病历书写(英文).ppt

HISTORYRECORDWhat is history recordTheclinicalrecorddocumentsthepatientshistoryandphysicalfindings.Itshowshowcliniciansassessthepatient,whatplanstheymakeonthepatientsbehave,whatactionstheytake,andhowthepatientrespondstotheirefforts.Importance of history record1.DiagnosisandtreatmentpurposeAnaccurate,clear,wellorganizedrecordreflectsandfacilitatessoundclinicalthinking.Itleadstogoodcommunicationamongthemanyprofessionalswhoparticipateincaringforthepatient2.Teachingandresearchpurpose3.MedicolegalpurposesHow to make a good history recordWhencreatingarecord,youdomorethansimplymakealistofwhatthepatienthastoldyouandwhatyouhavefoundonexamination.Youmustreviewyourdata,organizethem,evaluatetheimportanceandrelevanceofeachitem,andconstructaclear,concise,yetcomprehensivereport.How to make a good history record1.Orderisimperative2.Keepitemsofhistoryinthehistory3.Describespecificallyanypertinentnegativeinformation4.Datanotrecordedaredatalost5.Useshortwordsinsteadoflongandprobablyfancieroneswhentheymeanthesamething6.Beobjective7.YoushouldwritetherecordassoonaspossibleBasic requirement for the history record1.Tobewellorganizedandcanonical2.Nomucherasionandgridecouldbedoneinthehistoryrecord3.Tobeobjectiveandaccurate4.Usingprofessionaltermtorecordinsteadoffolksay5.RemembertohaveyoursignatureA.Outline of case record1.BiographicaldataBiographicalinformationofpatientshouldincludehisfullname,age(dateofbirth),sex,race,occupation,nationality,maritalstatusandpermanenthomeaddress.Also,thedateofadmission,thetimeatwhichyoutookthehistory,thesourceofhistoryandestimateofreliabilityshouldbeinvolved.2.chiefcomplaintThechiefcomplaintconsistsofmainsymptom(s)andduration.Itshouldconstituteinafewsimplewordsthemainreasonswhythepatientconsulteddoctorandshouldbestateasnearlyaspossibleinthepatientsownwards.Ingeneral,thechiefcomplaintshouldincludeage,sex,complaint,anddurationofthecomplaint.Itshouldnoincludeddiagnostictermsordiseaseentities.Forexample:”This70-yearoldmanhashadshortbreathforaweek.”3.Historyofpresentillness(HPI)Thehistoryofpresentillnessshouldbeawell-organized,sequentiallydevelopedelaborationofhischiefcomplaint(s)onitsvariouscharacteristics:dateofonset,characterofcomplaint,modeofonset,courseandduration,location,relationshiptoothersymptoms,bodilyfunctionandactivities,exacerbationandremissions,andeffectoftreatment.4.Pasthistory(PH)Itshouldincludeareviewofallpastillnesses,surgicalprocedures,andinjuries,andallergyhistory(medicine,food),whichareparticularlyrelatedtothepresentillness.5.Reviewofsystem(ROS)Thepurposeofsystemreviewistwofold:athoroughevaluationandadoublecheckpreventomissionofsignificantdatarelativetothepresentillness.Thereviewisacomprehensiveaccountofallcomplaintsreferabletoeachbodysystemprogressinginalogicalmannerfromtheheadtowardthefeet,includingrespiratorysystem,cardiovascularsystem,digestivesystem,Urinarysystem,hemopoieticsystem,endocrinesystem,nervoussystemandskeletalsystem.6.Personalhistory(socialandoccupationalhistory)Itincludespersonalhabits(smoking,alcoholdrinking),businesslife,sexlife,occupation(exposuretocertainirritatingagents),conditionofwork.7.MaritalhistoryItincludesdataconcerningthehealthofmate,sexualadjustment,thenumberofchildrenandtheirPhysicalstatus,andthegeneralsocialadjustmentwithinthefamily.8.Menstrualhistory(forfemalepatients)Ageofonset,intervalbetweenperiods,duration,amountandcharacterofflow,concomitantsymptoms,dateoflastmenstruation,ageofmenopause.9.Childbearing(reproductive)historyAgeanddateofpregnancy(ies)andchildbirth(s).Dateofartificialornaturalabortions,stillbirths,operativedelivery,puerperalfever.Methodoffamilyplanning,thepossiblefactorsofinfertility(alsoformalepatients).10.Familyhistory(FH)Thehealthstatusofthepatientsfamily(mother,father,siblingsandchildren)andifdied