病历书写(英文)

HISTORYRECORDWhatishistoryrecordTheclinicalrecorddocumentsthepatient'shistoryandphysicalfindings.Itshowshowcliniciansassessthepatient,whatplanstheymakeonthepatient'sbehave,whatactionstheytake,andhowthepatientrespondstotheirefforts.Importanceofhistoryrecord1.Diagnosisandtreatmentpurpose

Anaccurate,clear,wellorganizedrecordreflectsandfacilitatessoundclinicalthinking.Itleadstogoodcommunicationamongthemanyprofessionalswhoparticipateincaringforthepatient

2.Teachingandresearchpurpose3.MedicolegalpurposesHowtomakeagoodhistory

recordWhencreatingarecord,youdomorethansimplymakealistofwhatthepatienthastoldyouandwhatyouhavefoundonexamination.Youmustreviewyourdata,organizethem,evaluatetheimportanceandrelevanceofeachitem,andconstructaclear,concise,yetcomprehensivereport.Howtomakeagoodhistory

record1.Orderisimperative2.Keepitemsofhistoryinthehistory3.Describespecificallyanypertinentnegativeinformation

4.Datanotrecordedaredatalost5.Useshortwordsinsteadoflongandprobablyfancieroneswhentheymeanthesamething

6.Beobjective7.YoushouldwritetherecordassoonaspossibleBasicrequirementforthe

historyrecord1.Tobewellorganizedandcanonical2.Nomucherasionandgridecouldbedoneinthehistoryrecord3.Tobeobjectiveandaccurate4.Usingprofessionaltermtorecordinsteadoffolksay5.RemembertohaveyoursignatureA.Outlineofcaserecord1.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:①dateofonset,②characterofcomplaint,③modeofonset,courseandduration,④location,⑤relationshiptoothersymptoms,bodilyfunctionandactivities,⑥exacerbationandremissions,and⑦effectoftreatment.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).13Summary14.PrimarydiagnosisAstheresultsofdifferentialanalysisofanumberofsignificantdata,aprimarydiagnosiscouldbeestablished.Itconsistsofetiologicdiagnosis,pathologicaldiagnosis,pathophysioloicaldiagnosis(stageorperiodandclassificationorsubtype),cardiacor/andpulmonaryfunctionandcomplication(s).15.signatureB

OutlineofSummaryName,gender,ageandoccupationAdmissiondateAhiefcomplainsPresenthistory(70%-80%percentoftheoriginalpresenthistory)Simplifieddocumentoftheoriginalpasthistory(onlypositivedatarecruited)VerysimplifieddocumentoftheoriginalpersonalandfamilyhistoryPhysicalexamination:vitalsigns,importantpositiveandnegativesigns,especiallyvaluableinformationfordifferentiation,butyoucannotomitsuchimportantitemsasheart/lung/abdominalexamination.PositivelaboratoryandinstrumentalresultsExampleofcaserecord

Biographicaldata:Name

LUOLENSHENG

Age:

30Sex:

MMaritalstatus:MarriedNativeplace:

ChinaRace:

HanOccupation:MechanicDateofAdmissiondate:2003/11/16Statement:patientherselfChiefcomplaint:

recurrentabdominalpainandmelenaformorethanoneyearHistoryofpresentillness:

Mr.luohasbeensufferedfromabdominalpainandrecurrentmelenasince2002,beganonMay2,2002hehadupperabdominalpainandmelenafirsttime,withnoanyinducementfactors,obscureupperabdominalpainhappenedwithnoradiation,nobelching,novomiting,nofeverandtremor.Painwashungrypainandcanberelievedbyantacidagentorbymeal.Melenaoccurredthreetimesaday,about250geachtime,continuingfor5dayswithlittlefatigue,nohematomeses.HewenttothelocalcountyPasthistory:Previoushealthstatus:WellordinarybadinfectiousdiseaseImmunizationsallergies:NYclinicalmanifestation:allergenTraumahistory:surgeryhistory:Reviewofsystems:(Tickifpositive,crossoutifnegative.Ifpositive,youshouldwritedownyourdiseasehistoryandbriefcourseofdiagnoseandtherapy)

