病歷書寫英文課件

1、HISTORY RECORD第1頁，共43頁。What is history recordThe clinical record documents the patients history and physical findings. It shows how clinicians assess the patient, what plans they make on the patients behave, what actions they take, and how the patient responds to their efforts .第2頁，共43頁。Importance o

2、f history record1. Diagnosis and treatment purpose An accurate, clear, well organized record reflects and facilitates sound clinical thinking. It leads to good communication among the many professionals who participate in caring for the patient 2. Teaching and research purpose3. Medicolegal purposes

3、 第3頁，共43頁。How to make a good history recordWhen creating a record, you do more than simply make a list of what the patient has told you and what you have found on examination. You must review your data, organize them, evaluate the importance and relevance of each item, and construct a clear, concise

4、, yet comprehensive report. 第4頁，共43頁。How to make a good history record1. Order is imperative2. Keep items of history in the history 3. Describe specifically any pertinent negative information 4. Data not recorded are data lost 5. Use short words instead of long and probably fancier ones when they me

5、an the same thing 6. Be objective7. You should write the record as soon as possible 第5頁，共43頁。Basic requirement for the history record1. To be well organized and canonical2. No much erasion and gride could be done in the history record3. To be objective and accurate4. Using professional term to recor

6、d instead of folksay5. Remember to have your signature第6頁，共43頁。A. Outline of case record1. Biographical data Biographical information of patient should include his full name, age (date of birth), sex, race, occupation, nationality, marital status and permanent home address. Also, the date of admissi

7、on, the time at which you took the history, the source of history and estimate of reliability should be involved.2. chief complaint The chief complaint consists of main symptom(s) and duration. It should constitute in a few simple words the main reasons why the patient consulted doctor and should be

8、 state as nearly as possible in the patients own wards. In general, the chief complaint should include age, sex, complaint, and duration of the complaint. It should no included diagnostic terms or disease entities. For example:” This 70-year old man has had short breath for a week.”第7頁，共43頁。3. Histo

9、ry of present illness (HPI) The history of present ill ness should be a well-organized, sequentially developed elaboration of his chief complaint(s) on its various characteristics: date of onset, character of complaint, mode of onset, course and duration, location, relationship to other symptoms, bo

10、dily function and activities, exacerbation and remissions, and effect of treatment.4. Past history (PH) It should include a review of all past ill nesses, surgical procedures, and injuries, and allergy history (medicine, food), which are particularly related to the present illness.第8頁，共43頁。5. Review

11、 of system (ROS) The purpose of sys tem review is twofold: a thorough evaluation and a double check prevent omission of significant data relative to the present illness. The review is a comprehensive account of all complaints referable to each body system progressing in a logical manner from the hea

12、d toward the feet, including respiratory system, cardiovascular system, digestive system, Urinary system, hemopoietic system, endocrine system, nervous system and skeletal system.6. Personal history (social and occupational history) It includes personal habits (smoking, alcohol drinking), business l

13、ife, sex life, occupation (exposure to certain irritating agents), condition of work.第9頁，共43頁。7. Marital history It includes data concerning the health of mate, sexual adjustment, the number of children and their Physical status, and the general social adjustment within the family.8. Menstrual histo

14、ry ( for female patients) Age of onset, interval between periods, duration, amount and character of flow, concomitant symptoms, date of last menstruation, age of menopause.9. Childbearing (reproductive) history Age and date of pregnancy(ies) and childbirth(s). Date of artificial or natural abortions

15、, stillbirths, operative delivery, puerperal fever. Method of family planning, the possible factors of infertility (also for male patients).第10頁，共43頁。10. Family history (FH) The health status of the patients family (mother, father, siblings and children) and if died, the age and cause of death shoul

16、d be recorded, such as diabetes, hypertension, cancer, obesity, allergic disorders, coronary artery disease and mental illness.11. Physical examination (PE) The recording of Physical examination should follow a logical sequence as follows: vital signs, general status, skin, nodes, head, neck, chest,

17、 lungs, heart and blood vessels, abdomen, genitalia, rectum, spine and extremities, nervous reflexes.12. Laboratory tests and instrumental examination The findings of them onkly serve to confirm what you have found on history and Physical examination. The routine laboratory studies include blood, ur

