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1、医学英语病历书写重点Case History 病史 n In-Patient Case History 住院病历 Items of Case History 1. General Data, Biographical Data 一般项目 2. Chief Complaints (C. C.) 主诉 3. Present Illness (P. I.) 现病史 4. Past (Medical) History (P. H.) 既往病史 5. Personal History (Per. H.)/ Social History 个人史/社会史 6. Family History (F. H.)
2、家族史 7. Medications 曾用药物 8. Allergies 过敏史 9. System Review, Review of Systems 系统回顾 10. Physical Examination (P. E.) 体格检查/查体 11. Laboratory Data 实验室与其他检查/检查资料 12. Impression (Imp.) (Diagnosis) 诊断 13. Hospital Course 住院治疗情况记录 14. Discharge Instructions/ Recommendations出院医嘱 15. Discharge Medications 出院后
3、用药 General Data, Biographical Data 一般项目 nReliability (病历可靠性): Reliable(可靠)/ Not Entirely(不完全可靠)/ Not Clearly Defined (不够准确)/ Confused and Uncertain (混乱不清)/ Unobtainable (无法获得) nSupplier/ Complainer of History (供史者/病史陈述者): Patient/ Husband/ Wife/ Father/ Mother/ Colleague/ Neighbor Chief Complaints (
4、C. C.) 主诉: 病例重要部分之一，通常包括患者年龄、简要的相关的既往史、患者的就诊原因及目前症状持续的时间等。 nLanguage Characteristics 1) Common expressions symptom+since+time(时间点) symptom+for+time(时间段) symptom+of+time (时间段名词所有格)+duration symptom+time(时间段)+in duration time(时间段合成词)+history+of+symptom complete sentence: The duration of +symptom+was/
5、has been+time(时间段) 2) Common sentence patterns for chief complaints was admitted/seen with a chief complaint of complain chiefly of presented/entered with/came to the office with a chief complaint of was admitted because of was involved in was transferred tobecause 下面是书写主诉是最常用的格式： CC：The patient is
6、a (age)-year-old (race,ethnic,group,occupation,sex and/or very pertinent PMH),who is admitted to the hospital with a chief complaint of (symptom,not a sign or diagnosis) of (number followed by a unit of time) duration. Example 主诉：患者是一个48岁的妇女。入院主诉，6个月来，出力后心悸和呼吸困难。 CHIEF COMPLAINT: The patient is a 48
7、-year-old female, admitted with the chief complaint of palpitation and dyspnea following physical exertion for 6 months. History of Present Illness 现病史：是从医生的角度，进一步表述主诉内容，全面表述现有疾病的发病时间、主要症状、病情发展过程、症状间的联系、诊疗过程、目前患者身体状况、与现有疾病有直接关系的既往史等。记录患者入院情况时，多用一般过去时或过去完成时；记录目前病情时，用一般现在时或现在完成时。 nLanguage Characteris
8、tics 1) Sentence Patterns with Patients to Be Subject 以病人做主语的句型 start having 开始有的症状 begin having episodes of 开始发生的症状/疾病 become 变得 notice(perceive, note, recognize)+症状/疾病 have 有症状/疾病 have abrupt/sudden/explosive onset of 突然患 have episode of/have attack of患 develop+disease 出现/有了症状/疾病 are/is the prodro
9、me of 的前驱症状 2) Sentence with symptoms, illnesses as subjects 以症状、疾病做主语的句型 begin (occur, start)+time 从开始 date (go back) to +time 可追溯到 be present+time 在/从已存在 be preceded by 在之前已有 be followed by 在之后紧接着发生 be accompanied by/ coincide with 与同时发生 be (not) related to/have (no) correlation with 与有关 3) Illnes
10、s improving and worsening 表达疾病的好转与恶化 last+time 持续时间 take a bad turn; take a turn for the worse; be aggravated/exacerbated; become worse 恶化 take a good turn/take a turn for the better/improve 好转 be aggravated/abated/alleviated by 因而加剧/减轻 remain the same/unchanged 无变化 be (not) improved after treatment
11、 with 经用治疗而好转 (The symptom) cease/clean up/disappear/subside 症状消失/减退 4) No symptoms 没发生症状、疾病 without/with no/free of (symptoms) There be no history of/have no history of (The patient) denies (The patient) noted no (The patient) was not found to be 5) Description of main symptoms 描述主要症状 assume the ch
