Case History 病史⏹In-Patient Case History 住院病历Items of Case History1. General Data, Biographical Data 一般项目2. Chief Complaints (C. C.) 主诉3. Present Illness (P. I.) 现病史4. Past (Medical) History (P. H.) 既往病史5. Personal History (Per. H.)/ Social History 个人史/社会史6. Family History (F. H.) 家族史7. Medications 曾用药物8. Allergies 过敏史9. System Review, Review of Systems 系统回顾10. Physical Examination (P. E.) 体格检查/查体11. Laboratory Data 实验室与其他检查/检查资料12. Impression (Imp.) (Diagnosis) 诊断13. Hospital Course 住院治疗情况记录14. Discharge Instructions/ Recommendations出院医嘱15. Discharge Medications 出院后用药General Data, Biographical Data 一般项目⏹Reliability (病历可靠性):Reliable(可靠)/ Not Entirely(不完全可靠)/Not Clearly Defined (不够准确)/Confused and Uncertain (混乱不清)/ Unobtainable (无法获得)⏹Supplier/ Complainer of History (供史者/病史陈述者):Patient/ Husband/ Wife/ Father/ Mother/ Colleague/ NeighborChief Complaints (C. C.) 主诉: 病例重要部分之一，通常包括患者年龄、简要的相关的既往史、患者的就诊原因及目前症状持续的时间等。
⏹Language Characteristics1) Common expressions①symptom+since+time(时间点)②symptom+for+time(时间段)③symptom+of+time (时间段名词所有格)+duration④symptom+time(时间段)+in duration⑤time(时间段合成词)+history+of+symptom⑥complete sentence: The duration of +symptom+was/ has been+time(时间段)（少见）2) Common sentence patterns for chief complaints①…was admitted/seen with a chief complaint of…②…complain chiefly of…③…presented/entered with/came to the office with a chief complaint of④…was admitted because of…⑤…was involved in…⑥…was transferred to…because…下面是书写主诉是最常用的格式：CC：The patient is a (age)-year-old (race,ethnic,group,occupation,sex and/or very pertinent PMH),who is admitted to the hospital with a chief complaint of (symptom,not a sign or diagnosis) of (number followed by a unit of time) duration.Example主诉：患者是一个48岁的妇女。
入院主诉，6个月来，出力后心悸和呼吸困难。
CHIEF COMPLAINT: The patient is a 48-year-old female, admitted with the chief complaint of palpitation and dyspnea following physical exertion for 6 months.History of Present Illness 现病史：是从医生的角度，进一步表述主诉内容，全面表述现有疾病的发病时间、主要症状、病情发展过程、症状间的联系、诊疗过程、目前患者身体状况、与现有疾病有直接关系的既往史等。
记录患者入院情况时，多用一般过去时或过去完成时；记录目前病情时，用一般现在时或现在完成时。
⏹Language Characteristics1) Sentence Patterns with Patients to Be Subject 以病人做主语的句型①start having 开始有……的症状②begin having episodes of… 开始发生……的症状/疾病③become… 变得……④notice(perceive, note, recognize…)+症状/疾病⑤have… 有……症状/疾病⑥have abrupt/sudden/explosive onset of… 突然患……⑦have episode of…/have attack of…患……⑧develop+disease 出现/有了……症状/疾病⑨…are/is the prodrome of… ……的前驱症状2) Sentence with symptoms, illnesses as subjects 以症状、疾病做主语的句型①begin (occur, start…)+time 从……开始②date (go back) to +time 可追溯到……③be present+time 在/从……已存在④be preceded by… 在……之前已有⑤be followed by… 在……之后紧接着发生⑥be acc ompanied by…/ coincide with… 与……同时发生⑦be (not) related to…/have (no) correlation with… 与……有（无）关3) Illness’ improving and worsening表达疾病的好转与恶化①last+time 持续……时间②take a bad turn; take a turn for the worse; be aggravated/exacerbated; become worse 恶化③take a good turn/take a turn for the better/improve 好转④be aggravated/abated/all eviated by… 因……而加剧/减轻⑤remain the same/unchanged 无变化⑥be (not) improved after treatment with…经用……治疗而（无）好转⑦(The symptom) cease/clean up/disappear/subside 症状消失/减退4) No symptoms 没发生……症状、疾病①…without/with no/free of… (symptoms)②There be no histor y of…/…have no history of…③(The patient) denies…④(The patient) noted no…⑤(The patient) was not found to be…5) Description of main symptoms 描述主要症状①…assume the character of/be characterized by…②…have/present/develop/show/manifest the symptoms of…Past (Medical) History (P. H.)