英文病例汇报常用体格检查术语
1、肋骨和软组织[ribs and soft tissure]
?胸骨上切迹[suprasternal notch]
?浮肋[free ribs]
?胸壁[chest wall]
?扁平（桶状、佝偻、漏头、鸡）胸[flat (barrel,rachitic, funnel, pigeon) chest] ?皮下气肿[subcutaneous emphysema]
?捻发音[Crepitus]
?佝偻病串珠[rachitic rosary]
?软骨病[chondrosteoma]
?脂肪瘤[lipoma]
?软骨发育不全[achondroplasia (chondrodysplasia)]
?软组织损伤[soft tissue injury]
?肋骨畸形[abnormality of the ribs(rib deformity, costal anomaly)]
?肋骨串珠（错位）[beading (displacement) of rib]
?肋软骨畸形[costochondral deformity]
?肋软骨增生[costal cartilage hyperplasia]
?肋下切口[subcostal incision]
?肋间隙宽（窄）[wide (narrow) intercostal space]
2、乳房[breast]
?对称性[symmetry]
?乳头内陷（内缩）[crater (retracted) nipple]
?乳头皱裂[cracked nipple]
?乳头偏斜（抬高）[nipple skewness(elevation)]
?乳头溢液[nipple discharge]
?乳头脓肿（溃疡、血肿）[abscess (ulcer, hematoma) of nipple]
?乳头过小[hypomastia]
?乳斑[milk spots]
?乳房潮红[breast flush]
?乳房出血[mastorrhagia]
?乳房过早发育[premature thelarche]
?乳房肿胀（脓肿）[mammary swelling(abscess)]
?乳房湿疹[eczema mammae]
?乳房下垂[mastoptosis (pendulous breast)]
?乳房萎缩[mastatrophy]
?巨乳[macromastia]
?乳晕[mammary areola]
?乳房硬化[zaranthan]医.学.全.在线.网.站.提供
?异常泌乳[abnormal lactation]
?男子女性化乳房[gynecomastism]
?乳房皮肤红肿[erythroswelling of mammary skin]
?乳房桔皮征[mammary orange-peel sign]
?乳记局限性凹陷[mammary localized pitting]
?乳房瘘管[breast fistula]
?正常女性乳房[normal female breasts]
?无压痛性肿块[nontender mass]
3、肺[lung]
?呼吸缓慢（急促）[bradypnea (tachypnea)]
?呼吸浅慢（深快）[hypopnea (hyperpnea)]
?呼吸不规则[irregular respiration]
?点头呼吸[nodding breathing]
?端坐呼吸[orthopnea]
?三凹征[retraction sign of three fossae]
?叹息样呼吸[sighing respiration]
?浅快[shallow and rapid]
?呼（吸）气性呼吸困难[expiratory (inspiratory) dyspnea]
?呼吸道烧伤（塌陷）[burn (collapse) of respiratory tract(airway)]
?呼吸道阻塞[respiratory tract obstruction]
?呼吸均匀（呼吸加深或加快）[eupnea(exaggerated or acclerated respiratory)]
?呼吸停止[apnea]
?呼吸费力[respiration is labored]
?语音（触觉）震颤[vocal (tactile) fremitus]
?语颤相等（减弱、增强）[vocal fremitus is equal(diminished, accentuated)]
?间接（直接）叩诊[mediate (immediate) percussion]
?浊（实、鼓、清、过清、金属）音[dullness (flatness, tympany, vesicular resonance, hyperresonance, bell)]
?移动范围[range of movement]医学.全.在线.网.站.提供
?呼吸音消失（减弱，增强）[absence (diminution, exaggeration) of breath sound]
?呼吸音粗（清）[sound of breath(SOB) is rough (clear)]
?支气管（支气管肺泡，肺泡）音[bronchophony (bronchovesicular sound, vesicular sound)] ?管状呼吸音[tubular breath sound]
?捻发音[crepitantrales]
?爆裂音[crackles]
?干（湿）罗音[dry (moist) rales]
?细（中等、粗）罗音[fine (medium, coarse) rales]
?呼（吸）气未罗音[end-inspiratory (expiratory) rales]
?胸膜摩擦音[pleural friction rub]
?呼（吸）气延长[prolonged inspiratory (expiratory)]
?高（低）调鼾音[sibilant (sonorous) rhonchi (sonorous rales)]
?哨笛音[sibilant rales]
?哮鸣音[wheezing]
?小（中、大）水泡音[small(middle, big) bubbles]
?支气管语音[bronchophony]
?耳语音[whispered]
?羊鸣音[egophony]
?高（低）音调[high (low)-pitched]
?两肺部（右背部）[over both lung fields (right back)]