Reviewofsystems:(Tickifpositive,crossoutifnegative.Ifpositive,youshouldwritedownyourdiseasehistoryandbriefcourseofdiagnoseandtherapy)

Respiratorysystem:sorethroatchroniccoughsputumhemoptysiswheezingdyspneachestpainCardiovascularsystem:palpitationdyspneaonexertionhemoptysissyncopeedemaoflowerlimbsprecordialpainhypertention

Digestivesystem:anorexiasourregurgitationbelchingnauseavomitabdominaldistentionabdominalpainconstipationdiarrheahematemesismelenahematocheziajaundice

Urinarysystem:lumbagofrequentmicturitionurgentmicturitionurodyniadysuriahematurianocturiapolyuriaoliguriafacialedemaHemopoieticsystem:fatiguedizzinessblurredvisiongingivalbleedingsubcutaneoushemorrhageostealgiaepistaxis

Metabolicandendocrinesystem:excessiveappetiteanorexiasweetscoldintoleranceolydipsiapolyuriatremorhandschangeofcharacterobviousobesityemaciationhairinesshairlosingpigmentationchangeofsexualfunctionamenorrhea

Musculoskeletonsystem:floatingarthralgiaarthralgiaswellingofjointsdeformitiesmyalgiaatrophyofmuscleNervoussystem:dizzinessheadachevertigosyncopedegenerationofmemoryvisualdisturbanceinsomniadisturbanceofconsciousnesstremorspasmparalysisparesthesia

Personalhistory:birthplaceoccupationsexualhistory:NYsmoking:NYaboutyrsaveragepieces/dceasedforyrsalcoholintake:Noccasionalfrequentaboutyrsaverageml/dothers:

Maritialhistory:marryingagecompanion’sstateofhealthMenstruationandChildberinghistory:menarcheage--------dateoflastperiod(ageofmenopause)

amountofflow:littlenormallargemenstrualpain:NYcycle:regularirregularpregnancy:timesnaturallabortimesabortionstimesprematuredeliverytimesstillbirithstimesdifficultlaboranditscondition:

Familyhistory:(payattentiontothecongenitaldiseasesandcommunicablediseasesrelatedtothepatient)father:stillaliveillnessdiedcauseofdeathmother:stillaliveillnessdiedcauseofdeathsiblings:others:PhysicalexaminationVitalsigns:

T36℃P70/minR20/minBp110/70mmHg

GeneralAppearance:development:ortho-sthenictypeasthenictypesthenictypenutrition:wellfairlypoorcachexiafacialfeatures:normalacutechronicothersexpressions:naturalpainfulanxiousdreadfulindifferentposition:activesemi-recumbentothersgait:normalabnormalconsciousness:awaresomnolenceconfusionstuporcomadeliriumcooperation:wellbadlySkin,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:normalhoarseNeck: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,leftcmauscultation: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)

Normalboundaryoftheheart

right(cm)

intercostalsspaceleft(cm)

2-3Ⅱ2-3

2-3Ⅲ3.5-4.5

3-4Ⅳ5-6

Ⅴ

distancefromanteriormidlinetotheleftmidclavicularline(cm):auscultation:heartratebpm/minrhythm(regularirregularabsolutelyirregular)heartsound:S1normalincreaseddecreasedsplitS2normalincreaseddecreasedS2split:normalfixedparadoxicalS3NYS4NYA2P2extraheartsound:Ngallop(diastolicpresystolicsummationgallop)openingsnapothersmurmurs:NYLocation:apicalregionaorticareapulmonaryareatricuspidarealeftsternalborderin3ndintercostalsspaceOthersTiming:systolicdiastolicbothQuality:blowingrumblingsighingmusicalAustinFlintGrahamSteellGibsonIntensity:GradeⅠⅡⅢⅣⅤⅥTransmission:NYdirectiontoleftaxillaovertheapexoverthecarotidarteriesPericardialfrictionrubs:NYpalpation: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)acropachyNervoussystem:muscletone(normalincreaseparatonia)myodynamia(0ⅠⅡⅢⅣⅤ)paralysisoflimbs:NY(leftrightupperlower)reflex:abdominalwallreflex(uppermiddlelowernormalabnormal)bicepsreflex:left(normalabnormal)right(normal