英文病历书写方法.ppt

How to Write Medical History Dr. Lu, Qinchi Dept. Neurology Ren Ji Hospital Shanghai Second Medical University Qinchilu@Q inchil@ Chief Complaint (1). Symptom-for-Time: e.g. Cough with yellow sputum for 5 days (2). Symptom-of…..duration: e.g. Black tarry stools of three day’s duration (3). Symptom-Time-in duration: e.g. Low fever 2-3 months in duration (4). Time-of-Symptom: e.g. Two-day history of chest pain Present History 1. Onset Fulminant; explosive The onset was fulminating with fever The drug caused an explosive onset of pain Sudden; abrupt; precipitate The onset was sudden with the temperature rising to 40oC Attacks began and ended abruptly The attacks is often precipitated by a large or fatty meal Present History Rapid Coma occurred rapidly Gradual Gradual onset of listlessness and anorexia Occasionally; accidentally Occasionally he noticed a mass in the right upper abomen He perceived accidentally that his stool was mixed withblood Present History 2.Occurrence Recurrent bouts of fever and joint pain Attacks occurred often after meal Nocturnal attacks occurs sporadically Transitory attacks of dizziness Symptoms waned and waxed from time to time. Her illness hangs in the balance Present History Persistent fever Intermittent fever Patient had frequent episodes of vomiting An attack lasted on the average 4 to 5 hours The entire attack lasted for less than a minute The attack lasted a variable time from a few minutes to several hours Attacks occure usually between 2 and 4 AM The pain has been free of attacks for one month Present History 3. Factors affect the occurrence of the symptom Dyspnea occurs soon after lying The pain became more severe after meals Dyspnea is relieved by sitting up The chest pain had relation to respiration The pain had no relation to coughing Past Medical History 1. In intact medical history, it include: Infectious disease, allergy, surgery He had contact with pat