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( 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(Abdomen) 肛门直肠(Anus & rectum) 外生殖器(External genitalia) 四肢脊柱(Extremities & spine)
神经反射(Nerve reflex) To be continued 化验室资料(Lab data) (Blood test, Chem-7, EKG, EEG, X-ray examinations or X-ray slides, CT and NMR…) 印象与诊断(Impression and diagnosis, or Imp) 住院治疗情况记录(Hospital course) 出院医嘱(Discharge instructions or recommendations) 出院后用药(Discharge medications) 医师签名(Signature) Patterns and contents of an out-patient case history Contents: general data (GD), chief complaint (CC), present illness (PI), physical examination (PE), tentative diagnosis (TD) or impression (Imp), treatment (Rp), etc. An out-patient case history should be written in brief and to the very point. More abbreviations and noun phrases are used. Sample of an out-patient case history Male, 39 year old CC: Fever, headache and cough for two days. PE: G.C. looks fair. Pharynx congested and tonsils enlarged. Chest and abdomen negative. Imp: U.R.I. Rp: Penicillin 400,000u. (i.m.) q.d. x 3 days. Aspirin 1 tab. t.i.d. x 2 days. Vit C 100 mg t.i.d. x 3 days Signature Chief Complaint (C.C.)
  1. Sentence patterns in chief complaint ? 症状+for+时间 ? 症状+of+时间+duration ? 症状+时间+in duration ? 时间+of+症状 ? 症状+since+时间 Chief Complaint (C.C.)
  2. Commonly-used complaints: ? weakness, malaise, chills, fever, pain, headache, nausea and vomiting, diarrhea, neuro-psychiatric disorders, shortness of breath, bleeding or discharge, insomnia, stomachache, dyspepsia, no appetite, dysuria, cough, difficulty in coughing up sputum, sore throat, dizziness, palpitation, restlessness, etc. ?弱点,不适感,发冷、发烧、疼痛、头痛、恶心、
呕吐、腹泻、neuro-psychiatric 紊乱、气短、出血或排放、失眠、胃痛,消化不良,没有胃口,排尿困难、 咳嗽、咳痰、困难、喉咙痛、头晕、心悸、不安等。
? Present Illness (P.I.)简明病历书写手册.doc(p.27-
  35) The course of onset ? Date of onset ? Mode of onset ? Prodromal symptoms The cardinal symptoms The attack of illness The development of symptoms Diagnosis and treatment General condition Example
Special language structures in presenting present illness
  1. Describing the course of onset ? … started / began having / feeling … ? … first noticed / noted / perceived / recognized the onset of … ? … are the prodrome of …, … herald … Special language structures in presenting present illness
  2. Describing the mode and regularity of onset ? explosively / suddenly / acutely / abruptly ? gradually / chronically / increasingly / insidiously ? occasionally / accidentally ? often / frequently / in frequency / recurrently ? persistently / intermittently
爆炸性/突然/强烈?/突然 长期/越来越多?逐渐/ /在不知不觉之中 ?偶尔/偶 经常/经常在
  0.9%的频率/的循环 ?持久/断断续续的
Special language structures in presenting present illness
  3. Describing the cardinal symptoms ? … had / presented / developed / showed / manifested … ? … characterized by … ? … admits to … ? … states that … ? … feels … ? … denies …, … without / free of symptoms… Special language structures in presenting present illness
  4. Describing the attack of illness ? … appeared / occurred / came on … ? … had / developed episodes / attacks of … ? … was associated with …, …was accompanied by …, … was followed by …, … had relation to … ? … was preceded / heralded by … Special language structures in presenting present illness
  5. Describing the development of symptoms ? … disappeared / ceased / subsided … ? … took a favorable turn …., …took a turn for the better …, …relieved / improved / alleviated … ? … took a bad / unfavorable turn …, … took a turn for the worse …, …was aggravated / intensified / exacerbated by … ? … remained the same as …, … continued, … persisted without change Past History (P.H.) 简明病历书写手册.doc(p.
