetes hypertension cancer obesity allergicdisorders coronaryarterydiseaseandmentalillness 11 Physicalexamination PE TherecordingofPhysicalexaminationshouldfollowalogicalsequenceasfollows vitalsigns generalstatus skin nodes head neck chest lungs heartandbloodvessels abdomen genitalia rectum spineandextremities nervousreflexes 12 LaboratorytestsandinstrumentalexaminationThefindingsofthemonklyservetoconfirmwhatyouhavefoundonhistoryandPhysicalexamination Theroutinelaboratorystudiesincludeblood urineandstooltests electrolytes X raysandECG 13Summary14 PrimarydiagnosisAstheresultsofdifferentialanalysisofanumberofsignificantdata aprimarydiagnosiscouldbeestablished Itconsistsofetiologicdiagnosis pathologicaldiagnosis pathophysioloicaldiagnosis stageorperiodandclassificationorsubtype cardiacor andpulmonaryfunctionandcomplication s 15 signature BOutlineofSummary Name gender ageandoccupationAdmissiondateAhiefcomplainsPresenthistory 70 80 percentoftheoriginalpresenthistory Simplifieddocumentoftheoriginalpasthistory onlypositivedatarecruited VerysimplifieddocumentoftheoriginalpersonalandfamilyhistoryPhysicalexamination vitalsigns importantpositiveandnegativesigns especiallyvaluableinformationfordifferentiation butyoucannotomitsuchimportantitemsasheart lung abdominalexamination Positivelaboratoryandinstrumentalresults Exampleofcaserecord Biographicaldata NameLUOLENSHENGAge 30Sex MMaritalstatus MarriedNativeplace ChinaRace HanOccupation MechanicDateofAdmissiondate 2003 11 16Statement patientherself Chiefcomplaint recurrentabdominalpainandmelenaformorethanoneyearHistoryofpresentillness Mr luohasbeensufferedfromabdominalpainandrecurrentmelenasince2002 beganonMay2 2002hehadupperabdominalpainandmelenafirsttime withnoanyinducementfactors obscureupperabdominalpainhappenedwithnoradiation nobelching novomiting nofeverandtremor Painwashungrypainandcanberelievedbyantacidagentorbymeal Melenaoccurredthreetimesaday about250geachtime continuingfor5dayswithlittlefatigue nohematomeses Hewenttothelocalcounty hospitalonthethirddayofmelena wherehereceivedgastroscopythatshowedduodenalbulbulcerswithbleeding ThenhewasadministeredOmeprazole PPI intravenouslyfor6days 40mgeachtime twiceaday Bid Ontheseconddayoftreatment themelenadisappeared OnNov 15 2003 withoutanyinducementhehadmelenaagain3timesadayand250 500gm Everytimeaccompaniedwithfatigueandtimedbutnodizzinessandsyncope ThistimehewenttothesecondPeople shospital HetookPPIbutdidn treceivegastroscopy AfterreceivingPPI melenadisappear ButtheOB occultblood testwasstillpositive Thenextdayhewasshiftedto1staffiliatedhospitalofGuangxiMedicalUniversityandreceivedfurtherexaminationandtreatment Thegeneralconditionisgoodandworkisnotaffectedinanywaysincehehadsuchadisease Pasthistory Previoushealthstatus WellordinarybadinfectiousdiseaseImmunizationsallergies NYclinicalmanifestation allergenTraumahistory surgeryhistory Reviewofsystems Tickifpositive crossoutifnegative Ifpositive youshouldwritedownyourdiseasehistoryandbriefcourseofdiagnoseandtherapy Reviewofsystems Tickifpositive crossoutifnegative Ifpositive youshouldwritedownyourdiseasehistoryandbriefcourseofdiagnoseandtherapy Respiratorysystem sorethroatchroniccoughsputumhemoptysiswheezingdyspneachestpain Cardiovascularsystem palpitationdyspneaonexertionhemoptysissyncopeedemaoflowerlimbsprecordialpainhypertentionDigestivesystem anorexiasourregurgitationbelchingnauseavomitabdominaldistentionabdominalpainconstipationdiarrheahematemesismelenahematocheziajaundiceUrinarysystem lumbagofrequentmicturitionurgentmicturitionurodyniadysuriahematurianocturiapolyuriaoliguriafacialedema Hemopoieticsystem fatiguedizzinessblurredvisiongingivalbleedingsubcutaneoushemorrhageostealgiaepistaxisMetabolicandendocrinesystem