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1、整理有关英文病例的写作,提供大家查考:一、主要调查项目:1.主诉chiefcomplaint:weakness,malaise,chills,fever,sleep,pain,headache,appetite,weight,stomachandbowels,nauseaandvomiting,diarrhea,urine,genitalia,neuropsychiatricdisorders,respiration,shortnessofbreath,bleedingordischarge,etc.2.
2、现症历presentillness:onset(date,mode),durationbeforepresententry,excitingcauseandenvironmentalinfluences,prodromalsymptoms,generalsymptoms,courseorprogress(location,duration,severity,continuity,intermission,radiation,treatment),aggravatingandalleviatingfacto
3、rs,lossofweight,appetiteandstrength,sleep,bowelmovement,frequencyofurination,menstruation,etc.3.既往历pasthistory:1)formerplacesofresidence,previousstageofhealth(健壮的robust,纤弱的delicate),experiencewithsimilardisease,immunitytoinfectiousdisease2)previousillness
4、:麻疹measles,腮腺炎mumps,水痘chicken-pox,百日咳pertussis,流行性感冒influenza,猩红热scarletfever,白喉diphtheria,伤寒typhoidfever,支气管炎bronchitis,肺炎pneumonia,脑炎encephalitis,脑膜炎meningitis,破伤风tetanus,小儿麻痹poliomyelitis,赤痢dysentery,霍乱cholera,胸膜炎pleurisy,天花small-pox,疟疾malaria,结核病tuber
5、culosis,黄疸病jaundice,过敏性反应allergy,etc3)venerealdisease:specificsymptoms,signs,andthediseasebyname,treatment.4)Accidents(date,anydisability,sequelae),operationandhospitalization(date,procedure,nameofhospital,physician,complications,bleedingtendency)4.家族历fam
6、ilyhistory:familytendency,presenceofhereditarydisorders,cancer,tuberculosis,mentaldisorderandnervousaffection,rheumatism,diabetes,hypertension,cerebralvascularaccident,hemophilia,syphilis,tumor,epilespsy,allergy,contactwithdiseasedindividuals,relationship
7、ofpatient’schildhoodandadultlife,age,healthcondition,andcauseofdeathofparents,grandparents,self,spouse,siblings,orrelatives.5.个人历personalhistory:1)Socialhistory:fears,metalstatus,education,financialcondition,numberofdependents,familyharmonyorfractious,hyg
8、ienicconditionathome2)Maritalhistory:durationofmarriage,1stor2ndmarriage,ageanddeathofspouseandchildren,causeandageattimeofdeath,numberofchildren,pregnancies,流产次数miscarriages,死产数stillbirths3)occupationalhistory:dura