医学英语病历报告书写(简易版).docVIP

Case History Definition A case history is a medical record of a patient’s illness. It records the whole medical case and functions as the basis for medical practitioners to make an accurate diagnosis and proposes effective treatment or preventive measures. Case histories fall into two kinds: in-patient case histories and out-patient case histories. Language Features History and Physical usually involves past tense ( for history of present illness, past medical history, family history and review of systems concerning past information), and present tense ( review of system, physical examination, laboratory data, and plans ). Structurally, noun phrases are frequently used in physical examination, and ellipsis of subject is very common in review of system. In-patient Case Histories An in-patient case history is also termed as History and Physical. It is an account of a patient’s present complaints with descriptions of his past medical history,and the description of the present conditions as well as physical examinations and impression about the conditions.Format It usually consists of chief complaint, history of present illness, past medical history, review of systems, physical examination, impression, family history, social history, medications, allergies, laboratory on admission, and plan. However, what parts are included depends on the needs. 住院病人病历完整模式 病历（Case History） 姓名(Name) 职业(Occupation) 性别(Sex) 住址(Address) 年龄(Age or DOB) 供史者(Supplier of history) 婚姻(Marital status) 入院日期(Date of admission) 籍贯(Place of birth) 记录日期(Date of record) 民族(Race) 主述(C.C.) 现病史(HPI or P.I.) 过去史(PMH or P.H.) 社会活动史/个人史(SHx or Per.H.) 家族史(FHx or F.H.) 曾用药物(Meds) 过敏史(All) To be continued 系统回顾(ROS) 体格检查(PE or P.E.) 体温(T) 呼吸(R) 血压(BP) 脉搏(P) 一般状况(General status) 皮肤黏膜(Skin mucosa) 头眼耳鼻喉(HEENT) 颈部(Neck) 胸部与心肺(Chest, Heart and Lungs) 腹部(Abdom