病历书写英文

1、lhistory recordlthe clinical record documents the patients history and physical findings. it shows how clinicians assess the patient, what plans they make on the patients behave, what actions they take, and how the patient responds to their efforts .l1. diagnosis and treatment purpose an accurate, c

2、lear, well organized record reflects and facilitates sound clinical thinking. it leads to good communication among the many professionals who participate in caring for the patient l2. teaching and research purposel3. medicolegal purposes lwhen creating a record, you do more than simply make a list o

3、f what the patient has told you and what you have found on examination. you must review your data, organize them, evaluate the importance and relevance of each item, and construct a clear, concise, yet comprehensive report. l1. order is imperativel2. keep items of history in the history l3. describe

4、 specifically any pertinent negative information l4. data not recorded are data lost l5. use short words instead of long and probably fancier ones when they mean the same thing l6. be objectivel7. you should write the record as soon as possible l1. to be well organized and canonicall2. no much erasi

5、on and gride could be done in the history recordl3. to be objective and accuratel4. using professional term to record instead of folksayl5. remember to have your signaturel1. biographical data biographical information of patient should include his full name, age (date of birth), sex, race, occupatio

6、n, nationality, marital status and permanent home address. also, the date of admission, the time at which you took the history, the source of history and estimate of reliability should be involved.l2. chief complaint the chief complaint consists of main symptom(s) and duration. it should constitute

7、in a few simple words the main reasons why the patient consulted doctor and should be state as nearly as possible in the patients own wards. in general, the chief complaint should include age, sex, complaint, and duration of the complaint. it should no included diagnostic terms or disease entities.

8、for example:” this 70-year old man has had short breath for a week.”l3. history of present illness (hpi) the history of present ill ness should be a well-organized, sequentially developed elaboration of his chief complaint(s) on its various characteristics: date of onset, character of complaint, mod

9、e of onset, course and duration, location, relationship to other symptoms, bodily function and activities, exacerbation and remissions, and effect of treatment.l4. past history (ph) it should include a review of all past ill nesses, surgical procedures, and injuries, and allergy history (medicine, f

10、ood), which are particularly related to the present illness.l5. review of system (ros) the purpose of sys tem review is twofold: a thorough evaluation and a double check prevent omission of significant data relative to the present illness. the review is a comprehensive account of all complaints refe

11、rable to each body system progressing in a logical manner from the head toward the feet, including respiratory system, cardiovascular system, digestive system, urinary system, hemopoietic system, endocrine system, nervous system and skeletal system.l6. personal history (social and occupational histo

12、ry) it includes personal habits (smoking, alcohol drinking), business life, sex life, occupation (exposure to certain irritating agents), condition of work.l7. marital history it includes data concerning the health of mate, sexual adjustment, the number of children and their physical status, and the

13、 general social adjustment within the family.l8. menstrual history ( for female patients) age of onset, interval between periods, duration, amount and character of flow, concomitant symptoms, date of last menstruation, age of menopause.l9. childbearing (reproductive) history age and date of pregnanc

14、y(ies) and childbirth(s). date of artificial or natural abortions, stillbirths, operative delivery, puerperal fever. method of family planning, the possible factors of infertility (also for male patients).l10. family history (fh) the health status of the patients family (mother, father, siblings and

15、 children) and if died, the age and cause of death should be recorded, such as diabetes, hypertension, cancer, obesity, allergic disorders, coronary artery disease and mental illness.l11. physical examination (pe) the recording of physical examination should follow a logical sequence as follows: vit

16、al signs, general status, skin, nodes, head, neck, chest, lungs, heart and blood vessels, abdomen, genitalia, rectum, spine and extremities, nervous reflexes.l12. laboratory tests and instrumental examination the findings of them onkly serve to confirm what you have found on history and physical exa

17、mination. the routine laboratory studies include blood, urine and stool tests, electrolytes, x-rays and ecg.l13 summaryl14. primary diagnosis as the results of differential analysis of a number of significant data, a primary diagnosis could be established. it consists of etiologic diagnosis, patholo

