⏹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(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