,theageandcauseofdeathshouldberecorded,suchasdiabetes,hypertension,cancer,obesity,allergicdisorders,coronaryarterydiseaseandmentalillness.11.Physicalexamination(PE)TherecordingofPhysicalexaminationshouldfollowalogicalsequenceasfollows:vitalsigns,generalstatus,skin,nodes,head,neck,chest,lungs,heartandbloodvessels,abdomen,genitalia,rectum,spineandextremities,nervousreflexes.12.LaboratorytestsandinstrumentalexaminationThefindingsofthemonklyservetoconfirmwhatyouhavefoundonhistoryandPhysicalexamination.Theroutinelaboratorystudiesincludeblood,urineandstooltests,electrolytes,X-raysandECG.13Summary14.PrimarydiagnosisAstheresultsofdifferentialanalysisofanumberofsignificantdata,aprimarydiagnosiscouldbeestablished.Itconsistsofetiologicdiagnosis,pathologicaldiagnosis,pathophysioloicaldiagnosis(stageorperiodandclassificationorsubtype),cardiacor/andpulmonaryfunctionandcomplication(s).15.signatureBOutline of SummaryName,gender,ageandoccupationAdmissiondateAhiefcomplainsPresenthistory(70%-80%percentoftheoriginalpresenthistory)Simplifieddocumentoftheoriginalpasthistory(onlypositivedatarecruited)VerysimplifieddocumentoftheoriginalpersonalandfamilyhistoryPhysicalexamination:vitalsigns,importantpositiveandnegativesigns,especiallyvaluableinformationfordifferentiation,butyoucannotomitsuchimportantitemsasheart/lung/abdominalexamination.PositivelaboratoryandinstrumentalresultsExample of case record Biographicaldata:NameLUOLENSHENGAge:30Sex:MMaritalstatus:MarriedNativeplace:ChinaRace:HanOccupation:MechanicDateofAdmissiondate:2003/11/16Statement:patientherselfChiefcomplaint:recurrentabdominalpainandmelenaformorethanoneyearHistoryofpresentillness:Mr.luohasbeensufferedfromabdominalpainandrecurrentmelenasince2002,beganonMay2,2002hehadupperabdominalpainandmelenafirsttime,withnoanyinducementfactors,obscureupperabdominalpainhappenedwithnoradiation,nobelching,novomiting,nofeverandtremor.Painwashungrypainandcanberelievedbyantacidagentorbymeal.Melenaoccurredthreetimesaday,about250geachtime,continuingfor5dayswithlittlefatigue,nohematomeses.Hewenttothelocalcountyhospitalonthethirddayofmelena,wherehereceivedgastroscopythatshowedduodenalbulbulcerswithbleeding.ThenhewasadministeredOmeprazole(PPI)intravenouslyfor6days,40mgeachtime,twiceaday(Bid).Ontheseconddayoftreatment,themelenadisappeared.OnNov.15,2003,withoutanyinducementhehadmelenaagain3timesadayand250-500gm.Everytimeaccompaniedwithfatigueandtimedbutnodizzinessandsyncope.ThistimehewenttothesecondPeopleshospital.HetookPPIbutdidntreceivegastroscopy.AfterreceivingPPI.,melenadisappear.ButtheOB(occultblood)testwasstillpositive.Thenextdayhewasshiftedto1staffiliatedhospitalofGuangxiMedicalUniversityandreceivedfurtherexaminationandtreatment.Thegeneralconditionisgoodandworkisnotaffectedinanywaysincehehadsuchadisease.Pasthistory:Previoushealthstatus:WellordinarybadinfectiousdiseaseImmunizationsallergies:NYclinicalmanifestation:allergenTraumahistory:surgeryhistory:Reviewofsystems:(Tickifpositive,crossoutifnegative.Ifpositive,youshouldwritedownyourdiseasehistoryandbriefcourseofdiagnoseandtherapy)Review of systems:(Tick if positive,cross out ifnegative.If positive,you should write down yourdisease history and brief course of diagnose andtherapy)Respiratorysystem:sorethroatchroniccoughsputumhemoptysiswheezingdyspneachestpainCardiovascularsystem:palpitationdyspneaonexertionhemoptysissyncopeedemaoflowerlimbsprecordialpainhypertentionDigestivesystem:anorexiasourregurgitationbelchingnauseavomitabdominal distention abdominal pain constipation diarrheahematemesismelenahematocheziajaundiceUrinarysystem:lumbago frequent micturition urgent micturition urodynia dysuria hematuria nocturia polyuria