18、gical diagnosis, pathophysioloical diagnosis (stage or period and classification or subtype), cardiac or/and pulmonary function and complication(s).l15.signaturelname, gender, age and occupationladmission datelahief complainslpresent history(70%-80% percent of the original present history )lsimplifi

19、ed document of the original past history(only positive data recruited)lvery simplified document of the original personal and family historylphysical examination: vital signs, important positive and negative signs, especially valuable information for differentiation, but you can not omit such importa

20、nt items as heart/lung/abdominal examination. lpositive laboratory and instrumental resultsexample of case record lbiographical data:lnameluo len sheng age: 30 sex: m marital status: married native place: china race: hanloccupation : mechanic date of admission date: 2003/11/16lstatement: patient her

21、selflchief complaint: recurrent abdominal pain and melena for more than one yearlhistory of present illness:l lmr. luo has been suffered from abdominal pain and recurrent melena since 2002, began on may 2,2002 he had upper abdominal pain and melena first time, with no any inducement factors, obscure

22、 upper abdominal pain happened with no radiation, no belching ,no vomiting, no fever and tremor. pain was hungry pain and can be relieved by antacid agent or by meal. melena occurred three times a day, about 250g each time, continuing for 5 days with little fatigue, no hematomeses. he went to the lo

23、cal county lhospital on the third day of melena, where he received gastroscopy that showed duodenal bulb ulcers with bleeding. then he was administered omeprazole (ppi) intravenously for 6 days, 40mg each time, twice a day (bid). on the second day of treatment, the melena disappeared . on nov. 15, 2

24、003, without any inducement he had melena again 3 times a day and 250-500gm. every time accompanied with fatigue and timed but no dizziness and syncope. this time he went to the second peoples hospital. he took ppi but didnt receive gastroscopy. after receiving ppi., melena disappear. but the ob(occ

25、ult blood) test was still positive. the next day he was shifted to 1st affiliated hospital of guangxi medical university and received further examination and treatment. the general condition is good and work is not affected in any way since he had such a disease.lpast history:l previous health statu

26、s: well ordinary bad infectious diseasel immunizations allergies: n y clinical manifestation: allergenl trauma history: surgery history:lreview of systems: (tick if positive, cross out if negative. if positive, you should write down your disease history and brief course of diagnose and therapy)l lre

27、view of systems: (tick if positive, cross out if negative. if positive, you should write down your disease history and brief course of diagnose and therapy)l lrespiratory system:lsore throat chronic cough sputum hemoptysis wheezing dyspnea chest painlcardiovascular system:lpalpitation dyspnea on exe

28、rtion hemoptysis syncope edema of lower limbs precordial pain hypertentionl ldigestive system:lanorexia sour regurgitation belching nausea vomit abdominal distention abdominal pain constipation diarrhea hematemesis melenalhematochezia jaundicel lurinary system:llumbago frequent micturition urgent mi

29、cturition urodynia dysuria hematuria nocturia polyuria oliguria facial edemalhemopoietic system:lfatigue dizziness blurred vision gingival bleeding subcutaneous hemorrhage ostealgia epistaxisl l metabolic and endocrine system:lexcessive appetite anorexia sweets cold intolerance olydipsia polyuria tr

30、emor hands change of character obvious obesity emaciation hairiness hair losing pigmentation change of sexual function amenorrheal lmusculoskeleton system:lfloating arthralgia arthralgia swelling of joints deformities myalgia atrophy of musclelnervous system:ldizziness headache vertigo syncope degen

31、eration of memory visual disturbance linsomnia disturbance of consciousness tremor spasm paralysis paresthesial lpersonal history:lbirthplace occupation sexual history: n y smoking: n y about yrs average pieces/d ceased for yrs lalcohol intake: n occasional frequentlabout yrs average ml/d others:l l

