英文病历全攻略

1英文病历全攻略一、主要调查项目：1.主诉chiefcomplaint：weakness,malaise,chills,fever,sleep,pain,headache,appetite,weight,stomachandbowels,nauseaandvomiting,diarrhea,urine,genitalia,neuropsychiatricdisorders,respiration,shortnessofbreath,bleedingordischarge,etc.2.现症历presentillness：onset(date,mode),durationbeforepresententry,excitingcauseandenvironmentalinfluences,prodromalsymptoms,generalsymptoms,courseorprogress(location,duration,severity,continuity,intermission,radiation,treatment),aggravatingandalleviatingfactors,lossofweight,appetiteandstrength,sleep,bowelmovement,frequencyofurination,menstruation,etc.3.既往历pasthistory：1)formerplacesofresidence,previousstageofhealth(健壮的robust，纤弱的delicate),experiencewithsimilardisease,immunitytoinfectiousdisease2)previousillness：麻疹measles,腮腺炎mumps,水痘chicken-pox,百日咳pertussis,流行性感冒influenza,猩红热scarletfever,白喉diphtheria，伤寒typhoidfever,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)venerealdisease：specificsymptoms,signs,andthediseasebyname,treatment.4)Accidents(date,anydisability,sequelae),operationandhospitalization(date,procedure,nameofhospital,physician,complications,bleedingtendency)4.家族历familyhistory：familytendency,presenceofhereditarydisorders,cancer,tuberculosis,mentaldisorderandnervousaffection,rheumatism,diabetes,hypertension,cerebralvascularaccident,hemophilia,syphilis,tumor,epilespsy,allergy,contactwithdiseasedindividuals,relationshipofpatient’schildhoodandadultlife,age,healthcondition,andcauseofdeathofparents,grandparents,self,spouse,siblings,orrelatives.5.个人历personalhistory：1)Socialhistory：fears,metalstatus,education,financialcondition,numberofdependents,familyharmonyorfractious,hygienicconditionathome2)Maritalhistory：durationofmarriage,1stor2ndmarriage,ageanddeathofspouseandchildren,causeandageattimeofdeath,numberofchildren,pregnancies,流产次数miscarriages,死产数stillbirths3)occupationalhistory：durationofemployment,pastwork,exactnatureofwork,exposuretooccupationalhazards,whetherworkissatisfactoryornot.4)Habits：alcohol,tobacco,narcotic,coffee,tea,appetite,foodhabits,regularityofmeals,rapidityofeating,bowelmovements,sleep,exercise,interests,etc.6.系统检查systemreview：1)General：nutrition,fever,nightsweats,tremor,weightgainorloss,weakness,allergy.2)Skin：荨麻疹hives,rash,eczema3)Head：trauma,headache,lossofhair4)Eyes：vision,painglassesdiplopia.5)Ears：pain,discharge,deafness,tinnitus.6)Nose：obstruction,discharge,epistaxis,rhinitis.27)Mouth：teeth,lips,gums,tongue,disturbanceintaste.8)Throat.：sorethroat,tonsillitis,脓性扁桃腺炎quinsy,dysphagia9)Neck：adenitis,goiter,rigidity10)Cardiorespiratory：palpitation,tachycardia,bloodpressure,chestpain,dyspnea,cough,hemoptysis,seasonalcold,expectoration.11)Gastrointestinal：appetite,nausea,vomiting,distress(beforeoraftermeals),melena,colic,jaundice,fullness,hernia,hemorrhoid,constipation,diarrhea,frequencyofbowelmovement,heartburn,idiosyncrasies,relationofsymptomstoeating,typeandquantityoffood12)Genito-urinary：dysuria,urinaryfrequency,dribbling,hematuria,pyuria,nocturiaandvolume,enuresis,incontinence,soresaboutexternalgenitalia,symptomssuggestiveofsyphilis(mucouspatches,fallinghair),urethraldischarge,exposuretovenerealinfection,obstetrichistory,catamenia(ageofonset,dateoflastperiod,cycleandamount,periodicity,dysmenorrheal,menopause)leucorrhea,associatedheadache13)Neuromuscular：神经过敏nervousness,emotionalstress,weakness,muscleorjointpains,convulsion,numbness,neuralgia,anesthesia,muscularatrophiesordysatrophies,deformities.二、病历与时态1．现症历(presentillness)：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：Sedentaryhabitsofteninterferewithhealth例2：Heismentallyderangedanddisorientedastotime,place,andperson例3：Hegetsupat6everymorning.B.现在进行式（Be+pres.p.）表示现在某动作正在进行中。例1：Bothhisparentsarestilllivingandwell.例2：Thepatientsisgettingworseandworse.例3：Thepatientsisprogressivelydoingwell.C.表「经常的习惯」也用进行式，通常与always,constantly等副词连用。例1：Heisalwaystakinganapinclass.例2：Heisconstantlyforgettingpeoples’names.例3：Heisforevercomplainingofheadaches.D.通常不用进行式的动词。a)不随意动词(Verbsofinvoluntaryactions)：-知觉(perception)：feel,hear,notice,see,smell等。例1：Wheneverhehasacold,hecanneithertastenorsmell.-知识(knowledge)：believe,(dis)agree,doubt,find,forget,know,mind,remember,think,understand等。例1：Shedoesnotrememberspecificscratcheswhichmighthaveprecededthepresentlesions.-感情(emotion)：desire,despise,disgust,fear,hate,hope,(dis)like,love,prefer,want等。例1：Helikeslobster,butitdisagreeswithhim.b)表示继续状态的动词(Verbsofcontinuousstate)：表示存在、所有等动词：appear,be,belong,consist,flow,have,hold,live,look,possess,resemble,seem等。例1：Herfingersandhandsarestiffandcyanotic.例2：Hehasnodiscomfortandeatswell.2)A.现在完成式(Have+p.p)a)表示动作的完了(completionofanaction)或其结果的现在状态(presentstateofthings)：3例1：Thepatienthaspassedthecrisis.=Thepatientisoutofdangernow.例2：Hehascaughtcold.=Hehasacoldnow.注：常用的连用副词为：allthiswhile,(not)yet,already,just,now,bythistime,today,thisweek(ormonth,year,etc.),hitherto,tillnow,upto(till)now,recently,lately,oflate等。比较：过