头眼耳鼻喉(HEENT)
颈部(Neck) bottled
janet reno胸部与心肺(Chest, Heart and Lungs)
腹部(Abdomen)
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…)
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
pacificoceanMale, 39 year old
CC: 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
广州亚运会主题歌•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)
⏹The cour of ont
•Date of ont
•Mode of ont
•Prodromal symptoms
⏹The cardinal symptoms
⏹The attack of illness
⏹The development of symptoms
⏹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
quester• explosively / suddenly / acutely / abruptly
• gradually / chronically / increasingly / insidiously
• occasionally / accidentally
• often / frequently / in frequency / recurrently
•谢幕的意思 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
