大三下学期 医学英语ppt课件 生医（case-history-1-Finer）

CaseHistoriesHistoryandPhysicalAnaccountofapatient’spresentcomplaintswithdescriptionofhispastmedicalhistory,andthedescriptionofthepresentconditonsaswellasphysicalexaminationsandimpressionabouttheconditionAimsforStudentsToknowtheformatofthecasehistories;Tounderstandthelanguagefeaturesofthecasehistories;Tomasterthespeciallanguagestructuresofthecasehistories;Toknowhowtowriteacasehistory.ContentsIn-PatientCaseHistoriesASample(P68-69)FormatLanguageFeaturesSpecialLanguageStructures(P56-67)ExercisesOut-PatientCaseHistoriesFormat&LanguageFeaturesChiefComplaint(CC)HistoryofPresentIllnessPastMedicalHistoryReviewofSystems(usu.present,ellipsisofsubjects主语省略)PhysicalExamination(present,nounphrases)Impression(Imp)FamilyHistorySocialHistoryMedicationsAllergiesLaboratoryData(present)Plan(present)ChiefComplaint(CC)

FormallyknownasCCinthemedicalfield,ortermed

PresentingComplaint

(PC)intheUK,formsthesecondstepof

medicalhistorytaking,andisaconcisestatementdescribing:

symptom,problem,

condition,

diagnosis,orotherfactorthatisthereasonforamedicalencounter.patient’sage,abriefbutrelevantpastmedicalhistory,afewwordsaboutwhatproblembringsthepatienttothehospital(preferablequotethepatient),andduratione.g.34-year-oldmalewithadvancedAIDScomplainedofa”badcough”andfeversoverthelast8days.56-year-oldmalewithahistoryofulcerativecolitiscomplainedof3monthsofworseningbackstiffness,2weeksof“asoreonmyleg”,and3daysoffeversandbloody,painlessdiarrhea.ChiefComplaint:Persistentrightpleuralfluid.

ChiefComplaint(CC)HistoryofPresentIllness

Followingthe

chiefcomplaint

in

medicalhistory

taking,a

historyofthepresentillness

(abbreviatedHPI)

(termed

historyofpresentingcomplaint(HPC)intheUK)referstoadetailedinterviewpromptedbythe

chiefcomplaint

or

presentingsymptom

(forexample,

pain).FullsentencesinchronologicalmannerBedescriptivenotanalyticIncludingtheonsetoftheproblem,themanifestationandthetreatment.AttributesofASymptom:location,quantityorseverity,timing(onset,duration,frequency),thesettinginwhichtheyoccur,factorsthathaveaggravated([‘æɡrəveit]make(aproblem,injury,oroffence)worseormoreserious)

orrelievedthesymptom,associatedmanifestations.Pertinentpositives&pertinentnegativesHistoryofPresentIllnessCongestiveHeartFailure

A63-year-oldmalepresentstotheemergencyroomcomplainingofbreathlessnessforthepastthreedays.Cardiachistoryispositiveforamyocardialinfarctionthreeyearsagofollowedbyfour-vesselcoronaryarterybypasssurgery.Thepatienthasbeenasymptomaticsincesurgerywithnocomplaintsofchestpain.OverthelastthreemonthsPTA(priortoadmission

),thepatientnotesonsetofshortnessofbreathwhileunloadinggroceries,walkingstairs,andotherstrenuousADLs(activitiesofdailyliving).HistoryofPresentIllnesse.g.1Twoweeksago,hewasunabletocompletehisdailyone-milewalkatthehighschooltrack.Henotedswellinginhisfeetandankles.FourdaysPTAhewokeat2amshortofbreathandhadtosleepinhisreclinertherestofthenight.Hehasbeenunabletolayflatinbedatnightsincethenandhasslepton3pillows.Yesterday,hebecamebreathlesswalkingfromoneroomtoanother.Hepresentstodaywithextremeshortnessofbreath.Hedenieschestpain.HistoryofPresentIllnesse.g.133yearoldlefthandedwhitemalepresentswith:

