病历书写(英文)（课堂PPT）

HISTORYRECORD,1,Whatishistoryrecord,Theclinicalrecorddocumentsthepatientshistoryandphysicalfindings.Itshowshowcliniciansassessthepatient,whatplanstheymakeonthepatientsbehave,whatactionstheytake,andhowthepatientrespondstotheirefforts.,2,Importanceofhistoryrecord,1.DiagnosisandtreatmentpurposeAnaccurate,clear,wellorganizedrecordreflectsandfacilitatessoundclinicalthinking.Itleadstogoodcommunicationamongthemanyprofessionalswhoparticipateincaringforthepatient2.Teachingandresearchpurpose3.Medicolegalpurposes,3,Howtomakeagoodhistoryrecord,Whencreatingarecord,youdomorethansimplymakealistofwhatthepatienthastoldyouandwhatyouhavefoundonexamination.Youmustreviewyourdata,organizethem,evaluatetheimportanceandrelevanceofeachitem,andconstructaclear,concise,yetcomprehensivereport.,4,Howtomakeagoodhistoryrecord,1.Orderisimperative2.Keepitemsofhistoryinthehistory3.Describespecificallyanypertinentnegativeinformation4.Datanotrecordedaredatalost5.Useshortwordsinsteadoflongandprobablyfancieroneswhentheymeanthesamething6.Beobjective7.Youshouldwritetherecordassoonaspossible,5,Basicrequirementforthehistoryrecord,1.Tobewellorganizedandcanonical2.Nomucherasionandgridecouldbedoneinthehistoryrecord3.Tobeobjectiveandaccurate4.Usingprofessionaltermtorecordinsteadoffolksay5.Remembertohaveyoursignature,6,A.Outlineofcaserecord,1.BiographicaldataBiographicalinformationofpatientshouldincludehisfullname,age(dateofbirth),sex,race,occupation,nationality,maritalstatusandpermanenthomeaddress.Also,thedateofadmission,thetimeatwhichyoutookthehistory,thesourceofhistoryandestimateofreliabilityshouldbeinvolved.2.chiefcomplaintThechiefcomplaintconsistsofmainsymptom(s)andduration.Itshouldconstituteinafewsimplewordsthemainreasonswhythepatientconsulteddoctorandshouldbestateasnearlyaspossibleinthepatientsownwards.Ingeneral,thechiefcomplaintshouldincludeage,sex,complaint,anddurationofthecomplaint.Itshouldnoincludeddiagnostictermsordiseaseentities.Forexample:”This70-yearoldmanhashadshortbreathforaweek.”,7,3.Historyofpresentillness(HPI)Thehistoryofpresentillnessshouldbeawell-organized,sequentiallydevelopedelaborationofhischiefcomplaint(s)onitsvariouscharacteristics:dateofonset,characterofcomplaint,modeofonset,courseandduration,location,relationshiptoothersymptoms,bodilyfunctionandactivities,exacerbationandremissions,andeffectoftreatment.4.Pasthistory(PH)Itshouldincludeareviewofallpastillnesses,surgicalprocedures,andinjuries,andallergyhistory(medicine,food),whichareparticularlyrelatedtothepresentillness.,8,5.Reviewofsystem(ROS)Thepurposeofsystemreviewistwofold:athoroughevaluationandadoublecheckpreventomissionofsignificantdatarelativetothepresentillness.Thereviewisacomprehensiveaccountofallcomplaintsreferabletoeachbodysystemprogressinginalogicalmannerfromtheheadtowardthefeet,includingrespiratorysystem,cardiovascularsystem,digestivesystem,Urinarysystem,hemopoieticsystem,endocrinesystem,nervoussystemandskeletalsystem.6.Personalhistory(socialandoccupationalhistory)Itincludespersonalhabits(smoking,alcoholdrinking),businesslife,sexlife,occupation(exposuretocertainirritatingagents),conditionofwork.,9,7.