?两（左）肺底[over the both (left) lower lung]
?整个肺野[the whole lung field]
?左（右）上（下）肺[the left (right) upper (lower) lung]
?肺尖（底）[apex (base) of lung]
4、心脏[Heart]
?用手掌（指尖）触诊心尖搏动[palpate apical area with palm(fingertips)]
?心前区隆起（凹陷）[precordial bulge (retraction)]
?搏动弥漫（局限）[diffuse (local) pulsation]
?负性搏动[inward inpulse]
?心尖搏动[apex beat (apical impulse)]
?剑突下搏动[xiphoideusalpulsaton]
?抬举性心尖搏动[heaving apex impulse]
?心尖搏动最强点[point of maximal impulse (PMI)]
?锁骨中线[mid-calvicular line (MCL)]
?肋间[intercostal space (ICS)]
?收缩（舒张）期震颤[systolic (diastolic) thrill]
?心浊音界[the border of cardiac dullnes]
?心绝对（相对）浊音界扩大（缩小）[enlarged (diminished) absolute (relative) cardiac dullness]
?叩诊心脏大小正常[heart size is normal on (to) percussion]
?心脏向左（右）扩大[cardiac dilation (enlargement) to the left (right)]
?第1（2、3、4）心音[S1(S2,S3,S4)]
?第1心音增强（减弱，听不清）[first heart sound is exaggerate (decreased, muffled)] ?生（病）理性杂音（分裂）[physiologic (pathological) murmur (splitting)]
?生理性（固定、反常、逆）分裂[physiologic (fixed, paradoxical, reversed) splitting] ?肺动脉瓣第2心音>(=，<)主动脉瓣第2心音[P2>(=，<)A2]
?大炮音[connon sound]
?心音消失[heart sound is absent (disapeared)]
?心音增强（减弱）[accentuated (diminished) cardiac sound]
?心音响亮（遥远）[cardiac sound is loud (distant)]
?收缩期（舒张期，连续性）杂音[systolic (diastolic, continuous) murmur]
?收缩（舒张）前（中、晚）期杂音[pre-(mid-, post) systolic (diastolic) murmur]
?全收缩期的[holosystolic(pansystolic)]
?全舒张期的[holodiastolic (pandiastolic)]
?低（高）音调[low (high) pitched]
?递减（递增，递减-递增）性杂音[decrescendo (crescendo, decrescendo-crescendo)murmur] ?呈喷射型[be ejection in type]
?Ⅳ级喷射型收缩期杂音[grade Ⅳ(I-Ⅳ/6) systolic ejection murmur]
?吹风样杂音[murmur of puffing character]
?低音调隆隆样[low-pitched rumbling quality]
?柔和（粗糙）的[soft (harsh or rough)]
?吹风样（喷射性、隆隆样、沙沙声样、搔抓声样、机器声样、汽笛声样、倒水声样）杂音[blowing (ejection, rumbling, rustting, scratching, machinary, whistling, pouring )murmur]
?功能性（器质性）杂音[functional (organic) murmur]
?血管（静脉）杂音[vascular (venous) murmur]
?枪击音[pistol shot sound]医学全.在线网.站.提供
?静脉营营音[venous hum]
?奔马律[gallop rhythm]
?胎心律[embryocardia]
?心律齐（不齐）[regular (irregular) rhythm]
?心律不齐[arrhythmia]
?二（三）联律[bigeminy (trigeminy)]
?早搏[premature (extrasystol)]
?喀嗽音[click]
?钟摆律[pendular rhythm]
?二尖瓣开瓣音[mitral opening snap]
?心包摩擦音[pericardial friction sound]
?听诊[on auscultation]
?二尖瓣（主瓣，肺瓣，三尖瓣）听诊区[mitral (aortic, pulmonary, tricuspid) valve area] ?心包叩击音[pericardial knock]
?肿瘤扑落音[tumor plop]
5、腹部[abdomen]
?腹（妊娠）纹[abdominal striae (striaegravidarum)]
?腹膨隆[abdominal distention (prominence)]
?腹平坦（凹陷）[abdominal flatness (retraction)]
?蛙状（球状、舟状）腹[frog(bulbous, scaphoid) belly (abdomen)]
?腹围增大[increased abdominal girth]
?肠型[intestinal pattern]
?梯形腹[ladder-shaped abdomen]
?胃（小肠）蠕动波[gastric (intestinal) peristaltic wave]
?静脉曲张[varicosity (dilated tortuous vein)]
?疤痕[scar]
?腹壁紧张（松驰）[guarding (abdominal muscular relaxation)]
