病歷寫作常用句子及應注意文句

病   歷寫作常用句子及應注意文句

 

 

資料來源:

case records of the Massachusetts General Hospital

 

l   一般現在病史

n   The patient had a history of…/ as follows:

n   Approximately 時間 before the current/this admission, the patient…

n   The patient had been well until 數字 days before admission, when 症狀 developed.

n   The patient reported 形容詞 pain, which he/she rated at 數字 on a scele of 0 to 10, with 10 indicating the most severe pain.

n   人 self-administered (v. 自行服用) 藥物.

n   行為/藥物 alleviate the symptoms.

n   The pain waxed and waned for a few days.

n   Approximately 24 hours later, relatives took the patient (back) to the emergency department of the (other) hospital because of 症狀; he reported no chest pain.

n   On arrival at the emergency department, the patient…

n   In the emergency department of this hospital, the patient….

n   The patient sought medical advice. The patient consulted/saw/visited/ was sent for a doctor.

n   The patient was admitted/hospitalized.

l   婦產病史

n   Her menstrual periods occurred in 數字-day cycles; her most recent menstrual period had been 數字 weeks before this presentation.

l   身體檢查

n   The patient appeared to be 形容詞.

n   On examination, the temperature was 數字℃, the blood pressure 數字/數字 mm Hg, the heart rate 數字 beats per minute, the respiratory rate 數字 breaths per minute, and the oxygen saturation 數字% while the patient was breathing ambient air.

n   The weight was 數字 kg, the height 數字 cm, and the body-mass index (the weight in kilograms divided by the square of the height in meters) 數字.

n   人’s skin was 形容詞 (ashen 沒有血色的, mottled 斑駁的).

n   身體檢查的發現 (eg, rales, wheezing) was/were heard in the lungs

n   The abdomen was 形容詞 (soft), with normal bowel sounds; there was tenderness on palpation of the 位置 (right or left + upper or lower quadrant, the suprapubic region, the epigastric region), without guarding, rigidity, distention, or masses.

n   Examination of the rectum revealed a few external/internal hemorrhoids, and there was scant bright-red blood in the rectal vault; there were no skin tags or palpable fissures or masses.

l   血液檢查

l   糞便檢查

n   Stool samples, which were 形容詞 (liquid, soft, firm, brown, yellowish, bloody), were obtained for culture, examination for ova and parasites, tests for antigens of Clostridium difficile and Shiga toxins 1 and 2, and measurement of the calprotectin level.

l   影像檢查

n   A posteroanterior chest radiograph was clear.

n   A (posteroanterior) chest radiograph showed diffuse bilateral consolidations with some nodular opacification that were more prominent in the right lung than in the left lung; some had nodular contours. The size of the heart was normal, and no pleural fluid or pneumothorax was seen.

n   Computed tomography (CT) of the 位置, performed with/without the administration of intravenous contrast material, revealed…

n   Magnetic resonance imaging (MRI) of the 位置, performed with/without the administration of intravenous contrast material, revealed…

n   T2-weighted images and T2-weighted, fluid-attenuated inversion recovery images showed…

l   細菌病毒檢查

n   Blood samples were obtained for culture.

n   A rapid influenza diagnostic test of a nasal swab was reportedly positive/negative.

l   其他檢查

n   Lumbar puncture was performed. The opening pressure was 數字 cm of water, and the cerebrospinal fluid (CSF) was 顏色. On CSF analysis, the total protein level was 數字 mg per deciliter, and the glucose level 數字 mg per deciliter. There were 數字 white cells per microliter, of which 數字% were lymphocytes and 數字% were monocytes.

l   診斷

n   The 診斷 is most likely/not unlikely/unlikely/very unlikely.

n   The most likely diagnosis is 診斷.

l   處置

n   Intramuscular/intravenous 藥物 was administered

n   (High-flow) oxygen through a 氧氣供給裝置 (eg, nonrebreather face mask). The oxygen saturation rose to 89% within minutes.

[ROS]

. general

(1) Pain: pain scale: 0/10pts

(2) Emotion: fair to good(+), anxiety (-), depression (-) Suicidal ideation(-)

(3) Nutrition: body weight change (-); appetite change (-)

(4) Performance: can exercise/work/do daily activity

(5) Fatigue (-); insomnia (-) fever (-); chills (-)

(6) Frequent common colds(-)

. skin

(1) Pruritus (-); rashes (-); dryness (-); erythema (-); pigmented dermatitis (-); nodule (-); mass (-)

(2) Change in hair or nails (-)

. HEENT

General：wound(-); bleeding(-); discharge(-); swelling(-); tenderness(-)

(1) Headache (-); dizziness (-); vertigo (-); syncope (-); seizure (-); trauma (-)

(2) Eye: blurred vision (-); double vision (-); excessive tearing (-); spots (-); tenderness (-); itching (-)

(3) Ear: Tinnitus (-); ear discharge (-); hearing impair (-)

(4) Nose: rhinorrhea (-); nasal congestion (-); epistaxis (-)

(5) Mouth: oral ulcer (-); gum bleeding (-); toothaches (-); dry mouth (-); loose teeth(-); malocclusion(-); ageusia(-)

