病历书写英文实用教案

What is history record The clinical record documents the patients history and physical findings. It shows how clinicians assess the patient, what plans they make on the patients behave, what actions they take, and how the patient responds to their efforts .第1页/共43页第一页，共44页。Importance of history record 1. Diagnosis and treatment purpose An accurate, clear, well organized record reflects and facilitates sound clinical thinking. It leads to good communication among the many professionals who participate in caring for the patient 2. Teaching and research purpose 3. Medicolegal purposes 第2页/共43页第二页，共44页。How to make a good history record When creating a record, you do more than simply make a list of what the patient has told you and what you have found on examination. You must review your data, organize them, evaluate the importance and relevance of each item, and construct a clear, concise, yet comprehensive report. 第3页/共43页第三页，共44页。How to make a good history record 1. Order is imperative 2. Keep items of history in the history 3. Describe specifically any pertinent negative information 4. Data not recorded are data lost 5. Use short words instead of long and probably fancier ones when they mean the same thing 6. Be objective 7. You should write the record as soon as possible 第4页/共43页第四页，共44页。Basic requirement for the history record 1. To be well organized and canonical 2. No much erasion and gride could be done in the history record 3. To be objective and accurate 4. Using professional term to record instead of folksay 5. Remember to have your signature第5页/共43页第五页，共44页。A. Outline of case record 1. Biographical data Biographical information of patient should include his full name, age (date of birth), sex, race, occupation, nationality, marital status and permanent home address. Also, the date of admission, the time at which you took the history, the source of history and estimate of reliability should be involved. 2. chief complaint The chief complaint consists of main symptom(s) and duration. It should constitute in a few simple words the main reasons why the patient consulted doctor and should be state as nearly as possible in the patients own wards. In general, the chief complaint should include age, sex, complaint, and duration of the complaint. It should no included diagnostic terms or disease entities. For example:” This 70-year old man has had short breath for a week.”第6页/共43页第六页，共44页。 3. History of present illness (HPI) The history of present ill ness should be a well-organized, sequentially developed elaboration of his chief complaint(s) on its various characteristics: date of onset, character of complaint, mode of onset, course and duration, location, relationship to other symptoms, bodily function and activities, exacerbation and remissions, and effect of treatment. 4. Past history (PH) It should include a review of all past ill nesses, surgical procedures, and injuries, and allergy history (medicine, food), which are particularly related to the present illness.第7页/共43页第七页，共44页。 5. Review of system (ROS) The purpose of sys tem review is twofold: a thorough evaluation and a double check prevent omission of significant data relative to the present illness. The review is a comprehensive account of all complaints referable to each body system progressing in a logical manner from the head toward the feet, including respiratory system, cardiovascular system, digestive system, Urinary system, hemopoietic system, endocrine system, nervous system and skeletal system. 6. Personal history (social and occupational history) It includes personal habits (smoking, alcohol drinking), business life, sex life, occupation (exposure to certain irritating agents), condition of work.第8页/共43页第八页，共44页。 7. Marital history It includes data concerning the health of mate, sexual adjustment, the number of children and their Physical status, and the general social adjustment within the family. 8. Menstrual history ( for female patients) Age of onset, interval between periods, duration, amount and character of flow, concomitant symptoms, date of last menstruation, age of menopause. 9. Childbearing (reproductive) history Age and date of pregnancy(ies) and childbirth(s). Date of artificial or natural abortions, stillbirths, operative delivery, puerperal fever. Method of family planning, the possible factors of infertility (also for male patients).第9页/共43页第九页，共44页。 10. Family history (FH) The health status of the patients family (mother, father, siblings and children) and if died, the age and cause of death should be recorded, such as diabetes, hypertension, cancer, obesity, allergic disorders, coronary artery disease and mental illness. 11. Physical examination (PE) The recording of Physical examination should follow a logical sequence as follows: vital signs, general status, skin, nodes, head, neck, chest, lungs, heart and blood vessels, abdomen, genitalia, rectum, spine and extremities, nervous reflexes. 