醫(yī)學(xué)英語(yǔ)病歷報(bào)告書寫(簡(jiǎn)易版)

學(xué)習(xí)文檔僅供參考學(xué)習(xí)文檔僅供參考CaseHistoryDefinitionAcasehistoryisamedicalrecordofapatient’sillness.Itrecordsthewholemedicalcaseandfunctionsasthebasisformedicalpractitionerstomakeanaccuratediagnosisandproposeseffectivetreatmentorpreventivemeasures.Casehistoriesfallintotwokinds:in-patientcasehistoriesandout-patientcasehistories.LanguageFeaturesHistoryandPhysicalusuallyinvolvespasttense(forhistoryofpresentillness,pastmedicalhistory,familyhistoryandreviewofsystemsconcerningpastinformation),andpresenttense(reviewofsystem,physicalexamination,laboratorydata,andplans).Structurally,nounphrasesarefrequentlyusedinphysicalexamination,andellipsisofsubjectisverycommoninreviewofsystem.In-patientCaseHistoriesAnin-patientcasehistoryisalsotermedasHistoryandPhysical.Itisanaccountofapatient’spresentcomplaintswithdescriptionsofhispastmedicalhistory,Itusuallyconsistsofchiefcomplaint,historyofpresentillness,pastmedicalhistory,reviewofsystems,physicalexamination,impression,familyhistory,socialhistory,medications,allergies,laboratoryonadmission,andplan.However,whatpartsareincludeddependsontheneeds.住院病人病歷完整模式(Name)性別(Sex)年齡(AgeorDOB)婚姻(Maritalstatus)籍貫(Name)性別(Sex)年齡(AgeorDOB)婚姻(Maritalstatus)籍貫(Placeofbirth)住址(Address)供史者(Supplierofhistory)入院日期(Dateofadmission)記錄日期(口21?ofrecord)民族(Race)主述(C.C.)現(xiàn)病史(HPIorP.I.)過(guò)去史(PMHorP.H.)社會(huì)活動(dòng)史/個(gè)人史(SHxorPer.H.)家族史(FHxorF.H.)曾用藥物(Meds)過(guò)敏史心⑴Tobecontinued系統(tǒng)回憶(ROS)體格檢查(PEorP.E.)體溫(。 呼吸(R)血壓(BP) 脈搏(P)一般狀況(Generalstatus)皮膚黏膜(Skin&mucosa)頭眼耳鼻喉(HEENT)頸部(Neck)胸部與心肺(Chest,HeartandLungs)腹部(Abdomen)肛門直腸(Anus&rectum)外生殖器(Externalgenitalia)四肢脊柱(Extremities&spine)神經(jīng)反射(Nervereflex)Tobecontinued化驗(yàn)室資料(Labdata)(Bloodtest,Chem-7,EKG,EEG,X-rayexaminationsorX-rayslides,CTandNMR…)印象與診斷(Impressionanddiagnosis,orImp)住院治療情況記錄(Hospitalcourse)出院醫(yī)囑(Dischargeinstructionsorrecommendations)出院后用藥(Dischargemedications)醫(yī)師簽名(Signature)Patternsandcontentsofanout-patientcasehistoryContents:generaldata(GD),chiefcomplaint(CC),presentillness(PI),physicalexamination(PE),tentativediagnosis(TD)orimpression(Imp),treatment(Rp),etc.Anout-patientcasehistoryshouldbewritteninbriefandtotheverypoint.Moreabbreviationsandnounphrasesareused.Sampleofanout-patientcasehistoryMale,39yearoldCC:Fever,headacheandcoughfortwodays.PE:G.C.looksfair.Pharynxcongestedandtonsilsenlarged.Chestandabdomennegative.Imp:U.R.I.Rp:Penicillin400,000u.(i.m.)q.d.x3days.Aspirin1tab.t.i.d.x2days.VitC100mgt.i.d.x3daysSignature ChiefComplaint(C.C.)1.Sentencepatternsinchiefcomplaint癥狀+for+時(shí)間癥狀+of+時(shí)間+duration癥狀+時(shí)間+induration時(shí)間+of+癥狀癥狀+since+時(shí)間ChiefComplaint(C.C.)2.Commonly-usedcomplaints:weakness,malaise,chills,fever,pain,headache,nauseaandvomiting,diarrhea,neuro-psychiatricdisorders,shortnessofbreath,bleedingordischarge,insomnia,stomachache,dyspepsia,noappetite,dysuria,cough,difficultyincoughingupsputum,sorethroat,dizziness,palpitation,restlessness,etc.?弱點(diǎn)，不適感，發(fā)冷、發(fā)燒、疼痛、頭痛、惡心、嘔吐、腹瀉、neuro-psychiatric紊亂、氣短、出血或排放、失眠、胃痛，消化不良，沒(méi)有胃口，排尿困難、咳嗽、咳痰、困難、喉嚨痛、頭暈、心悸、不安等。PresentIllness(P.I.)簡(jiǎn)明病歷書寫手冊(cè).doc(p.27-35)■ThecourseofonsetDateofonsetModeofonsetProdromalsymptomsThecardinalsymptomsTheattackofillnessThedevelopmentofsymptomsDiagnosisandtreatmentGeneralconditionExampleSpeciallanguagestructuresinpresentingpresentillness1.Describingthecourseofonset…started/beganhaving/feeling……firstnoticed/noted/perceived/recognizedtheonsetof……aretheprodromeof…,…h(huán)erald…Speciallanguagestructuresinpresentingpresentillness2.Describingthemodeandregularityofonsetexplosively/suddenly/acutely/abruptlygradually/chronically/increasingly/insidiouslyoccasionally/accidentallyoften/frequently/infrequency/recurrentlypersistently/intermittently爆炸性/突然/強(qiáng)烈?/突然長(zhǎng)期/越來(lái)越多?逐漸//在不知不覺(jué)之中?