病历书写(英文)课件.ppt

1、1lHISTORY RECORD2lThe 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.3l1.Diagnosis and treatment purpose An accurate,clear

2、,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 l2.Teaching and research purposel3.Medicolegal purposes 4lWhen creating a record,you do more than simply make a list of what t

3、he 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,yet comprehensive report.5l1.Order is imperativel2.Keep items of history in the history l3.Describe specifically any

4、 pertinent negative information l4.Data not recorded are data lost l5.Use short words instead of long and probably fancier ones when they mean the same thing l6.Be objectivel7.You should write the record as soon as possible 6l1.To be well organized and canonicall2.No much erasion and gride could be

5、done in the history recordl3.To be objective and accuratel4.Using professional term to record instead of folksayl5.Remember to have your signature7l1.Biographical data Biographical information of patient should include his full name,age(date of birth),sex,race,occupation,nationality,marital status a

6、nd permanent home address.Also,the date of admission,the time at which you took the history,the source of history and estimate of reliability should be involved.l2.chief complaint The chief complaint consists of main symptom(s)and duration.It should constitute in a few simple words the main reasons

7、why the patient consulted doctor and should be 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 shor

8、t breath for a week.”8l3.History 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 t

9、o other symptoms,bodily function and activities,exacerbation and remissions,and effect of treatment.l4.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.9l5.Revie

10、w 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 head t

11、oward the feet,including respiratory system,cardiovascular system,digestive system,Urinary system,hemopoietic system,endocrine system,nervous system and skeletal system.l6.Personal history(social and occupational history)It includes personal habits(smoking,alcohol drinking),business life,sex life,oc

12、cupation(exposure to certain irritating agents),condition of work.10l7.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.l8.Menstrual history(for female patients)Age of

13、 onset,interval between periods,duration,amount and character of flow,concomitant symptoms,date of last menstruation,age of menopause.l9.Childbearing(reproductive)history Age and date of pregnancy(ies)and childbirth(s).Date of artificial or natural abortions,stillbirths,operative delivery,puerperal

14、fever.Method of family planning,the possible factors of infertility(also for male patients).11l10.Family history(FH)The health status of the patients family(mother,father,siblings and children)and if died,the age and cause of death should be recorded,such as diabetes,hypertension,cancer,obesity,alle

15、rgic disorders,coronary artery disease and mental illness.l11.Physical examination(PE)The recording of Physical examination should follow a logical sequence as follows:vital signs,general status,skin,nodes,head,neck,chest,lungs,heart and blood vessels,abdomen,genitalia,rectum,spine and extremities,n

16、ervous reflexes.l12.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,urine and stool tests,electrolytes,X-rays and ECG.12l13 Summaryl14.Primary diagnosis As t

17、he 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(stage or period and classification or subtype),cardiac or/and pulmonary function and complication(s).l15.

18、signature13lName,gender,age and occupationlAdmission datelAhief complainslPresent history(70%-80%percent of the original present history)lSimplified document of the original past history(only positive data recruited)lVery simplified document of the original personal and family historylPhysical exami

19、nation:vital signs,important positive and negative signs,especially valuable information for differentiation,but you can not omit such important items as heart/lung/abdominal examination.lPositive laboratory and instrumental results14lBiographical data:lNameLUO LEN SHENG Age:30 Sex:M Marital status:

20、Married Native place:China Race:HanlOccupation:Mechanic Date of Admission date:2003/11/16lStatement:patient herself15lChief complaint:recurrent abdominal pain and melena for more than one yearlHistory of present illness:l lMr.luo has been suffered from abdominal pain and recurrent melena since 2002,

21、began on May 2,2002 he had upper abdominal pain and melena first time,with no any inducement factors,obscure upper abdominal pain 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

22、day,about 250g each time,continuing for 5 days with little fatigue,no hematomeses.He went to the local county 16lhospital 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

23、 time,twice a day(Bid).On the second day of treatment,the melena disappeared.On Nov.15,2003,without 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 b