32、maritial history:lmarrying age companions state of healthlmenstruation and childbering history:lmenarche age - date of last period (age of menopause)l lamount of flow: little normal large menstrual pain: n y cycle: regular irregular pregnancy: times natural labor times abortions times premature deli

33、very timeslstillbiriths times difficult labor and its condition:l lfamily history: (pay attention to the congenital diseases and communicable diseases related to the patient)lfather: still alive illness died cause of death mother: still alive illnessldied cause of death siblings: others:lphysical ex

34、aminationlvital signs: l t 36 p 70 /min r 20 /min bp 110 /70 mmhg lgeneral appearance:ldevelopment: ortho-sthenic type asthenic type sthenic type nutrition: well fairly poor cachexia facial features: normal acute chronic others expressions: natural painful anxious dreadful indifferent position: acti

35、ve semi-recumbent others gait: normal abnormallconsciousness:aware somnolence confusion stupor coma delirium cooperation:well badlylskin, mucous membrane: color: normal red pale cyanosis yellow pigmentationlrash: n y (type and distribution) subcutaneous hemorrhage: n y (type and distribution)lhair:

36、normal scattering losing (position) moisture and temperature: normal cold dry wetlelasticity: normal reduced edema: n y (position and degree) hepatic palm: n ylspider angioma: n y (position numbers) others: llymph nodes:lsuperficial lymph nodes: non-swellinglswelling (position and characteristics) l

37、 head:lcranium:size:normal large small deformity:ln y(oxycephaly squared skull deforming skull)lothers: tenderness mass sunk (position )leyes: eyelid: normal edema ptosis trichiasis conjunctive: normal hyperemia edema hemorrhage eyeball: normal exophthalmos depression tremorlmotion dysfunction (left

38、 right) lsclera: normal yellow lcornea: normal abnormal (left right )lpupils: equal roundness same size unequal left cm, right cmlreaction to light: normal delay (left right ) disappear (left right ) others:lears: auricle: normal deformity fistula others (left right )lexcretions of external canal: n

39、 y (left right feature )ltenderness of mastoid: n y (left right ) audition dysfunction: n (left right )lnose: shape: normal abnormal( ) other abnormalities: n y nasal flaplobstruction excretions nasal sinus tenderness: n y (position )lmouth: lips: red cyanosis pale herpes fissure mucous: normal abno

40、rmal (pale bleeding)lopening of parotid gland duct: normal abnormal (swelling pyogenic excretions)ltongue: normal abnormal (coverings tremor leaning to left or right )lgums: normal swelling pus overflow hemorrhage pigmentslteeth: regular edentulous carious teeth false toothltonsils: pharynx: voice:

41、normal hoarselneck: resistance: n y carotid artery pulsation: normal increased decreased (left right)ljugular vein: normal distention high distention trachea: middle deviation to (left right)lhepatojugular reflux: (-) (+) lthyroid: normal swelling degree symmetryldominance in one side:lspreading nod

42、ular: soft hard others: n y (tenderness tremor bruits ) lchest: ltopography: normal barrel chest flat chest pigeon chest funnel chestlbulging or retraction (left right) bulging in the precordial region tenderness of sternumlbreast: normal symmetrical abnormal: left right (gynecomastia mass tendernes

43、s)lexcretions of nipples )llung:linspection: movement of respiration: normal abnormal: left right (increased decreased)lintercostals space: normal wide narrow (position )lpalpation: vocal fremitus: normal abnormal: left right (increased decreased)lpleural friction rubs: n y (position )lpercussion: r

44、esonance abnormal: dullness flatness hyperresonance tympanyllower borders: scapular line: right intercostals space left intercostals spacelrange of mobility: right cm, left cmlauscultation: breath: regular irregularlbreath sound: normal abnormal (feature, position )lrales: n y: rhonchi: sonorous sib

45、ilant moist rales: coarse medium fine rales crepituslvocal conduction: normal abnormal: reduced increasedlpleural friction rubs: n y (position )lheart:linspection: bulging in precordial region: n y apex impulse: normal unseen increased diffusinglpoisition: normal deviation (the distance from midclav