既往病史⏹Common expressions①had been sound/well until; had enjoyed good health until… 在……前一直健康②be apt/liable/subject to…;tend to have… 易患……③…was admitted to hospital for…/ …was hospitalized for… 曾因……而住院④…had (some illness) with recovery after…曾有（疾病），因…痊愈⑤…was diagnosed as…/…was suspicious of…断为……/疑为……⑥…was exposed to (toxic substances)/…had to breathe (poisoning gase s) 接触/吸入⑦…was inoculated against…接种过……⑧…was discharged/ dismissed from hospital…/…was out of hospital…出院Personal History (Per. H.)/ Social History 个人史/社会史⏹Note: menstruation经期（天）menstrual periodmenarche age——————age of menopause（初潮年龄menstrual cycle （绝经年龄）月经周期（天）⏹Characteristics of languageDeclarative sentences and elliptical sentences are usually used, and present tense, past tense and past perfect tense are adopted. Family History (F. H.) 家族史⏹Common expressions①…be living and well./…be in good health./ …be well with no evidence of (illness). 健在②(There is) No famil y history of (disease)./ (There was) No (disease) in one’s family.无（病）家族史③There was no case of (disease) in his//her family./ No one in his/her family experienced (disease) 家族成员未曾患过……④Family history showed/revealed… 家族史显示……⑤There was a familial/he reditary tendency to…/ There was a strong family history of…/There was a high incidence of…in the family. 家族有……倾向/发病率⑥There was a high prevalence of…in the family 家族中……患病率高⑦Positive for (some disease) in (some one). 曾患过……⑧…as a family charac teristic. 家族特点⑨FH: Noncontributory 家族史无意义Allergies 过敏史Common expressions①NKDA (no known drug allergies) 无过敏史②allergy, allergic, hypersensitive, hypersensitivity 过敏③sensitive, sensitivity, sensible, sensibility 敏感④allergic reaction 过敏反应⑤be al lergic to… 对……过敏⑥be sensible to… 对……敏感⑦have no history of allergy to…; have no history of…sensibility 对……有（无）过敏史⑧have an allergic diathesis 具有过敏体质⑨have no allergic reaction to any drugs 对用过的药物无过敏反应⑩show sensibility to…(e.g. house dust) 对……（如室内灰尘）过敏Physical Examination (P. E.)体格检查，查体1) Physical data/physical signs 一般资料/生理指标2) General appearance 一般情况或全身状态3) Head, eyes, ear, nose and throat (HEENT) 头眼与耳鼻喉4) Chest, heart and lungs 胸部与心肺5) Abdomen 腹部6) Extremities 四肢7) Nervous system, neurological (CNS/Neuro) 神经系统8) Musculoskeletal 骨骼肌肉系统9) Genitourinary 泌尿生殖系统Physical data/physical signs 一般资料/生理指标①Temperature (T.) 体温position: oral temperature 口温；axillary temperature 腋温；rectal temperature 肛温unit: Celsius, ℃; Fahrenheit, ℉Format: T 38 ℃(or 100.4℉)Pattern: The temperature is 38 ℃(or 100.4 ℉) taken by mouth/ by rectum/ by axilla.②Pulse (P.) 脉搏Format: P 80/min(or P80)Pattern: Pulse 80 per minute.The pulse numbered/beat/measured 80/min.③Respiration/ Respiratory Rate (R.) 呼吸Format: R 20/minCommon expressions:The respirations are 21 per minute.呼吸每分钟21次。