医学英语病历报告书写(简易版).doc

。n Case Historyn DefinitionA case history is a medical record of a patients illness. It records the whole medical case and functions as the basis for medical practitioners to make an accurate diagnosis and proposes effective treatment or preventive measures. Case histories fall into two kinds: in-patient case histories and out-patient case histories. n Language FeaturesHistory and Physical usually involves past tense ( for history of present illness, past medical history, family history and review of systems concerning past information), and present tense ( review of system, physical examination, laboratory data, and plans ).Structurally, noun phrases are frequently used in physical examination, and ellipsis of subject is very common in review of system.n In-patient Case HistoriesAn in-patient case history is also termed as History and Physical. It is an account of a patients present complaints with descriptions of his past medical history,and the description of the present conditions as well as physical examinations and impression about the conditions.Format It usually consists of chief complaint, history of present illness, past medical history, review of systems, physical examination, impression, family history, social history, medications, allergies, laboratory on admission, and plan. However, what parts are included depends on the needs.住院病人病历完整模式 病历（Case History）姓名(Name) 职业(Occupation)性别(Sex) 住址(Address)年龄(Age or DOB) 供史者(Supplier of history)婚姻(Marital status) 入院日期(Date of admission)籍贯(Place of birth) 记录日期(Date of record)民族(Race) 主述(C.C.)现病史(HPI or P.I.)过去史(PMH or P.H.)社会活动史/个人史(SHx or Per.H.)家族史(FHx or F.H.)曾用药物(Meds)过敏史(All) To be continued系统回顾(ROS)体格检查(PE or P.E.)体温(T) 呼吸(R)血压(BP) 脉搏(P)一般状况(General status)皮肤黏膜(Skin & mucosa)头眼耳鼻喉(HEENT)颈部(Neck) 胸部与心肺(Chest, Heart and Lungs)腹部(Abdomen) 肛门直肠(Anus & rectum)外生殖器(External genitalia)四肢脊柱(Extremities & spine)神经反射(Nerve reflex) To be continued化验室资料(Lab data)(Blood test, Chem-7, EKG, EEG, X-ray examinations or X-ray slides, CT and NMR)印象与诊断(Impression and diagnosis, or Imp)住院治疗情况记录(Hospital course)出院医嘱(Discharge instructions or recommendations)出院后用药(Discharge medications)医师签名(Signature)n Patterns and contents of an out-patient case historyContents: general data (GD), chief complaint (CC), present illness (PI), physical examination (PE), tentative diagnosis (TD) or impression (Imp), treatment (Rp), etc.An out-patient case history should be written in brief and to the very point. More abbreviations and noun phrases are used.n Sample of an out-patient case history Male, 39 year old CC: Fever, headache and cough for two days. PE: G.C. looks fair. Pharynx congested and tonsils enlarged. Chest and abdomen negative. Imp: U.R.I. Rp: Penicillin 400,000u. (i.m.) q.d. x 3 days. Aspirin 1 tab. t.i.d. x 2 days. Vit C 100 mg t.i.d. x 3 days Signature _n Chief Complaint (C.C.)n 1. Sentence patterns in chief complaint 症状+for+时间 症状+of+时间+duration 症状+时间+in duration 时间+of+症状 症状+since+时间n Chief Complaint (C.C.)n 2. Commonly-used complaints: weakness, malaise, chills, fever, pain, headache, nausea and vomiting, diarrhea, neuro-psychiatric disorders, shortness of breath, bleeding or discharge, insomnia, stomachache, dyspepsia, no appetite, dysuria, cough, difficulty in coughing up sputum, sore throat, dizziness, palpitation, restlessness, etc. 弱点,不适感,发冷、发烧、疼痛、头痛、恶心、呕吐、腹泻、neuro-psychiatric紊乱、气短、出血或排放、失眠、胃痛,消化不良,没有胃口,排尿困难、咳嗽、咳痰、困难、喉咙痛、头晕、心悸、不安等。 Present Illness (P.I.)简明病历书写手册.doc(p.27-35)n The course of onset Date of onset Mode of onset Prodromal symptomsn The cardinal symptomsn The attack of illnessn The development of symptoms n Diagnosis and treatmentn General conditionn Examplen Special language structures in presenting present illnessn 1. Describing the course of onset started / began having / feeling first noticed / noted / perceived / recognized the onset of are the prodrome of , herald n Special language structures in presenting present illnessn 2. Describing the mode and regularity of onset explosively / suddenly / acutely / abruptly gradually / chronically / increasingly / insidiously occasionally / accidentally often / frequently / in frequency / recurrently persistently / intermittentlyn 爆炸性/突然/强烈/突然n 长期/越来越多逐渐/ /在不知不觉之中n 偶尔/偶n 