18、ine and stool tests, electrolytes, X-rays and ECG.第11頁，共43頁。13 Summary14. Primary diagnosis As the results of differential analysis of a number of significant data, a primary diagnosis could be established. It consists of etiologic diagnosis, pathological diagnosis, pathophysioloical diagnosis (stag

19、e or period and classification or subtype), cardiac or/and pulmonary function and complication(s).15.signature第12頁，共43頁。BOutline of SummaryName, gender, age and occupationAdmission dateAhief complainsPresent history(70%-80% percent of the original present history )Simplified document of the original

20、 past history(only positive data recruited)Very simplified document of the original personal and family historyPhysical examination: vital signs, important positive and negative signs, especially valuable information for differentiation, but you can not omit such important items as heart/lung/abdomi

21、nal examination. Positive laboratory and instrumental results第13頁，共43頁。Example of case record Biographical data:NameLUO LEN SHENG Age: 30 Sex: M Marital status: Married Native place: China Race: HanOccupation : Mechanic Date of Admission date: 2003/11/16Statement: patient herself第14頁，共43頁。Chief comp

22、laint: recurrent abdominal pain and melena for more than one yearHistory of present illness: Mr. luo has been suffered from abdominal pain and recurrent melena since 2002, began on May 2,2002 he had upper abdominal pain and melena first time, with no any inducement factors, obscure upper abdominal p

23、ain happened with no radiation, no belching ,no vomiting, no fever and tremor. Pain was hungry pain and can be relieved by antacid agent or by meal. Melena occurred three times a day, about 250g each time, continuing for 5 days with little fatigue, no hematomeses. He went to the local county 第15頁，共4

24、3頁。hospital on the third day of melena, where he received gastroscopy that showed duodenal bulb ulcers with bleeding. Then he was administered Omeprazole (PPI) intravenously for 6 days, 40mg each time, twice a day (Bid). On the second day of treatment, the melena disappeared . On Nov. 15, 2003, with

25、out any inducement he had melena again 3 times a day and 250-500gm. Every time accompanied with fatigue and timed but no dizziness and syncope. This time he went to the second Peoples hospital. He took PPI but didnt receive gastroscopy. After receiving PPI., melena disappear. But the OB(occult blood

26、) test was still positive. The next day he was shifted to 1st affiliated hospital of Guangxi Medical University and received further examination and treatment. The general condition is good and work is not affected in any way since he had such a disease.第16頁，共43頁。Past history: Previous health status

27、: Well ordinary bad infectious disease Immunizations allergies: N Y clinical manifestation: allergen Trauma history: surgery history:Review of systems: (Tick if positive, cross out if negative. If positive, you should write down your disease history and brief course of diagnose and therapy)第17頁，共43頁

28、。Review of systems: (Tick if positive, cross out if negative. If positive, you should write down your disease history and brief course of diagnose and therapy)Respiratory system:sore throat chronic cough sputum hemoptysis wheezing dyspnea chest pain第18頁，共43頁。Cardiovascular system:palpitation dyspnea

29、 on exertion hemoptysis syncope edema of lower limbs precordial pain hypertentionDigestive system:anorexia sour regurgitation belching nausea vomit abdominal distention abdominal pain constipation diarrhea hematemesis melenahematochezia jaundiceUrinary system:lumbago frequent micturition urgent mict

30、urition urodynia dysuria hematuria nocturia polyuria oliguria facial edema第19頁，共43頁。Hemopoietic system:fatigue dizziness blurred vision gingival bleeding subcutaneous hemorrhage ostealgia epistaxisMetabolic and endocrine system:excessive appetite anorexia sweets cold intolerance olydipsia polyuria t

31、remor hands change of character obvious obesity emaciation hairiness hair losing pigmentation change of sexual function amenorrheaMusculoskeleton system:floating arthralgia arthralgia swelling of joints deformities myalgia atrophy of muscle第20頁，共43頁。Nervous system:dizziness headache vertigo syncope

32、degeneration of memory visual disturbance insomnia disturbance of consciousness tremor spasm paralysis paresthesiaPersonal history:birthplace occupation sexual history: N Y smoking: N Y about yrs average pieces/d ceased for yrs alcohol intake: N occasional frequentabout yrs average ml/d others:Marit

