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CASEHISTORY病历•病历(CaseHistory)•记载某个病例的症状、体征、各种检查结果、某些个人因素、社会因素、诊断、治疗及转归的过程、CaseHistoryincludes•1.GeneralData/BiographicalData•2.CC•ChiefComplaint•3.HPIorPI•HistoryofthePresentIllness•4.PMHorPH•Past(Medical)HistoryCaseHistoryincludes•5.FH•FamilyHistory•6.Per.H•PersonalHistory•7.Meds•MedicationCaseHistoryincludes•8.All•Allergies•9.ROS•ReviewofSystems•10.PE•PhysicalExamination•11.Lab/Data•LaboratoryandData•12.Assessment/Impression/Summary•13.Plan1.GeneralData(一般项目)Name:AprilAndrewSex:FemaleRace:CaucasianAge:31Religion:R.CRomanCatholicDateofBirth:06-10-1975Complainer:PatientMaritalStatus:MarriedReliability:ReliableOccupation:HousewifeDateofAdmission:02-14-2006Address:35FruitStreet,BostonTimeofrecord:02-14-2006,2:10amCC常用句型•Wasadmittedwithachiefcomplaintof•Wasseenintheofficecomplainedchieflyof•主诉:患者入院主诉严重腹痛,并伴有呕吐两天。ChiefComplaint:Thepatientwasadmittedwithachiefcomplaintofatwo-dayhistoryofsevereabdominalpainandvomiting•主诉:患者首次就诊时主诉寒战、视力模糊和呼吸困难一天•ChiefComplaint:Thepatientwasadmittedforthefirsttimewithchiefcomplaintofchills,blurredvisionanddifficultyinbreathingofoneday’sduration.•主诉:患者主诉柏油样大便三天,每天三次。•ChiefComplaint:Thepatientcomplainedchieflyofblacktarrystoolsofthreedays’durationwiththreetimesaday.常用表达方式:•症状+for+时间,e.g.Sorethroatforthreedays.•症状+since+时间,e.g.Coughingandfeversinceyesterday.•症状+时间+induration,e.g.Headachewithnauseaandvomitingtwomonthsinduration.P.I.常用句型•Have/present/develop/show/manifestthesymptomsof•她出现了慢性支气管炎的轻微症状。•Shemanifestedmildsymptomsofchronicbronchitis.•hadabrupt/sudden/explosiveonsetof•他的下腹部突然发生绞痛。•Hehadanexplosiveonsetofcolicpaininhislowerabdomen.好转improve/takeafavorableturn/takeaturnforthebetter恶化Worsen/takeanunfavorableturn/takeaturnfortheworse保持remainthesame/persistwithoutchange•之前beprecededby•呕吐前,脸色苍白,大汗淋漓。•Thevomitingwasprecededbypalloradprofusesweat.•之后befollowedby•感到不适后就失眠。•Thediscomfortwasfollowedbyinsomnia.•伴随beaccompaniedby/beassociatedwith•咳嗽伴有咳血和胸痛•ThecoughwasaccompaniedbyhemoptysisandchestpainPresentillness不完整电报式子句•Highfeverupto39°C,suddenonset,slightdizziness(+);poorappetite(+).VisitedDr.Chen’sclinic(Address:…,Tel#:…)dailyfor3days,IVinjectiondailyandtwokindsoft.i.d.tablets;noimprovement.•Muscleache(+),generalized,severe;•Drycough,dyspnea,sincethismorning;rapidlyprogressive.CametoER.Neededoxygenrightaway.•Nourinary,orrespiratorysymptoms.nausea(+)P.H常用句型hadbeensound/well/healthy/normaluntil•患者在此病发作前,身体非常健康。•Thepatienthadbeensounduntilhehadanexplosiveonsetofpresentillness.•deniedanyhistoryof•deniedexperiencing•病人说他没患过心血管疾病。