医学英语病历书写重点Case History 病史 n In-Patient Case History 住院病历 Items of Case History 1. General Data, Biographical Data 一般项目 2. Chief Complaints (C. C.) 主诉 3. Present Illness (P. I.) 现病史 4. Past (Medical) History (P. H.) 既往病史 5. Personal History (Per. H.)/ Social History 个人史/社会史 6. Family History (F. H.) 家族史 7. Medications 曾用药物 8. Allergies 过敏史 9. System Review, Review of Systems 系统回顾 10. Physical Examination (P. E.) 体格检查/查体 11. Laboratory Data 实验室与其他检查/检查资料 12. Impression (Imp.) (Diagnosis) 诊断 13. Hospital Course 住院治疗情况记录 14. Discharge Instructions/ Recommendations出院医嘱 15. Discharge Medications 出院后用药 General Data, Biographical Data 一般项目 nReliability (病历可靠性): Reliable(可靠)/ Not Entirely(不完全可靠)/ Not Clearly Defined (不够准确)/ Confused and Uncertain (混乱不清)/ Unobtainable (无法获得) nSupplier/ Complainer of History (供史者/病史陈述者): Patient/ Husband/ Wife/ Father/ Mother/ Colleague/ Neighbor Chief Complaints (C. C.) 主诉: 病例重要部分之一，通常包括患者年龄、简要的相关的既往史、患者的就诊原因及目前症状持续的时间等。 nLanguage Characteristics 1) Common expressions symptom+since+time(时间点) symptom+for+time(时间段) symptom+of+time (时间段名词所有格)+duration symptom+time(时间段)+in duration time(时间段合成词)+history+of+symptom complete sentence: The duration of +symptom+was/ has been+time(时间段) 2) Common sentence patterns for chief complaints was admitted/seen with a chief complaint of complain chiefly of presented/entered with/came to the office with a chief complaint of was admitted because of was involved in was transferred tobecause 下面是书写主诉是最常用的格式： CC：The patient is a (age)-year-old (race,ethnic,group,occupation,sex and/or very pertinent PMH),who is admitted to the hospital with a chief complaint of (symptom,not a sign or diagnosis) of (number followed by a unit of time) duration. Example 主诉：患者是一个48岁的妇女。入院主诉，6个月来，出力后心悸和呼吸困难。 CHIEF COMPLAINT: The patient is a 48-year-old female, admitted with the chief complaint of palpitation and dyspnea following physical exertion for 6 months. History of Present Illness 现病史：是从医生的角度，进一步表述主诉内容，全面表述现有疾病的发病时间、主要症状、病情发展过程、症状间的联系、诊疗过程、目前患者身体状况、与现有疾病有直接关系的既往史等。记录患者入院情况时，多用一般过去时或过去完成时；记录目前病情时，用一般现在时或现在完成时。 nLanguage Characteristics 1) Sentence Patterns with Patients to Be Subject 以病人做主语的句型 start having 开始有的症状 begin having episodes of 开始发生的症状/疾病 become 变得 notice(perceive, note, recognize)+症状/疾病 have 有症状/疾病 have abrupt/sudden/explosive onset of 突然患 have episode of/have attack of患 develop+disease 出现/有了症状/疾病 are/is the prodrome of 的前驱症状 2) Sentence with symptoms, illnesses as subjects 以症状、疾病做主语的句型 begin (occur, start)+time 从开始 date (go back) to +time 可追溯到 be present+time 在/从已存在 be preceded by 在之前已有 be followed by 在之后紧接着发生 be accompanied by/ coincide with 与同时发生 be (not) related to/have (no) correlation with 与有关 3) Illness improving and worsening 表达疾病的好转与恶化 last+time 持续时间 take a bad turn; take a turn for the worse; be aggravated/exacerbated; become worse 恶化 take a good turn/take a turn for the better/improve 好转 be aggravated/abated/alleviated by 因而加剧/减轻 remain the same/unchanged 无变化 be (not) improved after treatment with 经用治疗而好转 (The symptom) cease/clean up/disappear/subside 症状消失/减退 4) No symptoms 没发生症状、疾病 without/with no/free of (symptoms) There be no history of/have no history of (The patient) denies (The patient) noted no (The patient) was not found to be 5) Description of main symptoms 描述主要症状 assume the character of/be characterized by have/present/develop/show/manifest the symptoms of Past (Medical) History (P. H.)既往病史 nCommon expressions had been sound/well until; had enjoyed good health until 在前一直健康 be apt/liable/subject to;tend to have 易患 was admitted to hospital for/ was hospitalized for 曾因而住院 had (some illness) with recovery after 曾有，因痊愈 was diagnosed as/was suspicious of 断为/疑为 was exposed to (toxic substances)/ had to breathe (poisoning gases) 接触/吸入 was inoculated against接种过 was discharged/ dismissed from hospital/ was out of hospital出院 Personal History (Per. H.)/ Social History 个人史/社会史 nNote: menstruation 经期 menstrual period menarche ageage of menopause 月经周期 nCharacteristics of language nCommon expressions Declarative sentences and elliptical sentences are usually used, and present tense, past tense and past perfect tense are adopted. Family History (F. H.) 家族史 be living and well./be in good health./ be well with no evidence of (illness). 健在 (There is) No family history of (disease)./ (There was) No (disease) in ones family. 无家族史 There was no case of (disease) in his/her family./ No one in his/her family experienced (disease) 家族成员未曾患过 Family history showed/revealed 家族史显示 There was a familial/hereditary tendency to/ There was a strong family history of/ There was a