33、ial history:marrying age companions state of health第21頁，共43頁。Menstruation and Childbering history:menarche age - date of last period (age of menopause) amount of flow: little normal large menstrual pain: N Y cycle: regular irregular pregnancy: times natural labor times abortions times premature deli

34、very timesstillbiriths times difficult labor and its condition:Family history: (pay attention to the congenital diseases and communicable diseases related to the patient)father: still alive illness died cause of death mother: still alive illnessdied cause of death siblings: others:第22頁，共43頁。Physical

35、 examinationVital signs: T 36 P 70 /min R 20 /min Bp 110 /70 mmHgGeneral Appearance:development: ortho-sthenic type asthenic type sthenic type nutrition: well fairly poor cachexia facial features: normal acute chronic others expressions: natural painful anxious dreadful indifferent position: active

36、semi-recumbent others gait: normal abnormalconsciousness:aware somnolence confusion stupor coma delirium cooperation:well badly第23頁，共43頁。Skin, mucous membrane: color: normal red pale cyanosis yellow pigmentationrash: N Y (type and distribution) subcutaneous hemorrhage: N Y (type and distribution)hai

37、r: normal scattering losing (position) moisture and temperature: normal cold dry wetelasticity: normal reduced edema: N Y (position and degree) hepatic palm: N Yspider angioma: N Y (position numbers) others: 第24頁，共43頁。Lymph nodes:superficial lymph nodes: non-swellingswelling (position and characteri

38、stics)Head:cranium:size:normal large small deformity:N Y(oxycephaly squared skull deforming skull)others: tenderness mass sunk (position )eyes: eyelid: normal edema ptosis trichiasis conjunctive: normal hyperemia edema hemorrhage eyeball: normal exophthalmos depression tremormotion dysfunction (left

39、 right) 第25頁，共43頁。sclera: normal yellow cornea: normal abnormal (left right )pupils: equal roundness same size unequal left cm, right cmreaction to light: normal delay (left right ) disappear (left right ) others:ears: auricle: normal deformity fistula others (left right )excretions of external cana

40、l: N Y (left right feature )tenderness of mastoid: N Y (left right ) audition dysfunction: N (left right )nose: shape: normal abnormal( ) other abnormalities: N Y nasal flapobstruction excretions nasal sinus tenderness: N Y (position )第26頁，共43頁。mouth: lips: red cyanosis pale herpes fissure mucous: n

41、ormal abnormal (pale bleeding)opening of parotid gland duct: normal abnormal (swelling pyogenic excretions)tongue: normal abnormal (coverings tremor leaning to left or right )gums: normal swelling pus overflow hemorrhage pigmentsteeth: regular edentulous carious teeth false toothtonsils: pharynx: vo

42、ice: normal hoarse第27頁，共43頁。Neck: resistance: N Y carotid artery pulsation: normal increased decreased (left right)jugular vein: normal distention high distention trachea: middle deviation to (left right)hepatojugular reflux: (-) (+) thyroid: normal swelling degree symmetrydominance in one side:spre

43、ading nodular: soft hard others: N Y (tenderness tremor bruits ) 第28頁，共43頁。Chest: topography: normal barrel chest flat chest pigeon chest funnel chestbulging or retraction (left right) bulging in the precordial region tenderness of sternumbreast: normal symmetrical abnormal: left right (gynecomastia

44、 mass tenderness)excretions of nipples )第29頁，共43頁。Lung:inspection: movement of respiration: normal abnormal: left right (increased decreased)intercostals space: normal wide narrow (position )palpation: vocal fremitus: normal abnormal: left right (increased decreased)pleural friction rubs: N Y (posit

45、ion )percussion: resonance abnormal: dullness flatness hyperresonance tympanylower borders: scapular line: right intercostals space left intercostals spacerange of mobility: right cm, left cm第30頁，共43頁。auscultation: breath: regular irregularbreath sound: normal abnormal (feature, position )rales: N Y

46、: rhonchi: sonorous sibilant moist rales: coarse medium fine rales crepitusvocal conduction: normal abnormal: reduced increasedPleural friction rubs: N Y (position )第31頁，共43頁。Heart:inspection: bulging in precordial region: N Y apex impulse: normal unseen increased diffusingpoisition: normal deviatio