•Thepatientdeniedexperiencingcardiovasculardiseases.•wasdiagnosedashaving•wassuspiciousof•当时,他的病诊断为癫痫。•Atthattime,hewasdiagnosedashavingepilepsy.•在上次复查中,x线胸片上发现多发性损伤,疑为肺外肿瘤。•Duringthefollow-upexam,multiplelesionswerefoundonachestroentgenogram,whichweresuspiciousofanextrapulmonarytumor.•既往史:患者在这次病前身体健康,无任何手术史。无过敏史。一次妊娠,正常自然分娩。•PastHistory:Thepatienthadbeenhealthyuntilthepresentillness.Nosurgicalprocedures.Noallergies.Onepregnancywithnormalspontaneousdelivery.FH•家族史:患者自诉外祖母有类风湿性关节炎。•FamilyHistory:Thepatientadmitsafamilyhistoryofrheumatoidarthritisassociatedwithmaternalgrandmother.•疾病名称:•痴呆症:dementia•结核病:tuberculosis•慢性肠胃病:chronicgastrointestinaldiseases•性传染病:sexuallytransmitteddisease•冠心病:coronaryheartdiseaseFH常用句型•Familyhistoryshowed/revealed他的父母都患过结核病。•Familyhistoryshowedtuberculosisinbothofhisparents.•Positivefor(somedisease)insb•他祖父患过心力衰竭。•Positiveforheartfailureinhisgrandfather.Per.H•1.LifestyleandHabit:smoking,drinking,drug-taking•2.OccupationandWorkingconditions•3.Travelling(LocalDiseasesorInfectiousDiseases)•4.MarriageandChild-bearing•5MenstruationPer.H•个人生活史:患者否认吸烟、饮酒史,否认非法药物服用史或性传播疾病史。•PersonalHistory:ThepatientdeniesalcoholuseandillegaldruguseaswellasSTDhistoryandtobaccouse.•Havenormal/regularperiodthatlast….•这妇女经期正常,周期28天,行经4天。•Thewomanhasnormalperiodevery28daysthatlasts4days•Havea….Delivery/labor•该妇女自然分娩(难产、早产、习惯性早产)•Thewomanhadaspontaneousdelivery.•Adifficultydelivery•Prematurelabor•Habitualprematuredelivery•个人史:患者是一名退休教师。无儿女,和妻子相处很好。他否认有饮酒和吸毒的嗜好。偶有抽烟。•PersonalHistory:Thepatientisaretiredteacher.Havingnochildren,heandhiswifegetonwellwitheachother.Hedeniesintakeofalcoholordrugs,butadmitsoccasionalsmoking.Meds•患者目前服用阿莫西林-克拉维盐酸咀嚼片(125mg-31.25mg).•Amoxicillin-clavulanate•Chewabletablet•Thepatientiscurrentlytakingamoxicillin-clavulanate125-31.25mgchewabletablet.All•过敏史:患者自述对阿司匹林过敏,表现为胃肠道不适。•Allergies:ThepatientadmitsallergiestoaspirinresultinginGIupset.All•Beallergicto•他对青霉素过敏。•HeisallergictopenicillionROS•Head:Thepatienthasoccasionalfrontalheadaches,relievedbyaspirin.•头:偶有前额头痛,服阿司匹林缓解ROS•呼吸系统:素有慢性轻咳史,多发生在天凉时。•Respiratorysystem:Sheusuallyhadaslightchroniccough,especiallyincoldweather.•消化系统:童年时期常有腹痛发作及便虫史。药物驱虫后,发作性腹痛消失。•Digestivesystem:Frequentattacksofabdominalpainoccurredduringherchildhoodaccompaniedbythepassageofwormsinherstools.Theseattackssubsidedwhenwormswereexpelledwithmedication.•循环系统:偶有心悸及睑、面水肿,无呼吸困难。•Circulatorysystem:Sheoccasionallyhadpalpitationandedemaoftheeyelidsandfacebutnodyspnea.泌尿系统:婚后曾发作一次尿急、尿频、尿痛。Urinarysystem:Sheoncehadanurgencyandfreq
本文标题:casehistory.
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