医学英语课件case_history.ppt

Case Histories Teaching objectives To know the format of the case histories; To understand the language features of the case histories; To master the special language structures of the case histories; To know how to write a case history. Contents Definition Classification Out-Patient Case Histories In-Patient Case Histories Format Language Features A Sample Special Language Structures (P56-67) Exercises I. Definition and classification 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. II. Out-patient case history An out-patient case history is a record of the related medical information of a patient who seeks medical advice in an out-patient department of a hospital. It usually consists of general data (GD), chief complaint (CC), present illness (PI), physical examination (PE), tentative diagnosis (TD) or impression (Imp), treatment (Rp), etc. An out-patient case history should be written in brief and to the very point. More abbreviations and noun phrases are used. Sample of an out-patient case history Male, 39 year old CC: fever, headache and cough for two days. PE: G.C. looks fair. Pharynx congested and tonsils enlarged. Chest and abdomen negative. Imp: U.R.I. Rp: Penicillin 400,000u. (i.m.) q.d. x 3 day. Aspirin 1 tab. t.i.d. x 2 days. Vit C 100 mg t.i.d. x 3 days Signature ______ III. 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. 住院病人病历完整模式 病历（Case History） 姓名(Name)