?腹壁切口（创伤）[incision (wound) of abdominal wall]
?腹部分区[abdominal region]
?左（右）上（下）腹[left (right) upper (lower) quadrant]
?脐膨出[projection of the umbilicus]
?腹式呼吸[abdominal (diaphragmatic) breathing]
?腹壁松弛[lax abdominal wall]
?肝肿大[hepatomegaly (enlargement of the liver)]
?脾肿大[splenomegaly (enlargement of the spleen)]
?右肋下5厘米[5 cm below the right costal margin]
?肿块（肝）质硬[firm mass (liver)]
?莫菲氏征[murphy`s sigh]
?肌卫现象[muscle guarding (tension)]
?反跳痛[rebound tenderness]
?压痛点[tenderness point]
?剑突下压痛[tenderness beneath the xiphoid process]
?麦氏点压痛[McBurney`s point tenderness]
?腹肌强直（板状腹，板样强直）[rigor of abdominal muscle (wooden belly, board-like rigidity)]
?柔韧感[dough kneeding sensation]医学.全在线www.m e d126.c o m
?波动感[fluctuation]
?腹股沟疝[inguinofemoral hernia]
?腹壁反射[abdominal reflex]
?腹水征[sign of ascites]
?膀胱肿大[bladder expansion]
?膀胱区（脊肋角）压痛[tenderness of bladder region (costovertebral angle)]
?肾（肝）区叩击病[percussion tenderness on kidney (liver) region]
?移动性浊音[shifting dullness]
?鼓音[tympany(tampanitic resonance)]
?肝（脾）浊音区[hepatic (splenic)dullness area]
?肠鸣音正常（亢进、减弱、消失）[normal (hyperactive, diminished, absent) bowel sound] ?气过水声[gurgling]
?振水声[succusion (splashing) sound]
Writing Skills of Case Report in English 在医学刊物上发表的病例报告实际上是开始从事医学写作的最好的方法之一。病例报告的撰写,首先要做好题目的选择,肯定要选择与自己专业有关的临床工作,并能提出你认为是很感兴趣的,在概念上、临床上以及理论上存在的棘手问题。通常文字不超过3000字(包括参考文献和附录在内)。绝大多数的病例报告所采用的书写格式,类似于临床研究报告,应该包括:引言、病例叙述、讨论和结论。本文所采用的文章是从2004年英国LANCET杂志中摘录。 1、引言 引言部分要简短明了,应介绍与报告相关的主要临床和概念上的难题,说明病例的重要性,报道的原因,若可能的话,应引证一些最新的综述资料,并能简明地概括出所涉及到的资料内容。在时态上,由于陈述的是客观事实,故运用一般现在时。如: 2、病例叙述 病例叙述的宗旨就是让读者了解病例,明确全部相关结果。病例的叙述通常要
按照时间先后顺序排列,这一部分所涉及到的资料内容包括以下:①病人现有的体症和症状,主诉和病痛。②医学史及相关家史(如糖尿病、心脏病等)。③社会史,诸如吸烟、饮酒和吸食毒品等。④服用过的药物。⑤体检和化验的突出结果。⑥鉴别诊断或考虑诊断。⑦最后诊断。⑧治疗和治疗后结果。通常仅需要提供检查和化验的阳性结果。不过有个别杂志需要提供全面详尽的检验和程序结果。列出化验的正常值范围和不正常的检验结果。在时态的运用上,由于陈述病人过去健康状况和治疗情况,故采用一般过去时。
3、讨论 讨论部分就是要解释病例叙述中不明确的一些情况,并提供对结果的解释。例如,报道肝酶升高,但未发现显著的肝功能异常,给读者讲明为何肝酶升高。在讨论部分的时态运用上,由于提供的是自己现在的推断和观点,故采用一般现在时。如:
HUAZHONG UNIVERSITY OF SCIENCE AND TECHNOLOGY TONGJI MEDICAL COLLEGE ACCESSORY TONGJI HOSPITAL Hospitalization Records for None-operation Division Division: __________ Ward: __________ Bed: _________ Case No. ___________ Name: ______________ Sex: __________ Age: ___________ Nation: ___________ Birth Place: ________________________________ Marital Status:____________ Work-organization & Occupation: _______________________________________ Living Address & Tel: _________________________________________________ Date of admission: _______Date of history taken:_______ Informant:__________ Chief Complaint: ___________________________________________________ History of Present Illness: ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________
CASE REPORT FORM TEMPLATE Version: 6.0 (8 November 2012) PROTOCOL: [INSERT PROTOCOL NUMBER] [INSERT PROTOCOL TITLE] Participant Study Number: Study group:
