【原創】病歷例句

整理有關醫學英文病歷寫作，提供大家作參考：

一、主要調查項目：
1.主訴chief complaint：weakness, malaise, chills, fever, sleep, pain, headache,
appetite, weight, stomach and bowels, nausea and vomiting, diarrhea, urine,
genitalia, neuropsychiatric disorders, respiration, shortness of breath, bleeding or
discharge, etc.
2.現症歷present illness：onset(date, mode), duration before present entry, exciting
cause and environmental influences, prodromal symptoms, general symptoms,
course or progress( location, duration, severity, continuity, intermission, radiation,
treatment), aggravating and alleviating factors, loss of weight, appetite and
strength, sleep, bowel movement, frequency of urination, menstruation, etc.
3.既往歷past history：
1)former places of residence, previous stage of health( 健壯的robust，纖弱的
delicate), experience with similar disease, immunity to infectious disease
2)previous illness：麻疹measles, 腮腺炎mumps, 水痘chicken-pox, 百日咳
pertussis, 流行性感冒influenza, 猩紅熱scarlet fever, 白喉diphtheria，傷寒
typhoid fever, 支氣管炎bronchitis, 肺炎pneumonia，腦炎encephalitis,腦膜炎
meningitis，破傷風tetanus,小兒麻痺poliomyelitis,赤痢dysentery，霍亂cholera,
胸膜炎pleurisy,天花small-pox，瘧疾malaria,結核病tuberculosis，黃疸病
jaundice，過敏性反應allergy,etc
3)venereal disease：specific symptoms, signs, and the disease by name, treatment.
4)Accidents( date, any disability, sequelae), operation and hospitalization
(date , procedure, name of hospital , physician, complications, bleeding tendency)
4.家族歷family history：family tendency, presence of hereditary disorders, cancer,
tuberculosis, mental disorder and nervous affection, rheumatism, diabetes,
hypertension, cerebral vascular accident, hemophilia, syphilis, tumor, epilespsy,
allergy, 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.
5.個人歷personal history：
1)Social history：fears, metal status, education, financial condition, number of
dependents, family harmony or fractious , hygienic condition at home
2)Marital history：duration of marriage, 1st or 2nd marriage, age and death of
spouse and children , cause and age at time of death, number of children ,
pregnancies, 流產次數miscarriages, 死產數 stillbirths
3)occupational history：duration of employment, past work, exact nature of work,
exposure to occupational hazards, whether work is satisfactory or not.
4)Habits：alcohol, tobacco, narcotic, coffee, tea, appetite, food habits, regularity of
meals, rapidity of eating , bowel movements, sleep, exercise, interests, etc.
6.系統檢查system review：
1)General：nutrition, fever, night sweats, tremor, weight gain or loss, weakness,
allergy.
2)Skin：蕁蔴疹hives, rash, eczema
3)Head：trauma, headache, loss of hair
4)Eyes：vision, pain glasses diplopia.
5)Ears：pain, discharge, deafness, tinnitus.
6)Nose：obstruction, discharge, epistaxis, rhinitis.
7)Mouth：teeth, lips, gums, tongue, disturbance in taste.
8)Throat.：sore throat, tonsillitis, 膿性扁桃腺炎quinsy, dysphagia
9)Neck：adenitis, goiter , rigidity
10)Cardiorespiratory：palpitation, tachycardia, blood pressure, chest pain, dyspnea,
cough , hemoptysis , seasonal cold, expectoration.
11)Gastrointestinal：appetite, nausea, vomiting, distress(before or after meals),
melena, colic, jaundice, fullness, hernia, hemorrhoid, constipation, diarrhea,
frequency of bowel movement , heartburn, idiosyncrasies, relation of symptoms to
eating, type and quantity of food
12)Genito-urinary：dysuria, urinary frequency, dribbling , hematuria, pyuria, nocturia
and volume, enuresis, incontinence, sores about external genitalia, symptoms
suggestive of syphilis(mucous patches, falling hair), urethral discharge, exposure
to venereal infection, obstetric history, catamenia(age of onset, date of last
period, cycle and amount, periodicity , dysmenorrheal, menopause) leucorrhea,
associated headache
13)Neuromuscular：神經過敏nervousness, emotional stress, weakness, muscle or
joint pains, convulsion, numbness, neuralgia, anesthesia, muscular atrophies or
dysatrophies, deformities.