46、icular line cm)lo t h e r p r e c o r d i a l p u l s a t i o n s : n y (position )lpalpation:apex impulse: normal increased thrust unclearlthrills: n y (position period ) pericardial friction rubs n ylpercussion: relative cardiac outline: normal shrink extant (right left)l l normal boundary of the

47、heart l right(cm) intercostals space left(cm)l 2-3 2-3l 2-3 3.5-4.5l 3-4 5-6l l l distance from anterior midline to the left midclavicular line(cm):lauscultation: heart rate bpm/min rhythm (regular irregular absolutely irregular)lheart sound: s1 normal increased decreased split s2 normal increased d

48、ecreasedls2 split: normal fixed paradoxical s3 n y s4 n y a2 p2lextra heart sound: n gallop (diastolic presystolic summation gallop) opening snap otherslmurmurs: n yllocation: apical region aortic area pulmonary area tricuspid arealleft sternal border in 3nd intercostals space othersltiming: systoli

49、c diastolic bothlquality: blowing rumbling sighing musical austin flint graham steell gibsonlintensity: grade ltransmission: n y direction to left axilla over the apex over the carotid arterieslpericardial friction rubs: n ylperipheral vessels: normal pistol shot: n y duroziez sign: n ylwater hammer

50、 pulse: n y capillary pulsation: n ylpulse deficit: n y paradoxical pulse: n y lpulse alternations: n y othersl abdomen:linspection: shape: normal distention frog belly cm scaphoid abdomen apical bellylgastric pattern intestinal pattern peristalsis abdominal respiration: exist disappearlumbilicus: n

51、ormal protruding excretionslothers: n y (venous distention of abdomen purple striae surgical cars hernia)lpalpation: soft muscle tension position tenderness: n y rebound tenderness: n ylfluid trill: n y succusion splash: n y masses n y (position size)ldescription of feature:lliver: not touched be to

52、uched: subcostal cmldescription of feature:lgallbladder: not touched be touched: size cm tenderness: n y murphys sigh(+) (-) lspleen: not touched be touched: from costal margin cmldescription of feature:lkidney: not touched be touched: size consistency tenderness mobilityltenderness of ureters: n y

53、(position )lpercussion: borders of liver dullness (exist shrink obliteration)lupper border of liver: on right midclavicular line intercostals spacelshifting dullness: n y tenderness in renal region: n y (right left )lauscultation: gurgling sound: normal increased decreased disappearlvessel bruits: n

54、 y (position )lgenitalia: not examined normal abnormal:lrectum and anus: not examined normal abnormal:l spine and extremities:lspine: normal deformities (lateral anterior posterior protruding)lacanthi: tenderness pain at percussion (position ) mobility: normal restrictedllimbs: normal abnormal defor

55、mity swelling of joints joints stiffnessltenderness of muscles atrophy of muscleslvenous distention of lower limbs (position and feature ) acropachylnervous system:lmuscle tone (normal increase paratonia) myodynamia (0 )lparalysis of limbs: n y (left right upper lower)lreflex: abdominal wall reflex

56、(upper middle lower normal abnormal)lbiceps reflex: left (normal abnormal ) l right (normal abnormal )ltriceps reflex: left (normal abnormal ) l right (normal abnormal )lpatellar reflex: left (normal abnormal ) l right (normal abnormal )lachilles reflex: left (normal abnormal ) l right (normal abnor

57、mal )lhoffmann sign: left (+) (-) right (+) (-) babinski sigh: left (+) (-) right (+) (-)loppenheim sigh: left (+) (-) right (+) (-)lkernig sign: left (+) (-) right (+) (-) burdzinski sign: left (+) (-) right (+) (-)l llaboratory findingsl(the important laboratory examinations, x-ray, ecg and other result are included) l lmr. luo, 30 years old, has been suffered from abdominal pain and recurrent melena for more than one year and admitted to hospital on nov 16, 2003. b