BASELINE DATA General Instructions for Completion of the Case Report Forms (CRF) Completion of CRFs ? A CRF must be completed for each study participant who is successfully enrolled (received at least one dose of study drug) ?For reasons of confidentiality, the name and initials of the study participant should not appear on the CRF. General ?Please print all entries in BLOCK CAPITAL LETTERS using a black ballpoint pen. ?All text and explanatory comments should be brief. ?Answer every question explicitly; do not use ditto marks. ?Do not leave any question unanswered. If the answer t o a question is unknown, write “NK” (Not Known). If a requested test has not been done, write “ND” (Not Done). If a question is not applicable, write “NA” (Not Applicable). ?Where a choice is requested, cross (X) the appropriate response. Dates and Times ?All date entries must appear in the format DD-MMM-YYYY e.g. 05-May-2009. The month abbreviations are as follows: January = Jan May = May September = Sep February = Feb June = Jun October = Oct March = Mar July = Jul November = Nov April = Apr August = Aug December = Dec In the absence of a precise date for an event or therapy that precedes the participant’s inclusion into the study, a partial date may be recorded by recording “NK” in the fields that are unknown e.g. where the day and month are not clear, the following may be entered into the CRF: N K N K 2 0 0 9 DD MMM YYYY ?All time entries must appear in 24-hour format e.g. 13:00. Entries representing midnight should be recorded as 00:00 with the date of the new day that is starting at that time. Correction of Errors ?Do not overwrite erroneous entries, or use correction fluid or erasers. ?Draw a straight line through the entire erroneous entry without obliterating it. ?Clearly enter the correct value next to the original (erroneous) entry. ?Date and initial the correction. Protocol Number: Page 1 of 15
第二节心内科常用英文病历模板 熟练地阅读和书写英文病历是一名临床医师需要具备的基本外语技能。对英文病历的熟练掌握对于阅读英文文献和撰写英文论文都有很大的帮助。本章主要介绍心内科常见疾病英文病历的格式和基本模板。英文病历的书写格式大致与中文病历相似，主要包括以下部分： 1.General information（一般情况） 2.Chief complaint（主诉） 3.Present illness（现病史） 4.Past history（既往史） 5.Personal history（个人史） 6.Family history（家族史） 7.Physical examination（体格检查） 8.Investigation（辅助检查） 9.History summary（病史特点） 10.Impression（印象、初步诊断） 11.Signature（签名） 鉴于不同疾病的病历之间存在共性，本章按照病历的通用部分和心血管内科部分逐一进行介绍。 第一部分通用部分 1. General information（一般情况） 这一部分包括name（姓名），age（年龄），sex（性别），race（民族），nationality（国籍），address（地址和电话），occupation（职业），marital status（婚姻状况），date of admission（入院日期），date of record（记录日期），complainer of history（供史者）和reliability（可信度）等12项内容。基本格式如下：
