病历english

五、病历
 完整的住院病历一般包括以下几个内容：
1．   一般项目（general data, biological data ）
2．   主诉 （chief complaint, CC）
3．   现病史（history of present illness, HPI）
4．   即往史 （past history ）
5．   个人史 (personal history, PH)
6．   月经和生育史（menstrual and child-
        bearing history）
7．   家族史 （family history, FH）
8．   体格检查 （physical examination）
9．   印象 （impression） 或 
       诊断（diagnosis）

How to write / read a medical case?
Doctor’s Case-book
Sample 1
    A 56-year-old retired engineer stated that he had chronic bronchites characterized by an early morning cough for about 10 years. Several months ago, a cough somewhat different appeared and become progressively worse. This cough got worse by cigarettes (1 pack per day for 49 years), and he stopped smoking one month ago. Three weeks ago he noted blood-tinged sputum. Two weeks ago he developed sharp stabbing pain in the left chest. During this 2 weeks interval, he has had a lowgrade fever slight weight loss and night sweat but no chills.

现在观察一下时态
Sample 2
    A 60-year-old woman presents to the emergency department having collapse at home. She gives a three-
day history of increasingly severe pain in 
her left wrist. She has been unable to use the 
hand for 24 hours. There is no history of injury 
to her wrist.
 
    On admission, she had features ofosteoar-
thritis and a hot swollen left wrist with a temperature of 
39°C.