12. Laboratory tests and instrumental examination The findings of them onkly serve to confirm what you have found on history and Physical examination. The routine laboratory studies include blood, urine and stool tests, electrolytes, X-rays and ECG.第10页/共43页第十页，共44页。 13 Summary 14. Primary diagnosis As the results of differential analysis of a number of significant data, a primary diagnosis could be established. It consists of etiologic diagnosis, pathological diagnosis, pathophysioloical diagnosis (stage or period and classification or subtype), cardiac or/and pulmonary function and complication(s).第11页/共43页第十一页，共44页。BOutline of SummaryName, gender, age and occupationAdmission dateAhief complainsPresent history(70%-80% percent of the original present history )Simplified document of the original past history(only positive data recruited)Very simplified document of the original personal and family historyPhysical examination: vital signs, important positive and negative signs, especially valuable information for differentiation, but you can not omit such important items as heart/lung/abdominal examination. Positive laboratory and instrumental results第12页/共43页第十二页，共44页。Example of case record Biographical data: NameLUO LEN SHENG Age: 30 Sex: M Marital status: Married Native place: China Race: Han Occupation : Mechanic Date of Admission date: 2003/11/16 Statement: patient herself第13页/共43页第十三页，共44页。 Chief complaint: recurrent abdominal pain and melena for more than one year History of present illness: Mr. luo has been suffered from abdominal pain and recurrent melena since 2002, began on May 2,2002 he had upper abdominal pain and melena first time, with no any inducement factors, obscure upper abdominal pain happened with no radiation, no belching ,no vomiting, no fever and tremor. Pain was hungry pain and can be relieved by antacid agent or by meal. Melena occurred three times a day, about 250g each time, continuing for 5 days with little fatigue, no hematomeses. He went to the local county 第14页/共43页第十四页，共44页。 hospital on the third day of melena, where he received gastroscopy that showed duodenal bulb ulcers with bleeding. Then he was administered Omeprazole (PPI) intravenously for 6 days, 40mg each time, twice a day (Bid). On the second day of treatment, the melena disappeared . On Nov. 15, 2003, without any inducement he had melena again 3 times a day and 250-500gm. Every time accompanied with fatigue and timed but no dizziness and syncope. This time he went to the second Peoples hospital. He took PPI but didnt receive gastroscopy. After receiving PPI., melena disappear. But the OB(occult blood) test was still positive. The next day he was shifted to 1st affiliated hospital of Guangxi Medical University and received further examination and treatment. The general condition is good and work is not affected in any way since he had such a disease.第15页/共43页第十五页，共44页。 Past history: Previous health status: Well ordinary bad infectious disease Immunizations allergies: N Y clinical manifestation: allergen Trauma history: surgery history: Review of systems: (Tick if positive, cross out if negative. If positive, you should write down your disease history and brief course of diagnose and therapy)第16页/共43页第十六页，共44页。 Review of systems: (Tick if positive, cross out if negative. If positive, you should write down your disease history and brief course of diagnose and therapy) Respiratory system: sore throat chronic cough sputum hemoptysis wheezing dyspnea chest pain第17页/共43页第十七页，共44页。 Cardiovascular system: p a l p i t a t i o n d y s p n e a o n e x e r t i o n hemoptysis syncope edema of lower limbs precordial pain hypertention Digestive system: anorexia sour regurgitation belching nausea vomit abdominal distention abdominal pain constipation diarrhea hematemesis melena hematochezia jaundice Urinary system: lumbago frequent micturition urgent micturition urodynia dysuria hematuria nocturia polyuria oliguria facial edema第18页/共43页第十八页，共44页。 Hemopoietic system: fatigue dizziness blurred vision gingival bleeding subcutaneous hemorrhage ostealgia epistaxis Metabolic and endocrine system: excessive appetite anorexia sweets cold intolerance olydipsia polyuria tremor hands change of character obvious obesity emaciation hairiness hair losing pigmentation change of sexual function amenorrhea Musculoskeleton system: floating arthralgia arthralgia swelling of joints deformities myalgia atrophy of muscle第19页/共43页第十九页，共44页。 Nervous system: d i z z i n e s s h e a d a c h e v e r t i g o s y n c o p e degeneration of memory visual disturbance insomnia disturbance of consciousness tremor spasm paralysis paresthesia Personal history: birthplace occupation sexual history: N Y smoking: N Y about yrs average pieces/d ceased for yrs alcohol intake: N occasional frequent about yrs average ml/d others: Maritial history: marrying age companions state of health第20页/共43页第二十页，共44页。 