  36) History of vaccination and infectious diseases History of allergy to drugs and other substances History of surgical operation and external injury Systematic review of the past history and disease Special language structures in presenting past history … had enjoyed good health until… / … had been sound / well / healthy until… … had never been ill before … / had no illness of any kind before …
… denied any history of / had no related history of / … denied experiencing / having attack of … No history of … / No history suggestive of / indicative of … … suffered from … / … had an attack of … / … was attacked / troubled by / … had a past history of … Except for … had no … / … no … apart from / but … Common diseases mentioned in past history measles, mumps, chicken-pox, smallpox, pertussis, influenza, scarlet fever, diphtheria, typhoid fever, bronchitis, pneumonia, encephalitis, meningitis, tetanus, poliomyelitis, dysentery, cholera, pleurisy, tonsillitis, rheumatism, malaria, tuberculosis, jaundice, allergy, sexually transmitted diseases, gonorrhea, syphilis, sequela, complication, hospitalization…
麻疹,腮腺炎,chicken-pox氮、天花、百日咳、流行性感冒、猩红热、白喉、伤寒、支气管炎、肺炎、脑炎、脑 膜炎、破伤风、脊髓灰质炎(小儿麻痹)、痢疾、霍乱、胸膜炎、扁桃体炎、风湿、疟疾、肺结核、黄疸、过敏、 性传播疾病、淋病、梅毒、后遗症、并发症、住院…
Personal History (Per.H.) / Social History 简明病历书写手册.doc(p.
  37) Life style and habit Occupation and working environment Marital & childbearing history Menstrual history Traveling history Special language structures in presenting personal habits …have a long history of smoking / drinking …have a lifelong like / dislike for… …admitted to excessive use of… …denies the use of alcoholic beverages Special language structures in presenting occupational history …work / act / serve as… …be engaged in… …practice one’s profession in … …be exposed to industrial poisons / dust / radioactive substances / hazards / toxic substances… Special language structures in presenting marital & childbearing history 简明病历书写手册.doc(p.38-
  39) … have been married for … years without conception … have a history of abortion or premature births … delivered one normal / abnormal infant … delivered … days before / prior to the expected date of confinement Family History (F.H.) 简明病历书写手册.doc(p.
  39) Terms mentioned in family history ? family tendency, presence of hereditary disorders, cancer, tuberculosis, mental disorder and nervous affection, rheumatism, diabetes, hypertension, cerebral vascular accident, hemophilia, syphilis, tumor, epilepsy, allergy, etc. any 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. 家庭的倾向,存在?遗传疾病、癌症、肺结核、精神
障碍和紧张的感情、风湿、糖尿病、高血压、脑血管意外、血友病、梅毒、肿瘤、癫痫、过敏等任何接 触患病的个人关系,病人的童年和成年生活;年龄、健康状况、和死亡原因的父母、祖父母、本人,配偶、 兄弟姐妹或不相关的亲戚(联系)。
Special language structures in presenting family history
? … be in good health, be healthy, be living and well ? The family history did not reveal … ? There was no family history of … ? There was no case of … in the family. ? Family history was irrelevant to … ? Family history showed / revealed … ? There was a familial tendency to / toward… ? … died of …, … died from unknown causes Review of Systems 简明病历书写手册.doc(p.40-1
  15)
  1. General condition / physical signs ?
  1.1 temperature (T): oral / axillary / rectal temperature, 。C , 。F ?
  1.2 pulse (P): fast/rapid pulse, slow pulse, (ir)regular pulse, full / good pulse, weak / feeble pulse, paradoxical pulse, intermittent pulse, etc ?
  1.3 respiration (R): short of breath, bradypnea, pause/arrest, dyspnea, mouth breathing, interrupted /deep/shallow/laborious/difficult breathing, etc ?
  1.4 blood pressure (BP) ?
  1.5 height (Ht.) ?
  1.6 body weight (B.W. or Wt)
?
  1.1温度(T):会话/腋窝/直肠温度、地形、.F ?
  1.2脉冲(P):快速/脉搏加速,缓慢的脉搏,(ir)、全/好规律脉冲,脉冲脉,似是而非的弱/软弱、间歇脉冲,脉冲等 ?
  1.3呼吸(R):呼吸急促的,bradypnea,暂停/逮捕、呼吸困难、人工呼吸,就中断了/深/浅/勤劳/呼吸困难等 ?
  1.4血压(BP) ?
  1.5高度(Ht)。 ?
  1.6 体重(B.W.称或重)
Review of Systems
  2. General appearance ?
  2.1 mental state ?
  2.2 complexion, appearance & expression / objective sign ?
  2.3 nourishment and physical development ?
  2.4 body position ?
  2.5 skin, hair & nails Review of Systems
  3. HEENT ?
  3.1 head ?
  3.2 eyes ?
  3.3 ears ?
  3.4 nose ?
  3.5 mouth and throat ?
  3.6 neck Review of Systems
  4. Chest
  5. Heart
  6. Abdomen
  7. Extremities and spine
  8. Nervous system
  9. Genitalia
  •  
 

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