英文病例书写

英文病例书写

整理有关英文病例的写作，提供大家查考：

一、主要调查项目：

1.主诉chief complaint：weakness, malaise, chills, fever, sleep, pain, headache, appetite, weight, stomach and bowels, nausea and vomiting, diarrhea, urine, genitalia, neuropsychiatric disorders, respiration, shortness of breath, bleeding or

discharge, etc.

2.现症历present illness：onset(date, mode), duration before present entry, exciting cause and environmental influences, prodromal symptoms, general symptoms,

course or progress( location, duration, severity, continuity, intermission, radiation,

treatment), aggravating and alleviating factors, loss of weight, appetite and strength, sleep, bowel movement, frequency of urination, menstruation, etc.

3.既往历past history：

1)former places of residence, previous stage of health( 健壮的robust，纤弱的 delicate), experience with similar disease, immunity to infectious disease

2)previous illness：麻疹measles, 腮腺炎mumps, 水痘chicken-pox, 百日咳

pertussis, 流行性感冒influenza, 猩红热scarlet fever, 白喉diphtheria，伤寒 typhoid fever, 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,etc

3)venereal disease：specific symptoms, signs, and the disease by name, treatment.

4)Accidents( date, any disability, sequelae), operation and hospitalization (date , procedure, name of hospital , physician, complications, bleeding tendency)

4.家族历family history：family tendency, presence of hereditary disorders, cancer, tuberculosis, mental disorder and nervous affection, rheumatism, diabetes,

hypertension, cerebral vascular accident, hemophilia, syphilis, tumor, epilespsy, allergy, contact with diseased individuals, relationship of patient's childhood and adult life, age, health condition, and cause of death of parents, grandparents, self , spouse, siblings , or relatives.

5.个人历personal history：

1)Social history：fears, metal status, education, financial condition, number of dependents, family harmony or fractious , hygienic condition at home

2)Marital history：duration of marriage, 1st or 2nd marriage, age and death of spouse and children , cause and age at time of death, number of children , pregnancies, 流产次数miscarriages, 死产数 stillbirths

3)occupational history：duration of employment, past work, exact nature of work, exposure to occupational hazards, whether work is satisfactory or not.

4)Habits：alcohol, tobacco, narcotic, coffee, tea, appetite, food habits, regularity of

meals, rapidity of eating , bowel movements, sleep, exercise, interests, etc.

6.系统检查system review：