Name:Liu Side Age: Eighty Sex: Male Race:Han Nationality:China Address: NO.35, Dandong Road, Jiefang Rvenue, Hankou, Hubei. Tel: 857307523 Occupation: Retired Marital status: Married Date of admission:Aug 6th, 2001 Date of record: 11Am, Aug 6th, 2001 Complainer of history: patient’s son and wife Reliability: Reliable 2. Past history（既往史） 这一部分应首先总结既往一般健康状况、Operative history（手术史）、Infectious history（传染病史）、Allergic history（过敏史）等，然后对各系统健康状况进行回顾，包括Respiratory system（呼吸系统）、Circulatory system （循环系统）、Alimentary system（消化系统）、Genitourinary system（泌尿生殖系统）、Hematopoietic system（血液系统）、Endocrine system（内分泌系统）、Kinetic system（运动系统）和Neural system（神经系统）。基本格式示例如下： Past history The patient is healthy before. No history of infective diseases. No allergy history of food and drugs. Past history Operative history: Never undergoing any operation. Infectious history: No history of severe infectious disease. Allergic history: He was not allergic to penicillin or
英文大病例写作示例 时间:2007-06-04 17:19来源:中国医师协会作者: 点击: 355 次 撰写大病例是实习医师与住院医师的日常工作，也是上级医师作进一步诊断治疗的原始依据，国外的英文大病例并无统一格式，但是基本内容大致相仿，本节介绍的许多医疗记录的词汇值得借鉴。 Details个人资料 Name: Joe Bloggs (姓名：乔。伯劳格斯) Date: 1st January 2000（日期：2000年1月1日） Time: 0720(时间：7时20分) Place: A&E（地点：事故与急诊登记处） Age: 47 years（年龄：47岁） Sex: male（性别：男） Occupation: HGV(heavy goods vehicle ) driver（职业：大型货运卡车司机） PC(presenting complaint)（主诉） 4-hour crushing retrosternal chest pain（胸骨后压榨性疼痛４小时） HPC(history of presenting complaint)（现病史） Onset: 4 hours of “crushing tight” retrosternal chest pain, radiating to neck and both arms, gradual onset over 5-10 minutes.（起病特征：胸骨后压榨性疼痛４小时，向颈与双臂放 https://www.doczj.com/doc/b69812129.html,，5-10分钟内渐起病） Duration: persistent since onset（间期：发病起持续至今） Severe: “worst pain ever had”（严重性：“从未痛得如此厉害过）
CASE Medical Number: 682786 General information Name:Wang Runzhen Age: Forty three Sex: Female Race:Han Occupation: Teacher Nationality:China Marital status: Married Address: NO.38, Hangkong Road, Jiefang Rvenue, Hankou, Hubei. Tel: 82422500 Date of admission:Jan 11st, 2001 Date of record: 11Am, Jan 11st, 2001 Complainer of history: the patient herself Reliability: Reliable Chief complaint: Right breast mass found for more than half a month. Present illness: Half a month ago, the patient suddenly felt pain in her right chest when she put up her hand. After touching it, she found a mass in her right breast, but no tendness, and the patient didn’t pay attention it. Then the pain became more and more serious, so the patient went to tumour hospital and received a pathology centesis. Her diagnosis was breast cancer. Then she came to our hospital and asked for an operation. Since onset, her appetite was good, and both her spiritedness and physical energy are normal. Defecation and urination are normal, too. Past history Operative history: Never undergoing any operation. Infectious history:No history of severe infectious disease.
