医学英语病历书写重点

Case History 病史

⏹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

①symptom+since+time(时间点)

②symptom+for+time(时间段)

③symptom+of+time (时间段名词所有格)+duration

④symptom+time(时间段)+in duration

⑤time(时间段合成词)+history+of+symptom

⑥complete 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

①start having 开始有……的症状

②begin having episodes of… 开始发生……的症状/疾病

③become… 变得……

④notice(perceive, note, recognize…)+症状/疾病

⑤have… 有……症状/疾病

⑥have abrupt/sudden/explosive onset of… 突然患……

⑦have episode of…/have attack of…患……

⑧develop+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

①begin (occur, start…)+time 从……开始

②date (go back) to +time 可追溯到……

③be present+time 在/从……已存在

④be preceded by… 在……之前已有

⑤be followed by… 在……之后紧接着发生

⑥be acc ompanied by…/ coincide with… 与……同时发生

⑦be (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

①last+time 持续……时间

②take a bad turn; take a turn for the worse; be aggravated/exacerbated; become worse 恶化

③take a good turn/take a turn for the better/improve 好转

④be aggravated/abated/all eviated by… 因……而加剧/减轻

⑤remain the same/unchanged 无变化

⑥be (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)

②There be no histor y 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

①had been sound/well until; had enjoyed good health until… 在……前一直健康

②be 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 gase s) 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

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

⏹Common expressions

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