英文病历全攻略
一、主要调查项目：
1.主诉chief complaint：weakness, malai, chills, fever, sleep, pain, headache, appetite, weight, stomach and bowels, naua and vomiting, diarrhea, urine, genitalia, neuropsychiatric disorders, respiration, shortness of breath, bleeding or discharge, etc.
2.现症历prent illness：ont(date, mode), duration before prent entry, exciting cau and environmental influences, prodromal symptoms, general symptoms, cour or progress( location, duration, verity, continuity, intermission, radiation, treatment), aggravating and alleviating factors, loss of weight, appetite and strength, sleep, bowel movement, frequency of urination, menstruation, etc.
3.既往历past history：
李皮1)former places of residence, previous stage of health( 健壮的robust，纤弱的delicate), experience with similar dia, immunity to infectious dia
2)previous illness：麻疹measles, 腮腺炎mumps, 水痘chicken-pox, 百日咳pertussis, 流行性感冒influenza, 猩红热scarlet fever, 白喉diphtheria，伤寒typhoid fever, 支气管炎bronchitis, 肺炎pneumonia，脑炎encephalitis,脑膜炎meningitis，破伤风tetanus,小儿麻痹poliomyelitis,赤痢dyntery，霍乱cholera, 胸膜炎pleurisy,天花small-pox，疟疾malaria,结核病tuberculosis，黄疸病jaundice，过敏性反应allergy,etc
3)venereal dia：specific symptoms, signs, and the dia by name, treatment.
4)Accidents( date, any disability, quelae), operation and hospitalization (date , procedure, name of hospital , physician, complications, bleeding tendency)
4.家族历family history：family tendency, prence of hereditary disorders, cancer, tuberculosis, mental disorder and nervous affection, rheumatism, diabetes, hypertension, cerebral vascular accident, hemophilia, syphilis, tumor, epilespsy, allergy, contact with diad individuals, relationship of patient’s childhood and adult life, age, health condition, and cau of death of parents, grandparents, lf , spou, siblings , or relatives.谢鸣
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5.个人历personal history：
1)Social history：fears, metal status, education, financial condition, number of dependents, family harmony or fractious , hygienic condition at home
2)Marital history：duration of marriage, 1st or 2nd marriage, age and death of spou and children , cau and age at time of death, number of children , pregnancies, 流产次数miscarriages, 死产数 stillbirths
黑娃结局3)occupational history：duration of employment, past work, exact nature of work, exposure to occupational hazards, whether work is satisfactory or not.
4)Habits：alcohol, tobacco, narcotic, coffee, tea, appetite, food habits, regularity of meals, rapidity of eating , bowel movements, sleep, exerci, interests, etc.
6.系统检查system review：
1)General：nutrition, fever, night sweats, tremor, weight gain or loss, weakness, allergy.
2)Skin：荨麻疹hives, rash, eczema
3)Head：trauma, headache, loss of hair
4)Eyes：vision, pain glass diplopia.
5)Ears：pain, discharge, deafness, tinnitus.
6)No：obstruction, discharge, epistaxis, rhinitis.
玩核桃7)Mouth：teeth, lips, gums, tongue, disturbance in taste.
8)Throat.：sore throat, tonsillitis, 脓性扁桃腺炎quinsy, dysphagia
9)Neck：adenitis, goiter , rigidity
10)Cardiorespiratory：palpitation, tachycardia, blood pressure, chest pain, dyspnea, cough , hemoptysis , asonal cold, expectoration.
11)Gastrointestinal：appetite, naua, vomiting, distress(before or after meals), melena,
colic, jaundice, fullness, hernia, hemorrhoid, constipation, diarrhea, frequency of bowel movement , heartburn, idiosyncrasies, relation of symptoms to eating, type and quantity of food
12)Genito-urinary：dysuria, urinary frequency, dribbling , hematuria, pyuria, nocturia and volume, enuresis, incontinence, sores about external genitalia, symptoms suggestive of syphilis(mucous patches, falling hair), urethral discharge, exposure to venereal infection, obstetric history, catamenia(age of ont, date of last period, cycle and amount, periodicity , dysmenorrheal, menopau) leucorrhea, associated headache
13)Neuromuscular：神经过敏nervousness, emotional stress, weakness, muscle or joint pains, convulsion, numbness, neuralgia, anesthesia, muscular atrophies or dysatrophies, deformities.
时不与我二、病历与时态
小对象1．现症历(prent illness)：
1)A.现在式：表示一般的真理、职业、人格、习惯和现在的事实、动作或状态。
例1：Sedentary habits often interfere with health
例2：He is mentally deranged and disoriented as to time, place, and person
例3：He gets up at 6 every morning.
B.现在进行式（Be+ pres. p.）表示现在某动作正在进行中。
拍马屁的成语例1：Both his parents are still living and well.
例2：The patients is getting wor and wor.
例3：The patients is progressively doing well.
C.表「经常的习惯」也用进行式，通常与always, constantly等副词连用。
例1：He is always taking a nap in class.
例2：He is constantly forgetting peoples’ names.
例3：He is for ever complaining of headaches.
D.通常不用进行式的动词。
a)不随意动词( Verbs of involuntary actions)：
-知觉( perception)：feel, hear, notice, e, smell等。