24、ut didnt receive gastroscopy.After receiving PPI.,melena disappear.But the OB(occult blood)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 affecte

25、d in any way since he had such a disease.17lPast history:l Previous health status:Well ordinary bad infectious diseasel Immunizations allergies:N Y clinical manifestation:allergenl Trauma history:surgery history:lReview of systems:(Tick if positive,cross out if negative.If positive,you should write

26、down your disease history and brief course of diagnose and therapy)18l lReview 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)l lRespiratory system:lsore throat chronic cough sputum hemoptysis wheezin

27、g dyspnea chest pain19lCardiovascular system:lpalpitation dyspnea on exertion hemoptysis syncope edema of lower limbs precordial pain hypertentionl lDigestive system:lanorexia sour regurgitation belching nausea vomit abdominal distention abdominal pain constipation diarrhea hematemesis melenalhemato

28、chezia jaundicel lUrinary system:llumbago frequent micturition urgent micturition urodynia dysuria hematuria nocturia polyuria oliguria facial edema20lHemopoietic system:lfatigue dizziness blurred vision gingival bleeding subcutaneous hemorrhage ostealgia epistaxisl l Metabolic and endocrine system:

29、lexcessive appetite anorexia sweets cold intolerance olydipsia polyuria tremor hands change of character obvious obesity emaciation hairiness hair losing pigmentation change of sexual function amenorrheal lMusculoskeleton system:lfloating arthralgia arthralgia swelling of joints deformities myalgia

30、atrophy of muscle21lNervous system:ldizziness headache vertigo syncope degeneration of memory visual disturbance linsomnia disturbance of consciousness tremor spasm paralysis paresthesial lPersonal history:lbirthplace occupation sexual history:N Y smoking:N Y about yrs average pieces/d ceased for yr

31、s lalcohol intake:N occasional frequentlabout yrs average ml/d others:l lMaritial history:lmarrying age companions state of health22lMenstruation and Childbering history:lmenarche age-date of last period(age of menopause)l lamount of flow:little normal large menstrual pain:N Y cycle:regular irregula

32、r pregnancy:times natural labor times abortions times premature delivery timeslstillbiriths times difficult labor and its condition:l lFamily history:(pay attention to the congenital diseases and communicable diseases related to the patient)lfather:still alive illness died cause of death mother:stil

33、l alive illnessldied cause of death siblings:others:23lPhysical examinationlVital signs:l T 36 P 70 /min R 20 /min Bp 110 /70 mmHg lGeneral Appearance:ldevelopment:ortho-sthenic type asthenic type sthenic type nutrition:well fairly poor cachexia facial features:normal acute chronic others expression

34、s:natural painful anxious dreadful indifferent position:active semi-recumbent others gait:normal abnormallconsciousness:aware somnolence confusion stupor coma delirium cooperation:well badly24lSkin,mucous membrane:color:normal red pale cyanosis yellow pigmentationlrash:N Y(type and distribution)subc

35、utaneous hemorrhage:N Y(type and distribution)lhair:normal scattering losing(position)moisture and temperature:normal cold dry wetlelasticity:normal reduced edema:N Y(position and degree)hepatic palm:N Ylspider angioma:N Y(position numbers)others:25lLymph nodes:lsuperficial lymph nodes:non-swellingl

36、swelling(position and characteristics)l Head:lcranium:size:normal large small deformity:lN Y(oxycephaly squared skull deforming skull)lothers:tenderness mass sunk(position )leyes:eyelid:normal edema ptosis trichiasis conjunctive:normal hyperemia edema hemorrhage eyeball:normal exophthalmos depressio

37、n tremorlmotion dysfunction(left right)26lsclera:normal yellow lcornea:normal abnormal (left right )lpupils:equal roundness same size unequal left cm,right cmlreaction to light:normal delay(left right )disappear(left right )others:lears:auricle:normal deformity fistula others(left right )lexcretions

38、 of external canal:N Y(left right feature )ltenderness of mastoid:N Y(left right )audition dysfunction:N (left right )lnose:shape:normal abnormal()other abnormalities:N Y nasal flaplobstruction excretions nasal sinus tenderness:N Y(position )27lmouth:lips:red cyanosis pale herpes fissure mucous:norm