Menstruation and Childbering history: menarche age - date of last period (age of menopause) a m o u n t of f l o w : l i t t l e n o r m a l l a rg e menstrual pain: N Y cycle: regular irregular pregnancy: times natural labor times abortions times premature delivery times stillbiriths times difficult labor and its condition: Fa m i l y h i s t o r y : ( pa y a t t e n t i o n t o t h e congenital diseases and communicable diseases related to the patient) father: still alive illness died cause of death mother: still alive illness d i e d c a u s e o f d e a t h s i b l i n g s : others:第21页/共43页第二十一页，共44页。 Physical examination Vital signs: T 36 P 70 /min R 20 /min Bp 110 /70 mmHg General Appearance: development: ortho-sthenic type asthenic type sthenic type nutrition: well fairly poor cachexia facial features: normal acute chronic others expressions: natural painful anxious dreadful indifferent position: active semi-recumbent others gait: normal abnormal consciousness:aware somnolence confusion stupor coma delirium cooperation:well badly第22页/共43页第二十二页，共44页。 Skin, mucous membrane: color : normal red pale cyanosis yellow pigmentation rash: N Y (type and distribution) subcutaneous hemorrhage: N Y (type and distribution) hair: normal scattering losing (position) moisture and temperature: normal cold dry wet elasticity: normal reduced edema: N Y (position and degree) hepatic palm: N Y spider angioma: N Y (position numbers) others: 第23页/共43页第二十三页，共44页。 Lymph nodes: superficial lymph nodes: non-swelling swelling (position and characteristics) Head: cranium:size:normal large small deformity: N Y(oxycephaly squared skull deforming skull) others: tenderness mass sunk (position ) eyes: eyelid: normal edema ptosis trichiasis conjunctive: normal hyperemia edema hemorrhage eyeball: normal exophthalmos depression tremor motion dysfunction (left right) 第24页/共43页第二十四页，共44页。 sclera: normal yellow cornea: normal abnormal (left right ) pupils: equal roundness same size unequal left cm, right cm reaction to light: normal delay (left right ) disappear (left right ) others: ears: auricle: normal deformity fistula others (left right ) excretions of external canal: N Y (left right feature ) tenderness of mastoid: N Y (left right ) audition dysfunction: N (left right ) nose: shape: normal abnormal( ) other abnormalities: N Y nasal flap o b s t r u c t i o n e x c r e t i o n s n a s a l s i n u s tenderness: N Y (position )第25页/共43页第二十五页，共44页。 mouth: lips: red cyanosis pale herpes fissure mucous: normal abnormal (pale bleeding) opening of parotid gland duct: normal abnormal (swelling pyogenic excretions) tongue: normal abnormal (coverings tremor leaning to left or right ) gums: normal swelling pus overflow hemorrhage pigments teeth: regular edentulous carious teeth false tooth tonsils: pharynx: voice: normal hoarse第26页/共43页第二十六页，共44页。 Neck: resistance: N Y carotid artery pulsation: normal increased decreased (left right) jugular vein: normal distention high distention trachea: middle deviation to (left right) hepatojugular reflux: (-) (+) thyroid: normal swelling degree symmetry dominance in one side: spreading nodular: soft hard others: N Y (tenderness tremor bruits ) 第27页/共43页第二十七页，共44页。 Chest: topography: normal barrel chest flat chest pigeon chest funnel chest bulging or retraction (left right) bulging in the precordial region tenderness of sternum breast: normal symmetrical abnormal: left right (gynecomastia mass tenderness) excretions of nipples )第28页/共43页第二十八页，共44页。 Lung: inspection: movement of respiration: normal abnormal: left right (increased decreased) intercostals space: normal wide narrow (position ) palpation: vocal fremitus: normal abnormal: left right (increased decreased) p l e u r a l f r i c t i o n r u b s : N Y (position ) percussion: resonance abnormal: dullness flatness hyperresonance tympany lower borders: scapular line: right intercostals space left intercostals space range of mobility: right cm, left cm第29页/共43页第二十九页，共44页。 auscultation: breath: regular irregular breath sound: normal abnormal (feature, position ) rales: N Y: rhonchi: sonorous sibilant moist rales: coarse medium fine rales crepitus vocal conduction: normal abnormal: reduced increased Pleural friction rubs: N Y (position )第30页/共43页第三十页，共44页。 Heart: inspection: bulging in precordial region: N Y apex impulse: normal unseen increased diffusing poisition: normal deviation (the distance from midclavicular line cm) other precordial pulsations: N Y (position ) p a l p a t i o n :a p e x i m p u l s e : n o r m a l increased thrust unclear thrills: N Y (position period ) pericardial friction rubs N Y percussion: relative cardiac outline: normal shrink extant (right left)第31页/共43页第三十一页，共44页。 Normal boundary of the heart right(cm) intercostals space left(cm) 2-3 2-3 3-4 5-6 distance from anterior midline to the lef t midclavicular line(cm):第32页/共43页第三十二页，共44页。 auscultation: heart rate bpm/min rhythm (regular irregular absolutely irregular) heart sound: S1 normal increased decreased split S2 normal increased decreased S2 split: normal fixed paradoxical S3 N Y S4 N Y A2 P2 extra heart sound: N gallop (diastolic presystolic summation gallop) opening snap others murmurs: N Y第33页/共43页第三十三页，共44页。 