Nanjing children’s hospital Medical Records for Admisson Ward:321 Bed Number:32178 Medical Number: 696235 General information Name:Son of *** Sex: Male Age: 3 h Birthplace: *** county,Anhui province Race:Han Address:***town,***county,Anhu i province Date of admission:3:31pm Oct 16th,2015 Date of record: 3:31pm Oct 16th,2015 Parents Name: father *** Mother *** Complainer of history: patient’s father Reliability: Reliable Chief complaint: Shortness of breath and moaning for 3h Present illness: The afflicted baby was delivered 3h ago and had instaneous shortness of breath along with obtuse response and moaning.No aspnea or seizure or scream were observed. In local Hospital he received treatment of “naloxone、mezlocillin and Vit K1”, but his symptoms didn’t abate. So the parents took him to our hospital, he was admitted with a diagnosis of “acute respiratory dyspnea syndrome” .Breast feed has not been initiated.He has not vomitted,defecated or urinated since he was born,.
Medical Records for Admission Medical Number: 701721 General information Name:Liu Side Age: Eighty Sex: Male Race:Han Nationality:China Address: NO.**, Dandong Road, Jiefang Rvenue, Hankou, Hubei. Tel: ****** Occupation: Retired Marital status: Married Date of admission: Aug 6th, 2001 Date of record: 11Am, Aug 6th, 2001 Complainer of history: patient’s son and wife Reliability: Reliable Chief complaint: Upper abdominal pain for ten days, hematemesis, hematochezia and unconsciousness for four hours. Present illness: The patient felt upper abdominal pain for about ten days ago. He didn’t pay attention to it and thought he had ate something wrong. At 6 o’clock this morning he fainted and rejected lots of blood and gore. Then hemafecia began. His family sent him to our hospital and received emergent treatment. So the patient was accepted as “upper gastrointestine hemorrhage and hemorrhagic shock”. Since the disease coming on, the patient didn’t urinate. Past history The patient is healthy before. No history of infective diseases. No allergy history of food and drugs. Personal history He was born in Wuhan on Nov 19th, 1921 and almost always lived in Wuhan. His living conditions were good. No bad personal habits and customs. Family history: His parents have both deads. Physical examination
?Case History ?Definition A case history is a medical record of a patient’s illness. It records the whole medical case and functions as the basis for medical practitioners to make an accurate diagnosis and proposes effective treatment or preventive measures. Case histories fall into two kinds: in-patient case histories and out-patient case histories. ?Language Features History and Physical usually involves past tense ( for history of present illness, past medical history, family history and review of systems concerning past information), and present tense ( review of system, physical examination, laboratory data, and plans ). Structurally, noun phrases are frequently used in physical examination, and ellipsis of subject is very common in review of system. ?In-patient Case Histories An in-patient case history is also termed as History and Physical. It is an account of a patient’s present complaints with descriptions of his past medical history,and the description of the present conditions as well as physical examinations and impression about the conditions.Format It usually consists of chief complaint, history of present 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（Case History） 姓名(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(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) 肛门直肠(Anus & rectum) 外生殖器(External genitalia) 四肢脊柱(Extremities & spine)
POMR (Problem-Oriented Medical Records)表格式住院病历Biographical data: 一般项目： Name Age Sex Marital status Nativity Race 姓名年龄性别婚否xx民族 Occupation Date of admission Informant History 职业入院日期病史叙述者病史 主诉 History of present illness 现病史 Past history 既往xx： Previous health status: well ordinary bad Infectious diseases 平素健康状况： 良好一般较差传染病xx Immunizations Allergies: N Y clinical manifestation 预防接种xxxxxx无有临床表现 allergen: Trauma:
Surgery: 过敏原外伤xx手术xx Review of systems: (Tick if positive, cross out if negative. If postive, you should write down your disease history and brief course of diagnose and therapy) 系统回顾： (有打√无打×阳性病史应在下面空间内填写发病时间及扼要诊疗经 过)Respiratory system: 呼吸系统 Sore throat chronic cough sputum hemoptysis wheezing 咽痛慢性咳嗽咳痰咯血哮喘 dyspnea chest pain 呼吸困难胸痛 cadiovascular system: 循环系统 Palpitation dyspnea on exertion hemoptysis syncope 心悸活动后气促咯血晕厥 edema of lower limbs precordial pain hypertention 下肢水肿心前区疼痛高血压 Digestive system: 消化系统 Anorexia sour regurgitation belching nausea vomitting