12、aracter of/be characterized by have/present/develop/show/manifest the symptoms of Past (Medical) History (P. H.)既往病史 nCommon expressions had been sound/well until; had enjoyed good health until 在前一直健康 be apt/liable/subject to;tend to have 易患 was admitted to hospital for/ was hospitalized for 曾因而住院 h
13、ad (some illness) with recovery after 曾有，因痊愈 was diagnosed as/was suspicious of 断为/疑为 was exposed to (toxic substances)/ had to breathe (poisoning gases) 接触/吸入 was inoculated against接种过 was discharged/ dismissed from hospital/ was out of hospital出院 Personal History (Per. H.)/ Social History 个人史/社会史
14、nNote: menstruation 经期 menstrual period menarche ageage of menopause 月经周期 nCharacteristics of language nCommon expressions Declarative sentences and elliptical sentences are usually used, and present tense, past tense and past perfect tense are adopted. Family History (F. H.) 家族史 be living and well.
15、/be in good health./ be well with no evidence of (illness). 健在 (There is) No family history of (disease)./ (There was) No (disease) in ones family. 无家族史 There was no case of (disease) in his/her family./ No one in his/her family experienced (disease) 家族成员未曾患过 Family history showed/revealed 家族史显示 The
16、re was a familial/hereditary tendency to/ There was a strong family history of/ There was a high incidence ofin the family. 家族有倾向/发病率 There was a high prevalence ofin the family 家族中患病率高 Positive for (some disease) in (some one). 曾患过 as a family characteristic. 家族特点 FH: Noncontributory 家族史无意义 Allergi
17、es 过敏史 nCommon expressions NKDA (no known drug allergies) 无过敏史 allergy, allergic, hypersensitive, hypersensitivity 过敏 sensitive, sensitivity, sensible, sensibility 敏感 allergic reaction 过敏反应 be allergic to 对过敏 be sensible to 对敏感 have no history of allergy to; have no history ofsensibility 对有过敏史 have
18、an allergic diathesis 具有过敏体质 have no allergic reaction to any drugs 对用过的药物无过敏反应 show sensibility to(e.g. house dust) 对过敏 Physical Examination (P. E.)体格检查，查体 1) Physical data/physical signs 一般资料/生理指标 2) General appearance 一般情况或全身状态 3) Head, eyes, ear, nose and throat (HEENT) 头眼与耳鼻喉 4) Chest, heart an
19、d lungs 胸部与心肺 5) Abdomen 腹部 6) Extremities 四肢 7) Nervous system, neurological (CNS/Neuro) 神经系统 8) Musculoskeletal 骨骼肌肉系统 9) Genitourinary 泌尿生殖系统 Physical data/physical signs 一般资料/生理指标 Temperature (T.) 体温 position: oral temperature 口温； axillary temperature 腋温； rectal temperature 肛温 unit: Celsius, ; F
20、ahrenheit, Format: T 38 (or 100.4 ) Pattern: The temperature is 38 (or 100.4 ) taken by mouth/ by rectum/ by axilla. Pulse (P.) 脉搏 Format: P 80/min (or P80) Pattern: Pulse 80 per minute. The pulse numbered/beat/measured 80/min. Respiration/ Respiratory Rate (R.) 呼吸 Format: R 20/min Common expression
21、s: The respirations are 21 per minute.呼吸每分钟21次。 The examination showed no dyspnea at rest with respiratory rate of 20/min. 体检显示安静时无呼吸困难，呼吸率每分钟20次。 Blood Pressure (B. P.) 血压 Format: BP 16/10.5 kpa 血压16/10.5千帕 BP 150/95 mmHg 血压150/95毫米汞柱 BP stabilizes atkpa(mmHg) 血压稳定在千帕 BP fluctuates/ranges betweenan
22、d 血压波动在与之间 rise/drop fromto 由升/降到 Common expressions: Physical examination revealed his/her BP of 7.3/10.7kpa when sitting. 体检测知他的血压为7.3/10.7千帕。 Heart Rate (H. R.) 心率 Format: HR 80/min Heart Rate: 80 per minute 心率每分钟80次 Cardiac Rhythm 心律 General appearance一般情况或全身状态 Height (Ht.) Body Weight (BW/Wt.)
