英文电子病历.doc

英文病历全攻略一、主要調查項目：1.主訴chief complaint：weakness, malaise, chills, fever, sleep, pain, headache, appetite, weight, stomach and bowels, nausea and vomiting, diarrhea, urine, genitalia, neuropsychiatric disorders, respiration, shortness of breath, bleeding or discharge, etc.2.現症歷present illness：onset(date, mode), duration before present entry, exciting cause and environmental influences, prodromal symptoms, general symptoms, course or progress( location, duration, severity, continuity, intermission, radiation, treatment), aggravating and alleviating factors, loss of weight, appetite and strength, sleep, bowel movement, frequency of urination, menstruation, etc.3.既往歷past history：1)former places of residence, previous stage of health( 健壯的robust，纖弱的delicate), experience with similar disease, immunity to infectious disease2)previous illness：麻疹measles, 腮腺炎mumps, 水痘chicken-pox, 百日咳pertussis, 流行性感冒influenza, 猩紅熱scarlet fever, 白喉diphtheria，傷寒typhoid fever, 支氣管炎bronchitis, 肺炎pneumonia，腦炎encephalitis,腦膜炎meningitis，破傷風tetanus,小兒麻痺poliomyelitis,赤痢dysentery，霍亂cholera, 胸膜炎pleurisy,天花small-pox，瘧疾malaria,結核病tuberculosis，黃疸病jaundice，過敏性反應allergy,etc3)venereal disease：specific symptoms, signs, and the disease by name, treatment.4)Accidents( date, any disability, sequelae), operation and hospitalization (date , procedure, name of hospital , physician, complications, bleeding tendency)4.家族歷family history：family tendency, presence of hereditary disorders, cancer, tuberculosis, mental disorder and nervous affection, rheumatism, diabetes, hypertension, cerebral vascular accident, hemophilia, syphilis, tumor, epilespsy, allergy, contact with diseased individuals, relationship of patient’s childhood and adult life, age, health condition, and cause of death of parents, grandparents, self , spouse, siblings , or relatives.5.個人歷personal history：1)Social history：fears, metal status, education, financial condition, number of dependents, family harmony or fractious , hygienic condition at ho