47、n (the distance from midclavicular line cm)other precordial pulsations: N Y (position )palpation:apex impulse: normal increased thrust unclearthrills: N Y (position period ) pericardial friction rubs N Ypercussion: relative cardiac outline: normal shrink extant (right left)第32頁，共43頁。 Normal boundary

48、 of the heart right(cm) intercostals space left(cm) 2-3 2-3 2-3 3.5-4.5 3-4 5-6 distance from anterior midline to the left midclavicular line(cm):第33頁，共43頁。auscultation: heart rate bpm/min rhythm (regular irregular absolutely irregular)heart sound: S1 normal increased decreased split S2 normal incre

49、ased decreasedS2 split: normal fixed paradoxical S3 N Y S4 N Y A2 P2extra heart sound: N gallop (diastolic presystolic summation gallop) opening snap othersmurmurs: N Y第34頁，共43頁。Location: apical region aortic area pulmonary area tricuspid arealeft sternal border in 3nd intercostals space OthersTimin

50、g: systolic diastolic bothQuality: blowing rumbling sighing musical Austin Flint Graham Steell GibsonIntensity: Grade Transmission: N Y direction to left axilla over the apex over the carotid arteriesPericardial friction rubs: N Y第35頁，共43頁。Peripheral vessels: normal pistol shot: N Y Duroziez sign: N

51、 Ywater hammer pulse: N Y capillary pulsation: N Ypulse deficit: N Y paradoxical pulse: N Y pulse alternations: N Y othersAbdomen:inspection: shape: normal distention frog belly cm scaphoid abdomen apical bellygastric pattern intestinal pattern peristalsis abdominal respiration: exist disappearumbil

52、icus: normal protruding excretionsothers: N Y (venous distention of abdomen purple striae surgical cars hernia)第36頁，共43頁。palpation: soft muscle tension position tenderness: N Y rebound tenderness: N Yfluid trill: N Y succusion splash: N Y masses N Y (position size)description of feature:liver: not t

53、ouched be touched: subcostal cmdescription of feature:gallbladder: not touched be touched: size cm tenderness: N Y Murphys sigh(+) (-) spleen: not touched be touched: from costal margin cmdescription of feature:第37頁，共43頁。kidney: not touched be touched: size consistency tenderness mobilitytenderness

54、of ureters: N Y (position )percussion: borders of liver dullness (exist shrink obliteration)upper border of liver: on right midclavicular line intercostals spaceshifting dullness: N Y tenderness in renal region: N Y (right left )auscultation: gurgling sound: normal increased decreased disappearvesse

55、l bruits: N Y (position )第38頁，共43頁。Genitalia: not examined normal abnormal:Rectum and Anus: not examined normal abnormal:Spine and Extremities:spine: normal deformities (lateral anterior posterior protruding)acanthi: tenderness pain at percussion (position ) mobility: normal restrictedlimbs: normal

56、abnormal deformity swelling of joints joints stiffnesstenderness of muscles atrophy of musclesvenous distention of lower limbs (position and feature ) acropachy第39頁，共43頁。Nervous system:muscle tone (normal increase paratonia) myodynamia (0 )paralysis of limbs: N Y (left right upper lower)reflex: abdo

57、minal wall reflex (upper middle lower normal abnormal)biceps reflex: left (normal abnormal ) right (normal abnormal )triceps reflex: left (normal abnormal ) right (normal abnormal )patellar reflex: left (normal abnormal ) right (normal abnormal )achilles reflex: left (normal abnormal ) right (normal

58、 abnormal )第40頁，共43頁。Hoffmann sign: left (+) (-) right (+) (-) Babinski sigh: left (+) (-) right (+) (-)Oppenheim sigh: left (+) (-) right (+) (-)Kernig sign: left (+) (-) right (+) (-) Burdzinski sign: left (+) (-) right (+) (-)Laboratory findings(The important laboratory examinations, X-ray, ECG and other result are included) 第41頁，共43頁。AbstractMr. luo, 30 years old, has been suffered from abdominal pain and recurrent melena for more than one