怎樣寫(xiě)英文病歷

1、百度文庫(kù)-讓每個(gè)人平等地提升自我How to write patients case history怎樣寫(xiě)英文病歷PATIENT HISTORY病史A detailed patie nt history and physical exam form the foun dati on of patie nt uati on and vital patie nt data that en ables efficie nt, quality patie nt roun ds.一份詳細(xì)的病史和體檢是評(píng)估患者的基礎(chǔ)，也可為組織高質(zhì)量、高效率的查房提供重要的資料。On the other hand, a

2、poorly docume nted history and physical may leads to con fusi on, serious omissi on of vital data and in efficie ncy on patie nt roun ds. In this age of moder n tech no logy with equipme nt such as CT, MRI and PET scanners, the history and physical exam seem to be slowly evolving into a relic of a p

3、ast era! Both atte nding physicia ns as well as reside nts in trai ning seem to rely more heavily on laboratory and imagi ng modalities tha n history to establish the diag no sis. “ Howeverno part of the patie nt uati on is more esse ntial to diag no sis tha n the patie nt history. The importa nee o

4、f skillful data collecti on is un derscored by the widely accepted un dersta nding that the medical history con tributes 60% to 80% of the information needed for accurate diagnoses. Thus to neglect the patient history denies the physician of a“ vital ” diagnostic tool.另一方面，寫(xiě)得差的病史和體檢可能會(huì)引起混淆，導(dǎo)致重要資料的遺漏

5、和查房效率的低下。在這個(gè)具有現(xiàn)代化設(shè)備如 CT、MRI、PET的年代里，病史和體格檢查似乎已慢慢地成為一種歷史遺物。無(wú)論是主治醫(yī)生或住院醫(yī)生都似乎越來(lái)越依賴(lài)于實(shí)驗(yàn)室和影像學(xué)檢查而不是病史來(lái)明確 診斷。然而對(duì)診斷來(lái)說(shuō)，沒(méi)有一種評(píng)估手段比病人的病史更重要。盡管普遍認(rèn)為病史可提供準(zhǔn)確診斷所需的60% 80%的信息，但有效地收集資料的技能仍被低估了。所以若忽略了患者的 病史就意味著剝奪了醫(yī)生的一種最重要的診斷工具。The basic outl ine structure for the patie nt history and physical exam usually in cludes the f

6、ollow ing:Identification: patient name, age, gender, race, and occupationChief Complaint: (in the patient s words)HPI: (history of prese nt ill ness)PMHx: (past medical history)Medicatio ns: should in clude curre nt meds as well as medicati on allergies病史和體格檢查的基本框架內(nèi)容通常包括以下內(nèi)容：身份證明：患者姓名，年齡，性別，種族和職業(yè)主述：

7、(用患者的話表達(dá))HPI :現(xiàn)病史PMHx :過(guò)去史藥物史：包括現(xiàn)在使用的藥物以及藥物過(guò)敏史ROS: review of systemsSocial Hx.: in eludes family situati on (married, divorced, sin gle), habits; cigarettes, alcohol orillicit drug use, sexual behaviorPhysical Exam:Impressi on/Diag no sis:Treatme nt Pla n:ROS :系統(tǒng)回顧社會(huì)史：包括婚姻狀態(tài)(已婚、離婚、單身)、習(xí)慣、吸煙、飲酒或吸毒、冶游

8、史體格檢查：診斷：治療方案：Self- introduction:Upon arrival at the patients bedside, the physician should first try toestablish rapport with the patie nt by using“ non verbal cues ” such as maintaining eye con tactor extending a hand to shake the patient s hand (if “ culturally ” acceptable). The physicianor stud

9、ent should first introduce him or herself and state their reason for the visit. Also, they should ask the patie nt s permissi on to in terview them.自我介紹：到達(dá)病人床邊時(shí)，醫(yī)生應(yīng)通過(guò)非言語(yǔ)的方式如保持視線的接觸或伸手去和病人握 手(如果風(fēng)俗上可以接受)來(lái)與病人建立融洽的關(guān)系。醫(yī)生或醫(yī)學(xué)生首先應(yīng)自我介紹并解釋來(lái)看 病人的原因，并且應(yīng)在交流前取得病人的同意。Here are a few specific points about each sect

10、ion of the history outl ine:1. Identification - This should include the patients name, age, sex, race and occupation for example:“ Mr. Jones is a 55 yr. Old Caucasian male who works as a farmer.” The patient s n ame writte n in the history allows future in terviewers to address the patie nt by his n

11、 ame which con veys a sense of patie nt respect. The age, race, sex and occupatio n are an importa nt as many diseases are not only gender and age dependent,but may also occur morecom monly in specific eth nic and occupati on groups.以下是病史相關(guān)部分的說(shuō)明：1. 身份證明-這應(yīng)該包括病人的姓名、年齡、性別、種族和職業(yè)。比如“瓊斯先生是一位55歲的白人男性，職業(yè)是農(nóng)

12、民”。在病史中寫(xiě)明患者的姓名有利于以后的人員用病人的姓名來(lái)和他打招呼，這樣會(huì)使病人產(chǎn)生一種受尊重感。年齡、種族、性別、和職業(yè)都非常重要，因?yàn)樵S多 疾病不僅與性別和年齡有關(guān)，并且在特定的種族或職業(yè)人群中更為常見(jiàn)。2. Chief complaint - This should be written in the patient s words. For example “ chest pain ”rather tha n “ angina ” . Also the durati on of the chief compla int should be no ted“ chest painfor