(6) Sore throat (-); hoarseness (-); voice changes(-)

. neck

limit ROM (-); stiffness (-); palpable mass (-); tenderness (-)

. CV

(1) Dyspnea (-); orthopnea (-); paroxysmal nocturnal dyspnea (-); exertional dyspnea (-); bilateral peripheral edema (-)

(2) Chest tightness (-); chest pain (-); palpitation (-); irregular heart beats (-)

(3) Intermittent claudication (-); cold feet (-); cyanosis (-)

(4) Unilateral peripheral edema(-)

(5) Hemiparethsis (-)

. Resp

(1) Short of breath (-); wheezing (-);

(2) Cough (-); sputum (-); hemoptysis (-)

. GI

(1) Nausea (-); vomiting (-); hematemesis (-); dysphagia (-); odynophagia(-); globus sensation (-); heart burning (-)

(2) Abdominal pain (-); jaundice (-); palpable mass (-); ascites

(3) Constipation (-); diarrhea (-); bowel habit change (-); tenesmus (-)

(4) Stool: formed; small caliber (-); yellow-brown; hematochezia (-); bloody (-); black (-); white (-)

(5) Hemorrhoids (-); rectal pain (-)

. GU

(1) Frequency (-); urgency (-); nocturia (-); incontinence (-)

(2) Hesitancy (-); abdominal straining (-); dripping (-); urine retention (-);

(3) Polyuria (-); oligouria (-); dysuria (-)

(4) Urine: pink (-); red (-); blood-stinge (-); foamy (-)

. Neuro

(1) Seizure (-); incoordination (-); incontinence (-)

(2) Smell change (-); visual change (-);

(3) Weakness (-); paralysis (-); atrophy (-); tremor (-); involuntary movement (-)

(4) Numbness (-); paresthesias (-); tingling(-)

. musculoskeletal

(1) Weakness (-); stiffness (-); spastic (-)

(2) Muscle pain (-); bone pain (-); joint pain (-)

. endocrine

(1) Neck mass (-); weight change (-); excessive hunger/thirst (-); heat /cold intolerance (-)

(2) Polyuria (-); polydipsia (-)

(3) Easily fatigue(-)

. hematology

(1) Easily bruising (-); easily bleeding (-); petechiea (-), ecchymosis

(2) Easily infection (-); palpable lymph node (-); tenderness (-)

(3) Anemia (-)

 

[PE]

. GENERAL

 Acute ill looking (+)

 Cardiopulmonary distress (-)

. HEAD

 Skull deformity (-); wound or scar (-); palpable mass (-)

. EYES

 visual impairment (-)

. EARS

 hearing impairment (-); discharge (-)

. NOSE

 sinus tenderness (-)

. THROAT & MOUTH

 oral ulcer (-), uvula deviation (-), throat swelling (-)

 present gag reflex (+)

 lip laceration(-)

. NECK

 (1) Motion: stiffness (-)

 (2) Thyroid: palpable mass (-)

 (3) Trachea: deviation (-)

 (4) Carotid: bruits (-)

 (5) Jugular vein: engorgement (-)

. SKIN

 dryness (-); rashes (-); erythema (-); nodule (-); mass (-) ecchymosis (-); petechia(-) ;

 blisters (-); itchness (-)

. CHEST & LUNGS

 (1) Inspection: chest wall deformity (-); wound or scar (-); symmetric expansion, smooth and steady respiratory pattern, accessory muscle use (-)

 (2) Breath sounds: clear, rales (-); rhonchi (-); basal rales (-); wheeze (-); decreased breath sounds (-)

 (3) Percussion: hyperresonance (-), dullness (-)

 (4) Palpation: mass (-), crepitus (-)

. HEART

 (1) PMI: diffuse (-); displaced (-)

 (2) Auscultation: regular heart beat, clear S1 and S2, no murmur, S3 (-), S4 (-)

 (3) Palpitation: thrill (-), heave(-)

. ABDOMEN

 (1) Inspection: distend, wound or scar (-); hernia (-); superficial vein engorgement (-)

 (2) Auscultation: active bowel sounds (-); bruits (-)

 (3) Palpation: soft; guarding (-); mass (-); tenderness (-); rebound tenderness (-); hepatomegaly or splenomegaly (-)

 (4) Percussion: abnormal dullness (-)

 (5) Inguinal: hernia (-); lymphadenopathy (-); mass (-)

. BACK & SPINE

 (1) Wound or scar (-); spine deformity (-)

 (2) Spine tenderness (-); CV angle knocking tenderness (-)

. EXTREMITIES

 (1) Inspection: wound or scar (-);

 (2) Freely movable, full ROM (-); muscle power(5/5/5/5)

 (3) Upper: clubbing fingers (-), cyanosis (-), capillary refilling time: fine tremor (-)

 (4) Lower: pitting edema (-), pigmented dermatitis (-), varicose vein (-); pigmentation (-)

 (5) Peripheral pulsation:

 1. Radial: bilateral palpable, 2+/2+

 2. Dorsalis pedis: bilateral palpable, 2+/2+

 3. Posterior tibialis: bilateral palpable, 2+/2+