excessiveappetiteanorexiasweetscoldintoleranceolydipsiapolyuriatremorhandschangeofcharacterobviousobesityemaciationhairinesshairlosingpigmentationchangeofsexualfunctionamenorrheaMusculoskeletonsystem floatingarthralgiaarthralgiaswellingofjointsdeformitiesmyalgiaatrophyofmuscle Nervoussystem dizzinessheadachevertigosyncopedegenerationofmemoryvisualdisturbanceinsomniadisturbanceofconsciousnesstremorspasmparalysisparesthesiaPersonalhistory birthplaceoccupationsexualhistory NYsmoking NYaboutyrsaveragepieces dceasedforyrsalcoholintake Noccasionalfrequentaboutyrsaverageml dothers Maritialhistory marryingagecompanion sstateofhealth MenstruationandChildberinghistory menarcheage dateoflastperiod ageofmenopause amountofflow littlenormallargemenstrualpain NYcycle regularirregularpregnancy timesnaturallabortimesabortionstimesprematuredeliverytimesstillbirithstimesdifficultlaboranditscondition Familyhistory payattentiontothecongenitaldiseasesandcommunicablediseasesrelatedtothepatient father stillaliveillnessdiedcauseofdeathmother stillaliveillnessdiedcauseofdeathsiblings others PhysicalexaminationVitalsigns T36 P70 minR20 minBp110 70mmHgGeneralAppearance development ortho sthenictypeasthenictypesthenictypenutrition wellfairlypoorcachexiafacialfeatures normalacutechronicothersexpressions naturalpainfulanxiousdreadfulindifferentposition activesemi recumbentothersgait normalabnormalconsciousness awaresomnolenceconfusionstuporcomadeliriumcooperation wellbadly Skin mucousmembrane color normalredpalecyanosisyellowpigmentationrash NY typeanddistribution subcutaneoushemorrhage NY typeanddistribution hair normalscatteringlosing position moistureandtemperature normalcolddrywetelasticity normalreducededema NY positionanddegree hepaticpalm NYspiderangioma NY positionnumbers others Lymphnodes superficiallymphnodes non swellingswelling positionandcharacteristics Head cranium size normallargesmalldeformity NY oxycephalysquaredskulldeformingskull others tendernessmasssunk position eyes eyelid normaledemaptosistrichiasisconjunctive normalhyperemiaedemahemorrhageeyeball normalexophthalmosdepressiontremormotiondysfunction leftright sclera normalyellowcornea normalabnormal leftright pupils equalroundnesssamesizeunequalleftcm rightcmreactiontolight normaldelay leftright disappear leftright others ears auricle normaldeformityfistulaothers leftright excretionsofexternalcanal NY leftrightfeature tendernessofmastoid NY leftright auditiondysfunction N leftright nose shape normalabnormal otherabnormalities NYnasalflapobstructionexcretionsnasalsinustenderness NY position mouth lips redcyanosispaleherpesfissuremucous normalabnormal palebleeding openingofparotidglandduct normalabnormal swellingpyogenicexcretions tongue normalabnormal coveringstremorleaningtoleftorright gums normalswellingpusoverflowhemorrhagepigmentsteeth regularedentulouscariousteethfalsetoothtonsils pharynx voice normalhoarse Neck resistance NYcarotidarterypulsation normalincreaseddecreased leftright jugularvein normaldistentionhighdistentiontrachea middledeviationto leftright hepatojugularreflux thyroid normalswellingdegreesymmetrydominanceinoneside spreadingnodular softhardothers NY tendernesstremorbruits Chest topography normalbarrelchestflatchestpigeonchestfunnelchestbulgingorretraction leftright bulgingintheprecordialregiontendernessofsternumbreast normalsymmetricalabnormal leftright gynecomastiamasstenderness excretionsofnipples Lung inspection movementofrespiration normalabnormal leftright increaseddecreased intercostalsspace normalwidenarrow position palpation vocalfremitus normalabnormal leftright increaseddecreased