oliguriafacialedemaHemopoieticsystem:fatiguedizzinessblurredvisiongingivalbleedingsubcutaneoushemorrhageostealgiaepistaxisMetabolicandendocrinesystem:excessiveappetiteanorexiasweetscoldintoleranceolydipsiapolyuriatremorhandschangeofcharacterobviousobesityemaciationhairinesshairlosingpigmentationchangeofsexualfunctionamenorrheaMusculoskeletonsystem:floatingarthralgiaarthralgiaswellingofjointsdeformitiesmyalgiaatrophyofmuscleNervoussystem:dizziness headache vertigo syncope degenerationofmemoryvisualdisturbanceinsomniadisturbanceofconsciousnesstremorspasmparalysisparesthesiaPersonalhistory:birthplaceoccupationsexualhistory:NYsmoking:NYaboutyrsaveragepieces/dceasedforyrsalcoholintake:Noccasionalfrequentaboutyrsaverageml/dothers:Maritialhistory:marryingagecompanionsstateofhealthMenstruationandChildberinghistory:menarche age-date of last period(age ofmenopause)amountofflow:littlenormallargemenstrualpain:NYcycle:regularirregularpregnancy:timesnaturallabortimesabortionstimesprematuredeliverytimesstillbirithstimesdifficultlaboranditscondition:Family history:(pay attention to the congenital diseasesandcommunicablediseasesrelatedtothepatient)father:stillaliveillnessdiedcauseofdeathmother:stillaliveillnessdiedcauseofdeathsiblings:others:PhysicalexaminationVitalsigns:T36P70/minR20/minBp110/70mmHgGeneralAppearance:development:ortho-sthenic type asthenic type sthenictypenutrition:wellfairlypoorcachexiafacial features:normal acute chronic others expressions:natural painful anxious dreadful indifferentposition:activesemi-recumbentothersgait:normalabnormalconsciousness:aware somnolence confusion stuporcomadeliriumcooperation:wellbadlySkin,mucousmembrane:color:normalredpalecyanosisyellowpigmentationrash:N Y(type and distribution)subcutaneoushemorrhage:NY(typeanddistribution)hair:normalscatteringlosing(position)moistureandtemperature:normalcolddrywetelasticity:normalreducededema:NY(positionanddegree)hepaticpalm:NYspiderangioma:NY(positionnumbers)others:Lymphnodes:superficiallymphnodes:non-swellingswelling(positionandcharacteristics)Head:cranium:size:normallargesmalldeformity:NY(oxycephalysquaredskulldeformingskull)others:tendernessmasssunk(position)eyes:eyelid:normal edema ptosis trichiasis conjunctive:normalhyperemiaedemahemorrhage eyeball:normal exophthalmos depressiontremormotiondysfunction(leftright)sclera:normalyellowcornea:normalabnormal(leftright)pupils:equalroundnesssamesizeunequalleftcm,rightcmreactiontolight:normaldelay(leftright)disappear(leftright)others:ears:auricle:normaldeformityfistulaothers(leftright)excretionsofexternalcanal:NY(leftrightfeature)tendernessofmastoid:NY(leftright)auditiondysfunction:N(leftright)nose:shape:normalabnormal()otherabnormalities:NYnasalflapobstruction excretions nasal sinus tenderness:N Y(position)mouth:lips:redcyanosispaleherpesfissuremucous:normalabnormal(palebleeding)openingofparotidglandduct:normalabnormal(swellingpyogenicexcretions)tongue:normal abnormal(coverings tremor leaningtoleftorright)gums:normalswellingpusoverflowhemorrhagepigmentsteeth:regularedentulouscariousteethfalsetoothtonsils:pharynx:voice:normalhoarseNeck:resistance:N Y carotid arterypulsation:normalincreaseddecreased(leftright)jugular vein:normal distention highdistentiontrachea:middledeviationto(leftright)hepatojugularreflux:(-)(+)thyroid:normalswellingdegreesymmetrydominanceinoneside:spreadingnodular:softhardothers:NY(tendernesstremorbruits)Chest:topography:normalbarrelchestflatchestpigeonchestfunnelchestbulgingorretraction(leftright)bulgingintheprecordialregiontendernessofsternumbreast:normalsymmetricalabnormal:leftright(gynecomastiamasstenderness)excretionsofnipples)Lung:inspection:movement of respiration:normal abnormal:leftright(increaseddecreased)intercostalsspace:normalwidenarrow(position)palpation:vocalfremitus:normalabnormal:leftright(increaseddecreased)pleuralfrictionrubs:NY(position)percussion:resonance