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医学英语病历书写重点

发布时间:2014-08-03 00:41:58  
Case History 病史

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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.) 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 出院后用药 General Data, Biographical Data 一般项目 ?Reliability (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) ?Supplier/ Complainer of History (供史者/病史陈述者): Patient/ Husband/ Wife/ Father/ Mother/ Colleague/ Neighbor Chief Complaints (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。 ?Language Characteristics 1) Common expressions ① symptom+since+time(时间点) ② symptom+for+time(时间段) ③ symptom+of+time (时间段名词所有格)+duration ④ symptom+time(时间段)+in duration ⑤ time(时间段合成词)+history+of+symptom ⑥ complete sentence: The duration of +symptom+was/ has been+time(时间段)(少见) 2) Common sentence patterns for chief complaints ① …was admitted/seen with a chief complaint of… ② …complain chiefly of… ③ …presented/entered with/came to the office with a chief complaint of ④ …was admitted because of… ⑤ …was involved in… ⑥ …was transferred to…because… 下面是书写主诉是最常用的格式: CC:The patient is 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-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。 ?Language Characteristics 1) Sentence Patterns with Patients to Be Subject 以病人做主语的句型 ① start having 开始有……的症状 ② begin having episodes of… 开始发生……的症状/疾病

③ become… 变得…… ④ notice(perceive, note, recognize…)+症状/疾病 ⑤ have… 有……症状/疾病 ⑥ have abrupt/sudden/explosive onset of… 突然患…… ⑦ have episode of…/have attack of…患…… ⑧ develop+disease 出现/有了……症状/疾病 ⑨ …are/is the prodrome of… ……的前驱症状 2) Sentence with symptoms, illnesses as subjects 以症状、疾病做主语的句型 ① begin (occur, start…)+time 从……开始 ② date (go back) to +time 可追溯到…… ③ be present+time 在/从……已存在 ④ be preceded by… 在……之前已有 ⑤ be followed by… 在……之后紧接着发生 ⑥ be accompanied by…/ coincide with… 与……同时发生 ⑦ be (not) related to…/have (no) correlation with… 与……有(无)关 3) Illness’ improving and worsening 表达疾病的好转与恶化 ① last+time 持续……时间 ② take a bad turn; take a turn for the worse; be aggravated/exacerbated; become worse 恶化 ③ take a good turn/take a turn for the better/improve 好转 ④ be aggravated/abated/alleviated by… 因……而加剧/减轻 ⑤ remain the same/unchanged 无变化 ⑥ be (not) improved after treatment with… 经用……治疗而(无)好转 ⑦ (The symptom) cease/clean up/disappear/subside 症状消失/减退 4) No symptoms 没发生……症状、疾病 ① …without/with no/free of… (symptoms) ② There be no history of…/…have no history of… ③ (The patient) denies… ④ (The patient) noted no… ⑤ (The patient) was not found to be… 5) Description of main symptoms 描述主要症状 ① …assume the character of/be characterized by… ② …have/present/develop/show/manifest the symptoms of… Past (Medical) History (P. H.)既往病史 ?Common expressions ① had been sound/well until; had enjoyed good health until… 在……前一直健康 ② be apt/liable/subject to…;tend to have… 易患…… ③ …was admitted to hospital for…/ …was hospitalized for… 曾因……而住院 ④…had (some illness) with recovery after… 曾有(疾病) ,因…痊愈 ⑤ …was diagnosed as…/…was suspicious of… 断为……/疑为…… ⑥…was exposed to (toxic substances)/ …had to breathe (poisoning gases) 接触/吸入 ⑦…was inoculated against…接种过…… ⑧…was discharged/ dismissed from hospital…/ …was out of hospital…出院 Personal History (Per. H.)/ Social History 个人史/社会史

?Note: menstruation
经期(天) menstrual period menarche age——————age of menopause (初潮年龄 menstrual cycle (绝经年龄) 月经周期(天)

?Characteristics of language ?Common 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 ① …be living and well./…be in good health./ …be well with no evidence of (illness). 健在

②(There is) No family history of (disease)./ (There was) No (disease) in one’s family. 无(病)家族史 ③ 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…… ④ Family history showed/revealed… 家族史显示…… ⑤ There was a familial/hereditary tendency to…/ There was a strong family history of…/ There was a high incidence of…in the family. 家族有……倾向/发病率 ⑥ There was a high prevalence of…in the family 家族中……患病率高 ⑦ Positive for (some disease) in (some one). 曾患过…… ⑧ …as a family characteristic. 家族特点 ⑨ FH: Noncontributory 家族史无意义 Allergies 过敏史