经常/经常在0.9%的频率/的循环n 持久/断断续续的n Special language structures in presenting present illnessn 3. Describing the cardinal symptoms had / presented / developed / showed / manifested characterized by admits to states that feels denies , without / free of symptoms n Special language structures in presenting present illnessn 4. Describing the attack of illness appeared / occurred / came on had / developed episodes / attacks of was associated with , was accompanied by , was followed by , had relation to was preceded / heralded by n Special language structures in presenting present illnessn 5. Describing the development of symptoms disappeared / ceased / subsided took a favorable turn ., took a turn for the better , relieved / improved / alleviated took a bad / unfavorable turn , took a turn for the worse , was aggravated / intensified / exacerbated by remained the same as , continued, persisted without changen Past History (P.H.)简明病历书写手册.doc(p.36)n History of vaccination and infectious diseasesn History of allergy to drugs and other substancesn History of surgical operation and external injuryn Systematic review of the past history and disease n Special language structures in presenting past historyn had enjoyed good health until / had been sound / well / healthy until n had never been ill before / had no illness of any kind before n denied any history of / had no related history of / denied experiencing / having attack of n No history of / No history suggestive of / indicative of n suffered from / had an attack of / was attacked / troubled by / had a past history of n Except for had no / no apart from / but n Common diseases mentioned in past historyn measles, mumps, chicken-pox, smallpox, pertussis, influenza, scarlet fever, diphtheria, typhoid fever, bronchitis, pneumonia, encephalitis, meningitis, tetanus, poliomyelitis, dysentery, cholera, pleurisy, tonsillitis, rheumatism, malaria, tuberculosis, jaundice, allergy, sexually transmitted diseases, gonorrhea, syphilis, sequela, complication, hospitalization n 麻疹,腮腺炎,chicken-pox氮、天花、百日咳、流行性感冒、猩红热、白喉、伤寒、支气管炎、肺炎、脑炎、脑膜炎、破伤风、脊髓灰质炎(小儿麻痹)、痢疾、霍乱、胸膜炎、扁桃体炎、风湿、疟疾、肺结核、黄疸、过敏、性传播疾病、淋病、梅毒、后遗症、并发症、住院n Personal History (Per.H.) /Social History简明病历书写手册.doc(p.37)n Life style and habitn Occupation and working environmentn Marital & childbearing historyn Menstrual historyn Traveling historyn Special language structures in presenting personal habitsn have a long history of smoking / drinkingn have a lifelong like / dislike for n admitted to excessive use of n denies the use of alcoholic beveragesn Special language structures in presenting occupational historyn work / act / serve as n be engaged in n practice ones profession in n be exposed to industrial poisons / dust / radioactive substances / hazards / toxic substances n Special language structures in presenting marital & childbearing history简明病历书写手册.doc(p.38-39)n have been married for years without conceptionn have a history of abortion or premature birthsn delivered one normal / abnormal infantn delivered days before / prior to the expected date of confinementn Family History (F.H.)简明病历书写手册.doc(p.39)n Terms mentioned in family history family tendency, presence of hereditary disorders, cancer, tuberculosis, mental disorder and nervous affection, rheumatism, diabetes, hypertension, cerebral vascular accident, hemophilia, syphilis, tumor, epilepsy, allergy, etc. any contact with diseased individuals, relationship of patients childhood and adult life; age, health condition, and cause of death of parents, grandparents, self, spouse, siblings or relatives. 家庭的倾向,存在遗传疾病、癌症、肺结核、精神障碍和紧张的感情、风湿、糖尿病、高血压、脑血管意外、血友病、梅毒、肿瘤、癫痫、过敏等任何接触患病的个人关系,病人的童年和成年生活;年龄、健康状况、和死亡原因的父母、祖父母、本人,配偶、兄弟姐妹或不相关的亲戚(联系)。n Special language structures in presenting family history be in good health, be healthy, be living and well The family history did not reveal There was no family history of There was no case of in the family. Family history was irrelevant to Family history showed / revealed There was a familial tendency to / toward died of , died from unknown causesn Review of Systems简明病历书写手册.doc(p.40-115)n 1. General condition / physical signs 1.1 temperature (T): oral / axillary / rectal temperature, 。C , 。F 1.2 pulse (P): fast/rapid pulse, slow pulse, (ir)regu