偶爾/偶經(jīng)常/經(jīng)常在0.9%的頻率/的循環(huán)?持久/斷斷續(xù)續(xù)的Speciallanguagestructuresinpresentingpresentillness3.Describingthecardinalsymptoms…h(huán)ad/presented/developed/showed/manifested…… characterizedby…… admitsto…… statesthat…… feels……denies….，…without/freeofsymptoms….Speciallanguagestructuresinpresentingpresentillness4.Describingtheattackofillness…appeared/occurred/cameon……h(huán)ad/developedepisodes/attacksof……wasassociatedwith….，…wasaccompaniedby….，…wasfollowedby….，…h(huán)adrelationto……waspreceded/heraldedby…Speciallanguagestructuresinpresentingpresentillness5.Describingthedevelopmentofsymptoms…disappeared/ceased/subsided……tookafavorableturn….，….tookaturnforthebetter….，…relieved/improved/alleviated……tookabad/unfavorableturn…，…tookaturnfortheworse…，…wasaggravated/intensified/exacerbatedby……remainedthesameas…,…continued,…persistedwithoutchangePastHistory(P.H.)簡(jiǎn)明病歷書寫手冊(cè).doc(p.36)HistoryofvaccinationandinfectiousdiseasesHistoryofallergytodrugsandothersubstancesHistoryofsurgicaloperationandexternalinjurySystematicreviewofthepasthistoryanddiseaseSpeciallanguagestructuresinpresentingpasthistory...hadenjoyedgoodhealthuntil.../...hadbeensound/well/healthyuntil...…h(huán)adneverbeenillbefore./hadnoillnessofanykindbefore..deniedanyhistoryof/hadnorelatedhistoryof/. deniedexperiencing/havingattackof.Nohistoryof./Nohistorysuggestiveof/indicative of..sufferedfrom./.hadanattackof./.was attacked/troubledby/.hadapasthistoryof.Exceptfor.hadno./.no.apartfrom/but.Commondiseasesmentionedinpasthistorymeasles,mumps,chicken-pox,smallpox,pertussis,influenza,scarletfever,diphtheria,typhoidfever,bronchitis,pneumonia,encephalitis,meningitis,tetanus,poliomyelitis,dysentery,cholera,pleurisy,tonsillitis,rheumatism,malaria,tuberculosis,jaundice,allergy,sexuallytransmitteddiseases,gonorrhea,syphilis,sequela,complication,hospitalization.麻疹，腮腺炎,chicken-pox氮、天花、百日咳、流行性感冒、猩紅熱、白喉、傷寒、支氣管炎、肺炎、腦炎、腦膜炎、破傷風(fēng)、脊髓灰質(zhì)炎(小兒麻痹)、痢疾、霍亂、胸膜炎、扁桃體炎、風(fēng)濕、瘧疾、肺結(jié)核、黃疸、過(guò)敏、性傳播疾病、淋病、梅毒、后遺癥、并發(fā)癥、住院…PersonalHistory(Per.H.)/SocialHistory簡(jiǎn)明病歷書寫手冊(cè).doc(p.37)LifestyleandhabitOccupationandworkingenvironmentMarital&childbearinghistoryMenstrualhistoryTravelinghistorySpeciallanguagestructuresinpresentingpersonalhabits.havealonghistoryofsmoking/drinking.havealifelonglike/dislikefor..admittedtoexcessiveuseof..deniestheuseofalcoholicbeveragesSpeciallanguagestructuresinpresentingoccupationalhistory.work/act/serveas..beengagedin..practiceone’sprofessionin..beexposedtoindustrialpoisons/dust/radioactivesubstances/hazards/toxicsubstances.Speciallanguagestructuresinpresentingmarital&childbearinghistory簡(jiǎn)明病歷書寫手冊(cè).doc(p.38-39).havebeenmarriedfor.yearswithoutconception.haveahistoryofabortionorprematurebirths.deliveredonenormal/abnormalinfant.delivered.daysbefore/priortotheexpecteddateofconfinementFamilyHistory(F.H.)簡(jiǎn)明病歷書寫手冊(cè).doc(p.39)Termsmentionedinfamilyhistory?familytendency,presenceofhereditarydisorders,cancer,tuberculosis,mentaldisorderandnervousaffection,rheumatism,diabetes,hypertension,cerebralvascularaccident,hemophilia,syphilis,tumor,epilepsy,allergy,etc.anycontactwithdiseasedindividuals,relationshipofpatient’schildhoodandadultlife;age,healthcondition,andcauseofdeathofparents,grandparents,self,spouse,siblingsorrelatives.家庭的傾向，存在遺傳疾病、癌癥、肺結(jié)核、精神障礙和緊張的感情、風(fēng)濕、糖尿病、高血壓、腦血管意外、血友病、梅毒、腫瘤、癲癇、過(guò)敏等任何接觸患病的個(gè)人關(guān)系,病人的童年和成年生活;年齡、健康狀況、和死亡原因的父母、祖父母、本人,配偶、兄弟姐妹或不相關(guān)的親戚(聯(lián)系)。■Speciallanguagestructuresinpresentingfamilyhistory…beingoodhealth,behealthy,belivingandwellThefamilyhistorydidnotreveal…Therewasnofamilyhistoryof…Therewasnocaseof…inthefamily.Familyhistorywasirrelevantto…Familyhistoryshowed/revealed…Therewasafamilialtendencyto/toward……diedof…,…diedfromunknowncausesReviewofSystems簡(jiǎn)明病歷書寫手冊(cè).doc(p.40-115)1.Generalcondition/physicalsigns1.1temperature(T):oral/a