?Common expressions
① NKDA (no known drug allergies) 无过敏史 ② allergy, allergic, hypersensitive, hypersensitivity 过敏 ③ sensitive, sensitivity, sensible, sensibility 敏感 ④ allergic reaction 过敏反应 ⑤ be allergic to… 对……过敏 ⑥ be sensible to… 对……敏感 ⑦ have no history of allergy to…; have no history of…sensibility 对……有(无)过敏史 ⑧ have an allergic diathesis 具有过敏体质 ⑨ have no allergic reaction to any drugs 对用过的药物无过敏反应 ⑩ show sensibility to…(e.g. house dust) 对……(如室内灰尘)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 and 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 ① Temperature (T.) 体温 position: oral temperature 口温; axillary temperature 腋温; rectal temperature 肛温 unit: Celsius, ℃; Fahrenheit, ℉ Format: T 38 ℃ (or 100.4 ℉) Pattern: The temperature is 38 ℃ (or 100.4 ℉) taken by mouth/ by rectum/ by axilla. ② Pulse (P.) 脉搏 Format: P 80/min (or P80) Pattern: Pulse 80 per minute. The pulse numbered/beat/measured 80/min. ③ Respiration/ Respiratory Rate (R.) 呼吸 Format: R 20/min Common expressions: 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。 ④ 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 at…kpa(mmHg) 血压稳定在……千帕(毫米汞柱) BP fluctuates/ranges between…and… 血压波动在……与……之间 rise/drop from…to… 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(坐位式)血压为 7.3/10.7 千帕。 ⑤ Heart Rate (H. R.) 心率 Format: HR 80/min Heart Rate: 80 per minute 心率每分钟 80 次 ⑥ Cardiac Rhythm 心律 General appearance 一般情况或全身状态 ① Height (Ht.) ② Body Weight (BW/Wt.) ③ complexion 面色; appearance 面容; expression 面部表情 ④ mental state 神态; consciousness 意识; senses 感觉 ⑤ 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 ?Blood test ?Urinalysis ?Electrocardiogram (ECG) ?Electroencephalogram (EEG) ?X-ray examination and X-ray slides X 光检查及 X 光片 ?Computerized X-ray tomography (CT) 计算机 X 线断层扫描 ?Magnetic resonance imaging (MRI)/Nuclear magnetic resonance imaging (NMRI) 磁共振成像 ?Other lab data 其他检验资料

?Out-Patient Case History

门诊病历 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(introduction or abstract) ·病例介绍(case report or presentation) ·评论或讨论(comment or discussion) 有时病例报告还附有参考文献(references)和图表(graphs,illustrations)等。 (一) 、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 present 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(Description of the patient):主要说明病人的基本信息,但应避免提及病人的真实姓名及住院号等个人信息,通常只涉及年龄、性别,必要时说明职业或 种族;○ 2 病程(History of the presenting condition):主要说明典型的症状、并发症、诊断与治疗,避免无关的材料;○ 3 检查与诊断(Physical

examination):说明特殊的检查方法及结果; ○ 4 诊断与治疗 (Diagnosis and treatment):说明治疗方法、 用药情况等; ○ 5 治疗效果 (Expected/Actual outcome):说明症状是否减轻,是否有并发症等。 3、 讨论:讨论内容要与病例紧密联系,围绕所报道的病例做出必要的说明,阐明作者的观点或提出新的看法。讨论中要有充足论据,应说明 病例的罕见性和特殊性,总结归纳作者在诊断过程中的特殊经验和新观点。 (二) 、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(Hospital Course) 这部分需要简述患者住院期间接受的检查与治疗情况以及出院时的情况,即疗效,如临床治愈(cured)、好转(improved)、未改善(unchanged)、 死亡(died)等。 描述住院过程时常使用的句型: 1、 表示用药或治疗 The patient was given... The patient was treated with... A course of (medicine) was given to the patient...(用药一个疗程...) 2、表示病情恢复情况 ...returned to normal ...be reduced/controlled/improved ...be relieved (patient’s condition) be stable/improved/satisfactory (二) 、出院诊断(Discharge Diagnosis) 这部分记述出院时的最后诊断,一般采用词组形式。如: Discharge Diagnosis:Pneumococcal pneumonia,right low lobe,which confirms the diagnosis on admission. (三) 、出院后用药(Discharge Medication) 这一部分记述医生给病人的处方。一般采用的格式与处方书写相同: 药名 + 药量 + 用法。如: Discharge Medication: 1、 Prednisone 80mg q.d. 2、 Digoxin 0.25mg q.d. 或: The patient was discharge on Prednisone 80mg and Digoxin 0.25mg each day. (四) 、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]

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