醫(yī)學(xué)英語病歷報告書寫(簡易版)

CaseHistoryDefinitionAcasehistoryisamedicalrecordofapatient’sillness.Itrecordsthewholemedicalcaseandfunctionsasthebasisformedicalpractitionerstomakeanaccuratediagnosisandproposeseffectivetreatmentorpreventivemeasures.Casehistoriesfallintotwokinds:in-patientcasehistoriesandout-patientcasehistories.LanguageFeaturesHistoryandPhysicalusuallyinvolvespasttense(forhistoryofpresentillness,pastmedicalhistory,familyhistoryandreviewofsystemsconcerningpastinformation),andpresenttense(reviewofsystem,physicalexamination,laboratorydata,andplans).Structurally,nounphrasesarefrequentlyusedinphysicalexamination,andellipsisofsubjectisverycommoninreviewofsystem.In-patientCaseHistoriesAnin-patientcasehistoryisalsotermedasHistoryandPhysical.Itisanaccountofapatient’spresentcomplaintswithdescriptionsofhispastmedicalhistory,andthedescriptionofthepresentconditionsaswellasphysicalexaminationsandimpressionabouttheconditions.FormatItusuallyconsistsofchiefcomplaint,historyofpresentillness,pastmedicalhistory,reviewofsystems,physicalexamination,impression,familyhistory,socialhistory,medications,allergies,laboratoryonadmission,andplan.However,whatpartsareincludeddependsontheneeds.住院病人病歷完整模式病歷（CaseHistory）姓名(Name)職業(yè)(Occupation)性別(Sex)住址(Address)年齡(AgeorDOB)供史者(Supplierofhistory)婚姻(Maritalstatus)入院日期(Dateofadmission)籍貫(Placeofbirth)記錄日期(Dateofrecord)民族(Race)主述(C.C.)現(xiàn)病史(HPIorP.I.)過去史(PMHorP.H.)社會活動史/個人史(SHxorPer.H.)家族史(FHxorF.H.)曾用藥物(Meds)過敏史(All)Tobecontinued系統(tǒng)回顧(ROS)體格檢查(PEorP.E.)體溫(T)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.x3days Signature______ChiefComplaint(C.C.)1.Sentencepatternsinchiefcomplaint癥狀+for+時間癥狀+of+時間+duration癥狀+時間+induration時間+of+癥狀癥狀+since+時間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,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.)簡明病歷書寫手冊