pleuralfrictionrubs NY position percussion resonanceabnormal dullnessflatnesshyperresonancetympanylowerborders scapularline rightintercostalsspaceleftintercostalsspacerangeofmobility rightcm leftcm auscultation breath regularirregularbreathsound normalabnormal feature position rales NY rhonchi sonoroussibilantmoistrales coarsemediumfineralescrepitusvocalconduction normalabnormal reducedincreasedPleuralfrictionrubs NY position Heart inspection bulginginprecordialregion NYapeximpulse normalunseenincreaseddiffusingpoisition normaldeviation thedistancefrommidclavicularlinecm otherprecordialpulsations NY position palpation apeximpulse normalincreasedthrustunclearthrills NY positionperiod pericardialfrictionrubsNYpercussion relativecardiacoutline normalshrinkextant rightleft Normalboundaryoftheheartright cm intercostalsspaceleft cm 2 3 2 32 3 3 5 4 53 4 5 6 distancefromanteriormidlinetotheleftmidclavicularline cm auscultation heartratebpm minrhythm regularirregularabsolutelyirregular heartsound S1normalincreaseddecreasedsplitS2normalincreaseddecreasedS2split normalfixedparadoxicalS3NYS4NYA2P2extraheartsound Ngallop diastolicpresystolicsummationgallop openingsnapothersmurmurs NY Location apicalregionaorticareapulmonaryareatricuspidarealeftsternalborderin3ndintercostalsspaceOthersTiming systolicdiastolicbothQuality blowingrumblingsighingmusicalAustinFlintGrahamSteellGibsonIntensity Grade Transmission NYdirectiontoleftaxillaovertheapexoverthecarotidarteriesPericardialfrictionrubs NY Peripheralvessels normalpistolshot NYDuroziezsign NYwaterhammerpulse NYcapillarypulsation NYpulsedeficit NYparadoxicalpulse NYpulsealternations NYothersAbdomen inspection shape normaldistentionfrogbellycmscaphoidabdomenapicalbellygastricpatternintestinalpatternperistalsisabdominalrespiration existdisappearumbilicus normalprotrudingexcretionsothers NY venousdistentionofabdomenpurplestriaesurgicalcarshernia palpation softmuscletensionpositiontenderness NYreboundtenderness NYfluidtrill NYsuccusionsplash NYmassesNY positionsize descriptionoffeature liver nottouchedbetouched subcostalcmdescriptionoffeature gallbladder nottouchedbetouched sizecmtenderness NYMurphy ssigh spleen nottouchedbetouched fromcostalmargincmdescriptionoffeature kidney nottouchedbetouched sizeconsistencytendernessmobilitytendernessofureters NY position percussion bordersofliverdullness existshrinkobliteration upperborderofliver onrightmidclavicularlineintercostalsspaceshiftingdullness NYtendernessinrenalregion NY rightleft auscultation gurglingsound normalincreaseddecreaseddisappearvesselbruits NY position Genitalia notexaminednormalabnormal RectumandAnus notexaminednormalabnormal SpineandExtremities spine normaldeformities lateralanteriorposteriorprotruding acanthi tendernesspainatpercussion position mobility normalrestrictedlimbs normalabnormaldeformityswellingofjointsjointsstiffnesstendernessofmusclesatrophyofmusclesvenousdistentionoflowerlimbs positionandfeature acropachy Nervoussystem muscletone normalincreaseparatonia myodynamia 0 paralysisoflimbs NY leftrightupperlower reflex abdominalwallreflex uppermiddlelowernormalabnormal bicepsreflex left normalabnormal right normalabnormal tricepsreflex left normalabnormal right normalabnormal patellarreflex left normalabnormal right normalabnormal achillesreflex left normalabnormal right normalabnormal Hoffmannsign left right Babinskisigh left right Oppenheimsigh left right Kernigsign left right Burdzinskisign left right Laboratoryfindings Theimportantlaboratoryexaminations X ray ECGandotherresultareincluded Abstract Mr luo 30yearsold hasbeensufferedfromabdominalpainandrecurrentmelenaformorethanoneyearandadmittedtohospitalon