13、1 hour ” . Before moving on to the HPI, it would be appropriate to perform a“survey ofproblems ” asking the patient if there are any other current problems bothering them. Oncethese have bee n listed, the in terviewer can come back to the orig inal Chief Complai nt the patient presented with and obt

14、ain the details in the HPI. However“associated ” symptomsshould be descried in the HPI.2. 主述-主述應(yīng)該用病人的語(yǔ)言來(lái)寫(xiě)。比如“胸痛”而不是“心絞痛”。而且應(yīng)同時(shí)寫(xiě)明主訴的時(shí)間如胸痛1小時(shí)”。在開(kāi)始采集現(xiàn)病史之前，應(yīng)補(bǔ)充問(wèn)病人是否還有其他不適癥狀。一旦 發(fā)現(xiàn)有其他癥狀應(yīng)補(bǔ)充到主訴中，并在現(xiàn)病史中詳細(xì)描述。但伴隨癥狀應(yīng)在現(xiàn)病史中描述。3. HPI (History of Present Illness) -The history of the present illness is a more elabor

15、ate description of the patient s chief complaint and is the most important structural element of the medical history. This sect ion should give the followi ng details about the chief compla in t (s):3. 現(xiàn)病史-“現(xiàn)病史是對(duì)病人主訴更為詳細(xì)的描述，是病史中最為重要的組成部分?！痹谶@部分中應(yīng)對(duì)主訴從以下幾個(gè)方面加以詳細(xì)描述。a. Detailed description of the“ chief

16、complaint ”； “ a dull crushing chest pain ” including bodylocati on of the compla int.b. A chro no logical history and seque nee of the chief compla int.c. What circumsta nces precipitated it: climb ing stairs, emoti onal upset such as an ger, or sexual in tercourse.d. What circumsta nces relieve it

17、: rest ing for a few minu tes.a. 對(duì)“主訴”更為詳細(xì)地描述；如“壓榨樣胸部悶痛”，應(yīng)包括主訴的部位。b. 主述的發(fā)展變化。c. 誘因：如爬樓梯、情緒激動(dòng)，如發(fā)怒、性生活等。d. 緩解因素：如休息幾分鐘、硝酸甘油。醫(yī)學(xué)全在.線提供4. ROS (Review of Systems) - This sect ion is too ofte n omitted. Although it is somewhat cumbersome to go through a “ complete ” review of systems and it may not be nece

18、ssary todo so for “ each ” admission, at least one “ complete ” review of systems should be documented in the patients medical record. For subsequent admissions the history could simply refer back to the “ complete ROS ” documented on a specified date. However, even with subsequent admissions, a min

19、imum would be to include in the HPI a“ pertinent ” ROSof the orga n - system of Chief complai nt.、/4. ROS(系統(tǒng)回顧)-很多情況下這一部分被省略了。盡管對(duì)每個(gè)系統(tǒng)作一個(gè)完整的回顧有些麻煩，并且每次住院都這么做可能不一定必要，但是在病人的病史記錄中應(yīng)至少有一次完整的系統(tǒng)回顧。此后的住院即可指明參考某年某日這份完整的系統(tǒng)回顧。但是即使在以后的住院病史 中，至少應(yīng)在現(xiàn)病史中對(duì)主訴相關(guān)的器官系統(tǒng)作系統(tǒng)回顧。5. Social History - This secti on is the most n

20、 eglected sect ion of the patie nt history performed in China. Vital in formati on such as smok ing history, use of alcohol or illicit drugs and sexual behavior can give in valuable clues to the diag no sis. Cigarette smok ing is a risk factor for a vast array of diseases in clud ing cancer, coro na

21、ry heart disease, COPD and GI diseases. In China, the prence of smoking among females is only about 5%. However, its gradually increasing among young females. Thus physicia ns freque ntly forget to ask females about their smok ing history. Also documentation of the patient s marital status (divorced

22、) and family situation may give clues to the early diag no sis of an xiety or depressi on. A brief family medical history should also be in cluded if not already men ti oned in the HPI.5. 社會(huì)史-在中國(guó)的大病史中這一部分是最常被忽略的部分。重要的信息如吸煙史、飲酒或吸毒史、性行為對(duì)診斷常能提供非常重要的線索。吸煙是很多疾病的危險(xiǎn) 因素包括癌癥、冠心病、COPD和消化系統(tǒng)疾病。在中國(guó)，女性吸煙率僅為5%。但在青

23、年女性中在逐漸升高。而對(duì)于女病人來(lái)說(shuō)，醫(yī)生常常會(huì)忘記問(wèn)吸煙史。同時(shí)寫(xiě)明婚姻狀況(離婚)和家庭狀況對(duì)于早期診斷焦慮或抑郁也有幫助。如果在現(xiàn)病史未提到，則應(yīng)對(duì)家族史做一簡(jiǎn)單的闡述。Although we ve described a nice, neat“ outline ” for the patient history, when the medicalstude nt first begi ns to in terview take a history, he quickly discovers that fitt ing patie nt s respon ses into a “ n e

24、at ” history and physical outl ine is in deed a challe nge and requires much patienee and practice! Patients have not been told their responses are to “ fit ” into a structured format! When asked a specific questionby the medical student/physicianin terviewer, they may assume they should give as much in formatio n as possible, thus the in terviewer is forced to“ sift ” through their resp onse and retain only the pertinent data for themedical recor