Case History 病史
⏹ In-Patient Case History 住院病历
Items of Case History
1. General Data, Biographical Data 一般项目
2. Chief Complaints (C. C.) 主诉 3. Present Illness (P. I.) 现病史
伤花怒放4. Past (Medical) History (P. H.) 既往病史
5. Personal History (Per. H.)/ Social History 个人史/社会史
6. Family History (F. H.) 家族史
7. Medications 曾用药物
8. Allergies 过敏史
9. System Review, Review of Systems 系统回顾
10. Physical Examination (P. E.) 体格检查/查体
11. Laboratory Data 实验室与其他检查/检查资料
12. Impression (Imp.) (Diagnosis) 诊断
13. Hospital Course 住院情况记录
14. Discharge Instructions/ Recommendations出院医嘱
15. Discharge Medications 出院后用药
General Data, Biographical Data 一般项目
⏹Reliability (病历可靠性):
Reliable(可靠)/ Not Entirely(不完全可靠)/
Not Clearly Defined (不够准确)/
Confused and Uncertain (混乱不清)/ Unobtainable (无法获得)
⏹Supplier/ Complainer of History (供史者/病史陈述者):
Patient/ Husband/ Wife/ Father/ Mother/ Colleague/ Neighbor
Chief Complaints (C. C.) 主诉: 病例重要部分之一，通常包括患者年龄、简要的相关的既往史、患者的就诊原因及目前症状持续的时间等。 ⏹Language Characteristics
1) Common expressions
① symptom+since+time(时间点)
② symptom+for+time(时间段)
③ symptom+of+time (时间段名词所有格)+duration
④ symptom+time(时间段)+in duration
⑤ time(时间段合成词)+history+of+symptom
⑥ complete sentence: The duration of +symptom+was/ has been+time(时间段)（少见）
2) Common sentence patterns for chief complaints
① …was admitted/seen with a chief complaint of…
② …complain chiefly of…
③ …presented/entered with/came to the office with a chief complaint of
④ …was admitted because of…
⑤ …was involved in…
⑥ …was transferred to…because…
下面是书写主诉是最常用的格式：电报码
CC：The patient is a (age)-year-old (race,ethnic,group,occupation,sex and/or very pertinent PMH),who is admitted to the hospital with a chief complaint of (symptom,not a sign or diagnosis) of (number followed by a unit of time) duration.
Example
主诉：患者是一个48岁的妇女。入院主诉，6个月来，出力后心悸和呼吸困难。
CHIEF COMPLAINT: The patient is a 48-year-old female, admitted with the chief complaint of palpitation and dyspnea following physical exertion for 6 months.
History of Present Illness 现病史：是从医生的角度，进一步表述主诉内容，全面表述现有疾病的发病时间、主要症状、病情发展过程、症状间的联系、诊疗过程、目前患者身体状况、与现有疾病有直接关系的既往史等。记录患者入院情况时，多用一般过去时或过去完成时；记录目前病情时，用一般现在时或现在完成时。 ⏹Language Characteristics
FOS1) Sentence Patterns with Patients to Be Subject 以病人做主语的句型
① start having 开始有……的症状
② begin having episodes of… 开始发生……的症状/疾病
③ become… 变得……
④ notice(perceive, note, recognize…)+症状/疾病
⑤ have… 有……症状/疾病
⑥ have abrupt/sudden/explosive onset of… 突然患logo语言……
⑦ have episode of…/have attack of…患……
⑧ develop+disease 出现/有了……症状/疾病
⑨ …are/is the prodrome of… ……的前驱症状
2) Sentence with symptoms, illnesses as subjects 以症状、疾病做主语的句型
① begin (occur, start…)+time 从……开始
② date (go back) to +time 可追溯到……
③ be present+time 在/从……已存在
④ be preceded by… 在……之前已有
⑤ be followed by… 在……之后紧接着发生
⑥ be accompanied by…/ coincide with… 与……同时发生
⑦ be (not) related to…/have (no) correlation with… 与……有（无）关
3) Illness’ improving and worsening
表达疾病的好转与恶化
① last+time 持续……时间
② take a bad turn; take a turn for the worse; be aggravated/exacerbated; become worse 恶化
③ take a good turn/take a turn for the better/improve 好转
④ be aggravated/abated/alleviated by… 因……而加剧/减轻
⑤ remain the same/unchanged 无变化
⑥ be (not) improved after treatment with… 经用……而（无）好转
⑦ (The symptom) cease/clean up/disappear/subside 症状消失/减退
4) No symptoms 没发生……症状、疾病
① …without/with no/free of… (symptoms)
② There be no history of…/…have no history of…
③ (The patient) denies…
④ (The patient) noted no…
激点文学⑤ (The patient) was not found to be…
5) Description of main symptoms 描述主要症状
① …assume the character of/be characterized by…
张志俊太极拳② …have/present/develop/show/manifest the symptoms of…
Past (Medical) History (P. H.)既往病史
⏹Common expressions
① had been sound/well until; had enjoyed good health until… 在……前一直健康
② be apt/liable/subject to…;tend to have… 易患……
③ …was admitted to hospital for…/ …was hospitalized for… 曾因……而住院
④…had (some illness) with recovery after… 曾有（疾病），因…痊愈
⑤ …was diagnosed as…/…was suspicious of… 断为……/疑为……
⑥…was exposed to (toxic substances)/ …had to breathe (poisoning gases) 接触/吸入
⑦…was inoculated against…接种过……
⑧…was discharged/ dismissed from hospital…/ …was out of hospital…出院
Personal History (Per. H.)/ Social History 个人史/社会史
⏹Note: menstruation
经期（天）
menstrual period
menarche age——————age of menopause
（初潮年龄menstrual cycle （绝经年龄）
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