1.5weekhistoryofdifficultywithlanguagecomprehension

progressivediffuseheadachewithfatigueandmildnausea

novomitingorphotophobia(extremesensitivitytolight)HistoryofPresentIllnesse.g.2PastMedicalHistory

Childhoodillnesses,suchasmeasles,rubella,mumps,whoopingcough,chickenpox,rheumaticfever,scarletfever(猩红热),polioetc.E.g.Thepatientrecallsonlymumpsandmeaslesaschildhoodillness.E.g.Chickenpoxandmeaslesinchildhood.

Adultdisease,infourcategories:1.Medical,suchas:diabetes,hypertension,hepatitis,asthma,andHIVetc.2.Surgical,suchas:trauma,operation(date,type);3.Ob/Gyn:(obstetrics

and

gynecology)Menstruationhistory(lastmenstruationperiod/ageatmenopause,menstrualcycle,menstrualperiod)Obstetrichistory(pregnancy、deliveryandcomplications,)Sexualfunction;Methodofbirthcontrol,suchasoralcontraceptives,condoms,intrauterinering;4.Psychiatric;PastMedicalHistory[ɔbs’tetrik]

oforrelatingtochildbirthandtheprocessesassociatedwithit[ɡaini’kɔlədʒi]

thebranchofphysiologyandmedicinethatdealswiththefunctionsanddiseasesspecifictowomenandgirls,esp.thoseaffectingthereproductivesystem.

HealthmaintenanceImmunization(historyandrecentimmunization);Screeningtest(过筛试验),suchastuberculintest,stooltestforoccultblood(潜隐血),cholesteroltestetc.PastMedicalHistoryMI(myocardialinfarction)in1996,CABG(coronaryarterybypassgraft

surgery(pronounced"cabbage")4vesselin1996.Vaguehistoryofhypercholesteremia.Surgicalhistoryalsopositiveforinguinal(腹股沟的)herniarepair15yearsprevious.PastMedicalHistorye.g.1PastMedicalHistorye.g.2chroniclymphocyticleukemia

(ROS,alsocalleda

systemsenquiry

or

systemsreview)TheROSisbegunduringtheinitialinterviewwiththepatientandcompletedduringthephysicalexamination,asphysicalfindingspromptfurtherquestions.ReviewofSystemsNOTE:系统回顾中描述的是近期出现或尚处于活动期的疾病或症状，而非很久以前发生的。它的目的是尽量详尽和全面，避免漏掉与现病不相关而忽视的症状、疾病。本部分明确的任何问题，都需要在小结和诊疗计划中作进一步的阐述。在ROS中明确的问题，与现病相关的应放在现病史，既往重大健康事件应放在既往史。ReviewofSystemsGeneral:Usualweight,recentweightchange.Weakness,fatigue,orfever.GENERAL:Nofever,chilles,diaphoresis(出汗）.Shefeelstiredandweak,haslostabout2-3poundsofweightinthelastsixmonths.Skin:drynessorsweating;changesincolor;(regional)Rashes,lumps(肿块),sores,itching;changesinsizeorcolorofmoles(痣);changesinhairornails;SKIN:Hashadsmallnodularswellingundertheskinofarmsformanyyears,notcausinganyproblems.ReviewofSystemsHead,Eyes,Ears,Nose,Throat(HEENT)NeckBreastsCardiovascularGastrointestinalUrinaryGenital……ReviewofSystemsExercise1Restatethefollowingsentenceswiththewordsandexpressionsinbrackets.1.Hehasbeeningoodhealthfromhischildhoodandhashadnohistoryofseriousdisease.

(sound/haveneverbeenill)A.Hehasbeenthoroughlysoundsincehischildhood,andhasneverhadanyseriousdisease.B.Hehasneverbeenillsincehischildhood.Exercise1Restatethefollowingse