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).,10,10.Familyhistory(FH)Thehealthstatusofthepatientsfamily(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.,11,13Summary14.PrimarydiagnosisAstheresultsofdifferentialanalysisofanumberofsignificantdata,aprimarydiagnosiscouldbeestablished.Itconsistsofetiologicdiagnosis,pathologicaldiagnosis,pathophysioloicaldiagnosis(stageorperiodandclassificationorsubtype),cardiacor/andpulmonaryfunctionandcomplication(s).15.signature,12,BOutlineofSummary,Name,gender,ageandoccupationAdmissiondateAhiefcomplainsPresenthistory(70%-80%percentoftheoriginalpresenthistory)Simplifieddocumentoftheoriginalpasthistory(onlypositivedatarecruited)VerysimplifieddocumentoftheoriginalpersonalandfamilyhistoryPhysicalexamination:vitalsigns,importantpositiveandnegativesigns,especiallyvaluableinformationfordifferentiation,butyoucannotomitsuchimportantitemsasheart/lung/abdominalexamination.Positivelaboratoryandinstrumentalresults,13,Exampleofcaserecord,Biographicaldata:NameLUOLENSHENGAge:30Sex:MMaritalstatus:MarriedNativeplace:ChinaRace:HanOccupation:MechanicDateofAdmissiondate:2003/11/16Statement:patientherself,14,Chiefcomplaint:recurrentabdominalpainandmelenaformorethanoneyearHistoryofpresentillness:Mr.luohasbeensufferedfromabdominalpainandrecurrentmelenasince2002,beganonMay2,2002hehadupperabdominalpainandmelenafirsttime,withnoanyinducementfactors,obscureupperabdominalpainhappenedwithnoradiation,nobelching,novomiting,nofeverandtremor.Painwashungrypainandcanberelievedbyantacidagentorbymeal.Melenaoccurredthreetimesaday,about250geachtime,continuingfor5dayswithlittlefatigue,nohematomeses.Hewenttothelocalcounty,15,hospitalonthethirddayofmelena,wherehereceivedgastroscopythatshowedduodenalbulbulcerswithbleeding.ThenhewasadministeredOmeprazole(PPI)intravenouslyfor6days,40mgeachtime,twiceaday(Bid).Ontheseconddayoftreatment,themelenadisappeared.OnNov.15,2003,withoutanyinducementhehadmelenaagain3timesadayand250-500gm.Everytimeaccompaniedwithfatigueandtimedbutnodizzinessandsyncope.ThistimehewenttothesecondPeopleshospital.HetookPPIbutdidntreceivegastroscopy.AfterreceivingPPI.,melenadisappear.ButtheOB(occultblood)testwasstillpositive.Thenextdayhewasshiftedto1staffiliatedhospitalofGuangxiMedicalUniversityandreceivedfurtherexaminationandtreatment.Thegeneralconditionisgoodandworkisnotaffectedinanywaysincehehadsuchadisease.,16,Pasthistory:Previoushealthstatus:WellordinarybadinfectiousdiseaseImmunizationsallergies:NYclinicalmanifestation:allergenTraumahistory:surgeryhistory:Reviewofsystems:(Tickifpositive,crossoutifnegative.Ifpositive,youshouldwritedownyourdiseasehistoryandbriefcourseofdiagnoseandtherapy),17,Reviewofsystems:(Tickifpositive,crossoutifnegative.Ifpositive,youshouldwritedownyourdiseasehistoryandbriefcourseofdiagnoseandtherapy)Respiratorysystem:sorethroatchroniccoughsputumhemoptysiswheezingdyspneachestpain,18,Cardiovascularsystem:palpitationdyspneaonexertionhemoptysissyncopeedemaoflowerlimbsprecordialpainhypertentionDigestivesystem:anorexiasourregurgitationbelchingnauseavomitabdominaldistentionabdominalpainconstipationdiarrheahematemesismelenahematocheziajaundiceUrinarysystem:lumbagofrequentmicturitionurgentmicturitionurodyniadysuriahematurianocturiapolyuriaoliguriafacialedema,19,Hemopoieticsystem:fatiguedizzinessblurredvisiongingivalbleedingsubcutaneoushemorrhageostealgiaepistaxisMetabolicandendocrinesystem:excessiveappetiteanorexiasweetscoldintoleranceolydipsiapolyuriatremorhandschangeofcharacterobviousobesityemaciationhairinesshairlosingpigmentationchangeofsexualfunctionamenorrheaMusculoskeletonsystem:floatingarthralgiaarthralgiaswellingofjointsdeformitiesmyalgiaatrophyofmuscle,20,Nervoussystem:dizzinessheadachevertigosyncopedegenerationofmemoryvisualdisturbanceinsomniadisturbanceofconsciousnesstremorspasmparalysisparesthesiaPersonalhistory:birthplaceoccupationsexualhistory:NYsmoking:NYaboutyrsaveragepieces/dceasedforyrsalcoholintake:Noccasionalfrequentaboutyrsaverageml/dothers:Maritialhistory:marryingagecompanionsstateofhealth,21,MenstruationandChildberinghistory:menarcheage-dateoflastperiod(ageofmenopause)amountofflow:littlenormallargemenstrualpain:NYcycle:regularirregularpregnancy:timesnaturallabortimesabortionstimesprematuredeliverytimesstillbirithstimesdifficultlaboranditscondition:Familyhistory:(payattentiontothecongenitaldiseasesandcommunicablediseasesrelatedtothepatient)father:stillaliveillnessdiedcauseofdeathmother:stillaliveillnessdiedcauseofdeathsiblings:others:,22,PhysicalexaminationVitalsigns:T36P70/minR20/minBp110/70mmHgGeneralAppearance:development:ortho-sthenictypeasthenictypesthenictypenutrition:wellfairlypoorcachexiafacialfeatures:normalacutechronicothersexpressions:naturalpainfulanxiousdreadfulindifferentposition:activesemi-recumbentothersgait:normalabnormalconsciousness:awaresomnolenceconfusionstuporcomadeliriumcooperation:wellbadly,23,Skin,mucousmembrane:color:normalredpalecyanosisyellowpigmentationrash:NY(typeanddistribution)subcutaneoushemorrhage:NY(typeanddistribution)hair:normalscatteringlosing(position)moistureandtemperature:normalcolddrywetelasticity:normalreducededema:NY(positionanddegree)hepaticpalm:NYspiderangioma:NY(positionnumbers)others:,24,Lymphnodes:superficiallymphnodes:non-swellingswelling(positionandcharacteristics)Head:cranium:size:normallargesmalldeformity:NY(oxycephalysquaredskulldeformingskull)others:tendernessmasssunk(position)eyes:eyelid:normaledemaptosistrichiasisconjunctive:normalhyperemiaedemahemorrhageeyeball:normalexophthalmosdepressiontremormotiondysfunction(leftright),25,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),26,mouth:lips:redcyanosispaleherpesfissuremucous:normalabnormal(palebleeding)openingofparotidglandduct:normalabnormal(swellingpyogenicexcretions)tongue:normalabnormal(coveringstremorleaningtoleftorright)gums:normalswellingpusoverflowhemorrhagepigmentsteeth:regularedentulouscariousteethfalsetoothtonsils:pharynx:voice:normalhoarse,27,Neck:resistance:NYcarotidarterypulsation:normalincreaseddecreased(leftright)jugularvein:normaldistentionhighdistentiontrachea:middledeviationto(leftright)hepatojugularreflux:(-)(+)thyroid:normalswellingdegreesymmetrydominanceinoneside:spreadingnodular:softhardothers:NY(tendernesstremorbruits),28,Chest:topography:normalbarrelchestflatchestpigeonchestfunnelchestbulgingorretraction(leftright)bulgingintheprecordialregiontendernessofsternumbreast:normalsymmetricalabnormal:leftright(gynecomastiamasstenderness)excretionsofnipples),29,Lung:inspection:movementofrespiration:normalabnormal:leftright(increaseddecreased)intercostalsspace:normalwidenarrow(position)palpation:vocalfremitus:normalabnormal:leftright(increaseddecreased)pleuralfrictionrubs:NY(position)percussion:resonanceabnormal:dullnessflatnesshyperresonancetympanylowerborders:scapularline:rightintercostalsspaceleftintercostalsspacerangeofmobility:rightcm,leftcm,30,auscultation:breath:regularirregularbreathsound:normalabnormal(feature,position)rales:NY:rhonchi:sonoroussibilantmoistrales:coarsemediumfineralescrepitusvocalconduction:normalabnormal:reducedincreasedPleuralfrictionrubs:NY(position),31,Heart:inspection:bulginginprecordialregion:NYapeximpulse:normalunseenincreaseddiffusingpoisition:normaldeviation(thedistancefrommidclavicularlinecm)otherprecordialpulsations:NY(position)palpation:apeximpulse:normalincreasedthrustunclearthrills:NY(positionperiod)pericardialfrictionrubsNYpercussion:relativecardiacoutline:normalshrinkextant(rightleft),32,Normalboundaryoftheheartright(cm)intercostalsspaceleft(cm)2-32-32-33.5-4.53-45-6distancefromanteriormidlinetotheleftmidclavicularline(cm):,33,auscultation:heartratebpm/minrhythm(regularirregularabsolutelyirregular)heartsound:S1normalincreaseddecreasedsplitS2normalincreaseddecreasedS2split:normalfixedparadoxicalS3NYS4NYA2P2extraheartsound:Ngallop(diastolicpresystolicsummationgallop)openingsnapothersmurmurs:NY,34,Location:apicalregionaorticareapulmonaryareatricuspidarealeftsternalborderin3ndintercostalsspaceOthersTiming:systolicdiastolicbothQuality:blowingrumblingsighingmusicalAustinFlintGrahamSteellGibsonIntensity:GradeTransmission:NYdirectiontoleftaxillaovertheapexoverthecarotidarteriesPericardialfrictionrubs:NY,35,Peripheralvessels:normalpistolshot:NYDuroziezsign:NYwaterhammerpulse:NYcapillarypulsation:NYpulsedeficit:NYparadoxicalpulse:NYpulsealternations:NYothersAbdomen:inspection:shape:normaldistentionfrogbellycmscaphoidabdomenapicalbellygastricpatternintestinalpatternperistalsisabdominalrespiration:existdisappearumbilicus:normalprotrudingexcretionsothers:NY(venousdistentionofabdomenpurplestriaesurgicalcarshernia),36,palpation:softmuscletensionpositiontenderness:NYreboundtenderness:NYfluidtrill:NYsuccusionsplash:NYmassesNY(positionsize)descriptionoffeature:liver:nottouchedbetouched:subcostalcmdescriptionoffeature:gallbladder:nottouchedbetouched:sizecmtenderness:NYMurphyssigh(+)(-)spleen:nottouchedbetouched:fromcostalmargincmdescriptionoffeature:,37,kidney:nottouchedbetouched:sizeconsistencytendernessmobilitytendernessofureters:NY(position)percussion:bordersofliverdullness(existshrinkobliteration)upperborderofliver:onrightmidclavicularlineintercostalsspaceshiftingdullness:NYtendernessinrenalregion:NY(rightleft)auscultation:gurglingsound:normalincreaseddecreaseddisappearvesselbruits:NY(position),38,Genitalia:notexaminednormalabnormal:RectumandAnus:notexaminednormalabnormal:SpineandExtremities:spine:normaldeformities(lateralanteriorposteriorprotruding)acanthi:tendernesspainatpercussion(position)mobility:normalrestrictedlimbs:normalabnormaldeformityswellingofjointsjointsstiffnesstendernessofmusclesatrophyofmusclesvenousdistentionoflowerlimbs(positionandfeature)acropachy,39,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),40,Hoffmannsign:left(+)(-)right(+)(-)Babinskisigh:left(+)(-)right(+)(-)Oppenheimsigh:left(+)(-)right(+)(-)Kernigsign:left(+)(-)right(+)(-)Burdzinskisign:left(+)(-)right(+)(-)Laboratoryfindings(Theimportantlaboratoryexaminations,X-ray,ECGandotherresultareincluded),41,Abstract,Mr.luo,30yearsold,hasbeensufferedfromabdominalpainandrecu