Case History Definition A case history is a medical record of a patient’s illness. It records the whole medical case and functions as the basis for medical practitioners to make an accurate diagnosis and proposes effective treatment or preventive measures. Case histories fall into two kinds: in-patient case histories and out-patient case histories. Language Features History and Physical usually involves past tense ( for history of present illness, past medical history, family history and review of systems concerning past information), and present tense ( review of system, physical examination, laboratory data, and plans ). Structurally, noun phrases are frequently used in physical examination, and ellipsis of subject is very common in review of system. In-patient Case Histories An in-patient case history is also termed as History and Physical. It is an account of a patient’s present complaints with descriptions of his past medical history,and the description of the present conditions as well as physical examinations and impression about the It usually consists of chief complaint, history of present 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（Case History） 姓名(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.) 现病史(HPI or .) 过去史(PMH or .) 社会活动史/个人史(SHx or .) 家族史(FHx or .) 曾用药物(Meds) 过敏史(All) To be continued 系统回顾(ROS) 体格检查(PE or .) 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) 肛门直肠(Anus & rectum) 外生殖器(External genitalia) 四肢脊柱(Extremities & spine)
Division: __________ Ward: __________ Bed: _________ Case No. ___________ Name: ______________ Sex: __________ Age: ___________ Nation: ___________ Birth Place: ________________________________ Marital Status:____________ Work-organization & Occupation: _______________________________________ Living Address & Tel: _________________________________________________ Date of admission: _______Date of history taken:_______ Informant:__________ Chief Complaint: ___________________________________________________ History of Present Illness: ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ Past History:
Medical Records for Admisson Medical Number: 696235 General information Name:Zhang Yi Age: thirteen Sex: Female Race:Han Nationality:China Address: NO.23, Yunchun Road, Jiefang Rvenue, Hankou, Hubei. Tel: 85763723 Parents Name: father Zhang Hesheng Mother Yang Chiulian Date of admission: May 8th, 2001 Date of record: 11Am, May 8th, 2001 Complainer of history: patient’s mother Reliability: Reliabl Chief complaint: Pharyngalgia and fever for four days. Present illness: The patient felt pharyngalgia and weak about four days ago. She ate some medicine (not clear), but it do nothing. Then she found ulcer in her mouth and fever all along, but she felt no nausea and never vomited. So her parents took her to Wuhan Children’s Hospital, there s he received treatment of antibiotics, but her symptoms didn’t abate. So her parents took her to our hospital, she was admitted with a diagnosis of “fever of unknown” Since onset, her appetite was not good, and both her spiritedness and physical energy are bad. Defecation and urination are normal. Past history The patient is healthy before. No history of “measles” or “pertussis” etc and no contact history with T.B or other infective diseases. No allergy history of food but she was allergy to sulfa. Personal history 1.Natal: First birth born, uneventfully and on full term with birth weight 2.7 Kg. The state of her at birth was good, no cyanosis, apnea, convulsion or bleeding. 2.Development: Able to raise head at second month. The first tooth erupted at 6th. She began to walk at one. Her intelligence was normal. 3.Nutrition: She was only feeded with breast milk before she was 6 months old. Then the additives were added. She was weaned from the breast at 14th month. 4.Immunization: Inoculated on schedule after birth (such as B.C.G, D.P.T and smallpox vaccination). Physical examination T 39.5℃, P 120/min, R 30/min, BP 110/90mmHg. She is well developed and moderately nourished. Active position. The skin was not stained yellow. No cyanosis. No