Location: apical region aortic area pulmonary area tricuspid area left sternal border in 3nd intercostals space Others Timing: systolic diastolic both Quality: blowing rumbling sighing musical Austin Flint Graham Steell Gibson Intensity: Grade Transmission: N Y direction to left axilla over the apex over the carotid arteries Pericardial friction rubs: N Y第34页/共43页第三十四页，共44页。 Peripheral vessels: normal pistol shot: N Y Duroziez sign: N Y water hammer pulse: N Y capillary pulsation: N Y pulse deficit: N Y paradoxical pulse: N Y pulse alternations: N Y others Abdomen: inspection: shape: normal distention frog belly cm scaphoid abdomen apical belly gastric pattern intestinal pattern peristalsis abdominal respiration: exist disappear u m b i l i c u s : n o r m a l p r o t r u d i n g excretions others: N Y (venous distention of abdomen purple striae surgical cars hernia)第35页/共43页第三十五页，共44页。 palpation: soft muscle tension position tenderness: N Y rebound tenderness: N Y fluid trill: N Y succusion splash: N Y masses N Y (position size) description of feature: liver: not touched be touched: subcostal cm description of feature: gallbladder: not touched be touched: size cm tenderness: N Y Murphys sigh(+) (-) spleen: not touched be touched: from costal margin cm description of feature:第36页/共43页第三十六页，共44页。 kidney: not touched be touched: size consistency tenderness mobility t e n d e r n e s s o f u r e t e r s : N Y (position ) percussion: borders of liver dullness (exist shrink obliteration) u p p e r b o r d e r o f l i v e r : o n r i g h t midclavicular line intercostals space shifting dullness: N Y tenderness in renal region: N Y (right left ) auscultation: gurgling sound: normal increased decreased disappear vessel bruits: N Y (position )第37页/共43页第三十七页，共44页。 Genitalia: n o t e x a m i n e d n o r m a l abnormal: Rectum and Anus: not examined normal abnormal: Spine and Extremities: spine: normal deformities (lateral anterior posterior protruding) acanthi: tenderness pain at percussion ( p o s i t i o n ) m o b i l i t y : n o r m a l restricted limbs: normal abnormal deformity swelling of joints joints stiffness tenderness of muscles atrophy of muscles venous distention of lower limbs (position and feature ) acropachy第38页/共43页第三十八页，共44页。 Nervous system: muscle tone (normal increase paratonia) myodynamia (0 ) paralysis of limbs: N Y (left right upper lower) reflex: abdominal wall reflex (upper middle lower normal abnormal) biceps reflex: left (normal abnormal ) right (normal abnormal ) triceps reflex: left (normal abnormal ) right (normal abnormal ) patellar reflex: left (normal abnormal ) right (normal abnormal ) achilles reflex: left (normal abnormal ) right (normal abnormal )第39页/共43页第三十九页，共44页。 Hoffmann sign: left (+) (-) right (+) (-) Babinski sigh: left (+) (-) right (+) (-) Oppenheim sigh: left (+) (-) right (+) (-) Kernig sign: left (+) (-) right (+) (-) Burdzinski sign: left (+) (-) right (+) (-) Laboratory findings (The important laboratory examinations, X-ray, ECG and other result are included) 第40页/共43页第四十页，共44页。Abstract Mr. luo, 30 years old, has been suffered from abdominal pain and recurrent melena for more than one year and admitted to hospital on Nov 16, 2003. began on May 2,2002 he had upper abdominal pain and melena first time, with no any inducement factors, obscure upper abdominal pain happened with no radiation, Pain was hungry pain and can be relieved by antacid agent or by meal. Melena occurred three times a day, about 250g each time, continuing for 5 days with little fatigue. He went to the local county hospital on the third day of melena, where he received gastroscopy that showed duodenal bulb ulcers with bleeding. Then he was administered Omeprazole (PPI) intravenously for 6 days, 40mg each time, twice a day (Bid). On the second day of treatment, the melena disappeared . On Nov. 15, 2003, without any inducement he had melena again 3 times a day and 250-500gm. Every time accompanied with fatigue and timed but no dizziness and syncope. This time he went to the second Peoples hospital. He took PPI but didnt receive gastroscopy. The general condition is good and work is not affected in any way since he had such a disease.第41页/共43页第四十一页，共44页。 Physical examination revealed normal vital signs; patients consiousness seamed good, co-operated well; normal superficial lymph nodes( non-suelling) and pale skin observed. No paecordial protrusion, no enlargement of the border of the heart and nuoverma heard. chest are symmetrical, no vesicular sounds heard; Normal soft abdomen, no engorged vein and shighting dullness negative. Liver, spleen and kidney cant be palpated and no edema in lower limbs. Physiological reflex is normal, pathological relex is negative. Special examination indudes (a) decreased hemoglobin level (85g/L) , (b) Occult blood test (+) posi