⏹Ca History
⏹Definition
A ca history is a medical record of a patient’s illness. It records the whole medical ca and functions as the basis for medical practitioners to make an accurate diagnosis and propos effective treatment or preventive measures.
Ca histories fall into two kinds:
in-patient ca histories and out-patient ca histories.
⏹Language Features
History and Physical usually involves past ten ( for history of prent illness, past medical history, family history and review of systems concerning past information), and prent ten ( review of system, physical examination, laboratory data, and plans ).
腾达
Structurally, noun phras are frequently ud in physical examination, and ellipsis of subject is very common in review of system.
⏹In-patient Ca Histories
An in-patient ca history is also termed as History and Physical. It is an account of a patient’s prent complaints with descriptions of his past medical history,and the description of the prent conditions as well as physical examinations and impression about the conditions.Format
It usually consists of chief complaint, history of prent illness, past medical history, review of systems, physical examination, impression, family history, social history, medications, allergies, laboratory on admission, and plan. However, what parts are included depends on the needs.
住院病人病历完整模式
病历（Ca History）
(Name) 职业(Occupation)
性别(Sex) 住址(Address)
年龄(Age or DOB) 供史者(Supplier of history)
婚姻(Marital status) 入院日期(Date of admission)
籍贯(Place of birth) 记录日期(Date of record)
民族(Race)
主述(C.C.)
现病史(HPI or P.I.)
过去史(PMH or P.H.)
社会活动史/个人史(SHx or Per.H.)
家族史(FHx or F.H.)
曾用药物(Meds)
过敏史(All)
To be continued
系统回顾(ROS)
体格检查入职感言(PE or P.E.)
体温(T) 呼吸(R)
血压(BP) 脉搏(P)
一般状况(General status)
皮肤黏膜(Skin & mucosa)
头眼耳鼻喉(HEENT)
颈部(Neck)
胸部与心肺(Chest, Heart and Lungs)
腹部(Abdomen)
公司仓库管理方案
肛门直肠(Anus & rectum)
外生殖器(External genitalia)
四肢脊柱(Extremities & spine)
神经反射(Nerve reflex)
To be continued
化验室资料(Lab data)
(Blood test, Chem-7, EKG, EEG, X-ray examinations or X-ray slides, CT and NMR…)
田加偏旁印象与诊断(Impression and diagnosis, or Imp)
住院治疗情况记录(Hospital cour)
出院医嘱(Discharge instructions or recommendations)
出院后用药(Discharge medications)
医师签名(Signature)
⏹Patterns and contents of an out-patient ca history
Contents: general data (GD), chief complaint (CC), prent illness (PI), physical examination (PE), tentative diagnosis (TD) or impression (Imp), treatment (Rp), etc.
An out-patient ca history should be written in brief and to the very point. More abbreviations and noun phras are ud.
⏹Sample of an out-patient ca history
Male, 39 year old
iso9001CC: Fever, headache and cough for two days.
PE: G.C. looks fair. Pharynx congested and tonsils enlarged. Chest and abdomen negative.
Imp: U.R.I.
Rp: Penicillin 400,000u. (i.m.) q.d. x 3 days.
Aspirin 1 tab. t.i.d. x 2 days.
Vit C 100 mg t.i.d. x 3 days
Signature ______
⏹Chief Complaint (C.C.)
⏹1. Sentence patterns in chief complaint
•症状+for+时间
•症状+of+时间+duration
•症状+时间+in duration
•时间+of+症状
•症状+since+时间
⏹Chief Complaint (C.C.)
⏹2. Commonly-ud complaints:
•weakness, malai, chills, fever, pain, headache, naua and vomiting, diarrhea, neuro-psychiatric disorders, shortness of breath, bleeding or discharge, insomnia, stomachache, dyspepsia, no appetite, dysuria, cough, difficulty in coughing up sputum, sore throat, dizziness, palpitation, restlessness, etc. •弱点,不适感,发冷、发烧、疼痛、头痛、恶心、呕吐、腹泻、neuro-psychiatric紊乱、气短、出血或排放、失眠、胃痛,消化不良,没有胃口,排尿困难、咳嗽、咳痰、困难、喉咙痛、头晕、心悸、不安等。
•Prent Illness (P.I.)简明病历书写手册.doc(p.27-35)
油烟机选择
⏹The cour of ont
•Date of ont
•Mode of ont
•Prodromal symptoms
⏹The cardinal symptoms
⏹The attack of illness
⏹The development of symptoms
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⏹Diagnosis and treatment
⏹General condition
⏹Example
⏹Special language structures in prenting prent illness
⏹1. Describing the cour of ont
• … started / began having / feeling …
• … first noticed / noted / perceived / recognized the ont of …
• … are the prodrome of …, … herald …
⏹Special language structures in prenting prent illness
⏹2. Describing the mode and regularity of ont
• explosively / suddenly / acutely / abruptly
• gradually / chronically / increasingly / insidiously
• occasionally / accidentally
• often / frequently / in frequency / recurrently
•昭苏 persistently / intermittently
⏹爆炸性/突然/强烈•/突然
⏹长期/越来越多•逐渐/ /在不知不觉之中
⏹•偶尔/偶
⏹经常/经常在0.9%的频率/的循环
