英文病历全攻略.docx

英文病历全攻略一、主要调查项目：1. 主诉 chief complaint：weakness, malaise, chills, fever, sleep, pain, headache, appetite, weight, stomach and bowels, nausea and vomiting, diarrhea, urine, genitalia, neuropsychiatric disorders, respiration, shortness of breath, bleeding or discharge, etc.2. 现症历 present illness：onset(date, mode), duration before present entry, exciting cause and environmental influences, prodromal symptoms, general symptoms, course or progress( location, duration, severity, 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：1) former places of residence, previous stage of health( 健壮的 robust ，纤弱的 delicate), experience with similar disease, immunity to infectious disease2) 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 dysentery，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,etc3) venereal disease: specific symptoms, signs, and the disease by name, treatment.4) Accidents( date, any disability, sequelae), operation and hospitalization (date , procedure, name of hospital , physician, complications, bleeding tendency)4. 家族历 family history: family tendency, presence of hereditary disorders, cancer, tuberculosis, mental disorder and nervous affection, rheumatism, diabetes, hypertension, cerebral vascular accident, hemophilia, syphilis, tumor, epilespsy, allergy, contact with diseased individuals, relationship of patient's childhood and adult life, age, health condition, and cause of death of parents, grandparents, self , spouse, siblings , or relatives.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 home2) Marital history: duration of marriage, 1st or 2nd marriage, age and death of spouse and children , cause and age at time of death, number of children , pregnancies, 流产次数 miscarriages, 死产数 stillbirths3) 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, exercise, 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, eczema3) Head: trauma, headache, loss of hair4) Eyes： vision, pain glasses diplopia.5) Ears： pain, discharge, deafness, tinnitus.6) Nose： obstruction, discharge, epistaxis, rhinitis.7) Mouth：teeth, lips, gums, tongue, disturbance in taste.8) Throat.：sore throat, tonsillitis, 脓性扁桃腺炎 quinsy, dysphagia9) Neck：adenitis, goiter , rigidity10) Cardiorespiratory： palpitation, tachycardia, blood pressure, chest pain, dyspnea, cough , hemoptysis , seasonal cold, expectoration.11) Gastrointestinal：appetite, nausea, 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 food12) 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 onset, date of last period, cycle and amount, periodicity , dysmenorrheal, menopause) leucorrhea, associated headache13) Neuromuscular:神经过敏 nervousness, emotional stress, weakness, muscle or joint pains, convulsion, numbness, neuralgia, anesthesia, muscular atrophies or dysatrophies, deformities.二、病历与时态1 .现症历(present 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例 1 ： Both his parents are still living and well.例 2： The patients is getting worse and worse. 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, see, smell等例 1 ： Whenever he has a cold, he can neither taste nor smell.-知识 (knowledge) ： believe, (dis)agree, doubt, find, forget, know, mind, remember, think, understand 等例 1 ： She does not remember 。