23、complexion 面色； appearance 面容； expression 面部表情 mental state 神态； consciousness 意识； senses 感觉 nutrition 营养状况 well-nourished 营养良好； moderately nourished 营养中等 ill-nourished/malnourished/malnutrition/poorly-nourished/under-nourished 营养不良 fat/obese 肥胖 lean/emaciated/thin/underweight 消瘦 Laboratory Data 检查资料
24、nBlood test nUrinalysis nElectrocardiogram (ECG) nElectroencephalogram (EEG) nX-ray examination and X-ray slides X光检查及X光片 nComputerized X-ray tomography (CT) 计算机X线断层扫描 nMagnetic resonance imaging (MRI)/Nuclear magnetic resonance imaging (NMRI) 磁共振成像 nOther lab data 其他检验资料 nOut-Patient Case History 门
25、诊病历 Items of Case History 1. General Data, Biographical Data 一般项目 2. Chief Complaints (C. C.) 主诉 3. Present Illness (P. I.) 现病史 (4. Past (Medical) History (P. H.) 既往病史) 5. Physical Examination (P. E.) 体格检查，查体 6. Impression (Imp.) (Diagnosis) 诊断 7. Treatment 治疗 Case Report 病例报告 病例报告是医学论文的一种常见文体，通过对一两
26、个具体的病例的记录和描述，在疾病表现、机理以及诊断治疗等方面提供第一手感性资料的医学报告。因此，病例报告应具有以下三个特点：1）罕见，尤其是首次发现；2）病程曲折，有异常现象；3）在诊断和治疗的方法上有创新、在医术研究上有价值。 病例报告的结构主要有三部分： 引言或摘要、主要部分的写作要求 1、 引言：病例报告的引言主要说明病例报告的对象、目的及意义，语言应尽量简明扼要。如：Malignant disease should be remembered in the differential diagnosis of common rehumatological disorders.We pre
27、sent a patient whose pain proved to be due to malignant disease and not to simple trochanteric bursitis. 2、 病例介绍：病例报告中的核心部分之一，包括病人的年龄、性别、病史、诊断及治疗等内容，必要时还要详细说明常规检查结果、术后或药物治疗后的临床过程;如果报道多个病例，应分别列出Case 1、Case2等。病例介绍大致分为以下部分：1、基本情况介绍、语言特点 1、 病例报告的题目要尽量反映病例的特异和罕见，或突出新经验的独到之处，可供临床借鉴。 2、 必须简明扼要，既要摒弃繁琐叙述，又要说
28、明诊断依据，突出本例特色，提供必要的实验室检查资料。 3、 病例描述多用一般过去时，引言和讨论部分多用一般现在时。 示例 Case Report 出院总结 Discharge Summary 如住院病例一样，在书写格式上要求不甚严格，但是总体内容基本一致。首先对患者的基本情况进行描述，然后记述病人的住院过程、出院小结、出院后用药及医嘱。 (一）、住院过程、出院诊断、出院后用药、出院医嘱（Discharge Plan/Instruction) 这一部分记述医生对患者提出的出院后注意事项、治疗方案、复诊安排等。如： Discharge Plan/Instruction： The patient was told to avoid catching cold and to rest for two-off days. 示例