abnormal:dullness flatnesshyperresonancetympanylowerborders:scapular line:right intercostalsspaceleftintercostalsspacerangeofmobility:rightcm,leftcmauscultation:breath:regularirregularbreath sound:normal abnormal(feature,position)rales:NY:rhonchi:sonoroussibilantmoistrales:coarsemediumfineralescrepitusvocalconduction:normalabnormal:reducedincreasedPleuralfrictionrubs:NY(position)Heart:inspection:bulginginprecordialregion:NYapeximpulse:normalunseenincreaseddiffusingpoisition:normaldeviation(thedistancefrommidclavicularlinecm)other precordial pulsations:N Y(position )palpation:apex impulse:normal increased thrustunclearthrills:NY(positionperiod)pericardialfrictionrubsNYpercussion:relative cardiacoutline:normalshrinkextant(rightleft)Normalboundaryoftheheartright(cm)intercostalsspaceleft(cm)2-32-32-33.5-4.53-45-6distancefromanteriormidlinetotheleftmidclavicularline(cm):auscultation:heartratebpm/minrhythm(regularirregularabsolutelyirregular)heart sound:S1 normal increased decreased split S2 normal increased decreasedS2split:normalfixedparadoxicalS3NYS4NYA2P2extra heart sound:N gallop(diastolic presystolicsummationgallop)openingsnapothersmurmurs:NYLocation:apicalregionaorticareapulmonaryareatricuspidarealeft sternal border in 3nd intercostals space OthersTiming:systolicdiastolicbothQuality:blowingrumblingsighingmusicalAustinFlintGrahamSteellGibsonIntensity:Grade Transmission:NYdirectiontoleftaxillaovertheapexoverthecarotidarteriesPericardialfrictionrubs:NYPeripheral vessels:normal pistol shot:N Y Duroziezsign:NYwaterhammerpulse:NYcapillarypulsation:NYpulsedeficit:NYparadoxicalpulse:NYpulsealternations:NYothersAbdomen:inspection:shape:normaldistentionfrogbellycmscaphoidabdomenapicalbellygastric pattern intestinal pattern peristalsis abdominalrespiration:existdisappearumbilicus:normalprotrudingexcretionsothers:NY(venousdistentionofabdomenpurplestriaesurgicalcarshernia)palpation:soft muscle tension position tenderness:NYreboundtenderness:NYfluidtrill:NYsuccusionsplash:NYmassesNY(positionsize)descriptionoffeature:liver:nottouchedbetouched:subcostalcmdescriptionoffeature:gallbladder:nottouchedbetouched:sizecmtenderness:NYMurphyssigh(+)(-)spleen:not touched be touched:from costal margin cmdescriptionoffeature:kidney:nottouchedbetouched:sizeconsistencytendernessmobilitytendernessofureters:NY(position)percussion:bordersofliverdullness(existshrinkobliteration)upper border of liver:on right midclavicular line intercostalsspaceshiftingdullness:N Y tenderness inrenalregion:NY(rightleft)auscultation:gurgling sound:normal increased decreaseddisappearvesselbruits:NY(position)Genitalia:notexaminednormalabnormal:Rectum and Anus:not examined normal abnormal:SpineandExtremities:spine:normal deformities(lateral anterior posteriorprotruding)acanthi:tendernesspainatpercussion(position)mobility:normalrestrictedlimbs:normalabnormaldeformityswellingofjointsjointsstiffnesstendernessofmusclesatrophyofmusclesvenous distention of lower limbs(position andfeature)acropachyNervoussystem:muscletone(normalincreaseparatonia)myodynamia(0)paralysisoflimbs:NY(leftrightupperlower)reflex:abdominal wall reflex(upper middle lower normalabnormal)bicepsreflex:left(normalabnormal)right(normalabnormal)tricepsreflex:left(normalabnormal)right(normalabnormal)patellarreflex:left(normalabnormal)right(normalabnormal)achillesreflex:left(normalabnormal)right(normalabnormal)Hoffmann sign:left(+)(-)right(+)(-)Babinskisigh:left(+)(-)right(+)(-)Oppenheimsigh:left(+)(-)right(+)(-)Kernig sign:left(+)(-)right(+)(-)Burdzinskisign:left(+)(-)right(+)(-)Laboratoryfindings(Theimportantlaboratoryexaminations,X-ray,ECGandotherresultareincluded)AbstractMr.luo,30yearsold,hasbeensufferedfromabdominalpainandrecurrentmelenaformoret