39、al abnormal(pale bleeding)lopening of parotid gland duct:normal abnormal(swelling pyogenic excretions)ltongue:normal abnormal(coverings tremor leaning to left or right)lgums:normal swelling pus overflow hemorrhage pigmentslteeth:regular edentulous carious teeth false toothltonsils:pharynx:voice:norm

40、al hoarse28lNeck:resistance:N Y carotid artery pulsation:normal increased decreased(left right)ljugular vein:normal distention high distention trachea:middle deviation to(left right)lhepatojugular reflux:(-)(+)lthyroid:normal swelling degree symmetryldominance in one side:lspreading nodular:soft har

41、d others:N Y(tenderness tremor bruits )29lChest:ltopography:normal barrel chest flat chest pigeon chest funnel chestlbulging or retraction(left right)bulging in the precordial region tenderness of sternumlbreast:normal symmetrical abnormal:left right(gynecomastia mass tenderness)lexcretions of nippl

42、es )30lLung:linspection:movement of respiration:normal abnormal:left right(increased decreased)lintercostals space:normal wide narrow(position )lpalpation:vocal fremitus:normal abnormal:left right (increased decreased)lpleural friction rubs:N Y(position )lpercussion:resonance abnormal:dullness flatn

43、ess hyperresonance tympanyllower borders:scapular line:right intercostals space left intercostals spacelrange of mobility:right cm,left cm31lauscultation:breath:regular irregularlbreath sound:normal abnormal(feature,position )lrales:N Y:rhonchi:sonorous sibilant moist rales:coarse medium fine rales

44、crepituslvocal conduction:normal abnormal:reduced increasedlPleural friction rubs:N Y(position )32lHeart:linspection:bulging in precordial region:N Y apex impulse:normal unseen increased diffusinglpoisition:normal deviation(the distance from midclavicular line cm)lo t h e r p r e c o r d i a l p u l

45、 s a t i o n s:N Y(position )lpalpation:apex impulse:normal increased thrust unclearlthrills:N Y(position period )pericardial friction rubs N Ylpercussion:relative cardiac outline:normal shrink extant(right left)33l l Normal boundary of the heart l right(cm)intercostals space left(cm)l 2-3 2-3l 2-3

46、3.5-4.5l 3-4 5-6l l l distance from anterior midline to the left midclavicular line(cm):34lauscultation:heart rate bpm/min rhythm(regular irregular absolutely irregular)lheart sound:S1 normal increased decreased split S2 normal increased decreasedlS2 split:normal fixed paradoxical S3 N Y S4 N Y A2 P

47、2lextra heart sound:N gallop(diastolic presystolic summation gallop)opening snap otherslmurmurs:N Y35lLocation:apical region aortic area pulmonary area tricuspid arealleft sternal border in 3nd intercostals space OtherslTiming:systolic diastolic bothlQuality:blowing rumbling sighing musical Austin F

48、lint Graham Steell GibsonlIntensity:Grade lTransmission:N Y direction to left axilla over the apex over the carotid arterieslPericardial friction rubs:N Y36lPeripheral vessels:normal pistol shot:N Y Duroziez sign:N Ylwater hammer pulse:N Y capillary pulsation:N Ylpulse deficit:N Y paradoxical pulse:

49、N Y lpulse alternations:N Y othersl Abdomen:linspection:shape:normal distention frog belly cm scaphoid abdomen apical bellylgastric pattern intestinal pattern peristalsis abdominal respiration:exist disappearlumbilicus:normal protruding excretionslothers:N Y(venous distention of abdomen purple stria

50、e surgical cars hernia)37lpalpation:soft muscle tension position tenderness:N Y rebound tenderness:N Ylfluid trill:N Y succusion splash:N Y masses N Y(position size)ldescription of feature:lliver:not touched be touched:subcostal cmldescription of feature:lgallbladder:not touched be touched:size cm t