科研教学 > 医学英语
皮肤科英文查房手册连载(15):英文门诊病历示例 
皮肤科医师之家       2013年8月1日        阅读数:516        字体:      


  The history is the single most important tool in obtaining a diagnosis. All physical findings and laboratory and imaging studies are first obtained and then interpreted in the light of the pertinent history. The art of seeking this information in a nonjudgmental, 
sensitive, and thorough manner can not be overemphasized.


  不同的国家,不同的医疗体系,患者的病历格式是完全不同的。不少医院在门诊中采用格式病历,一般项目由助手先行采集。医生在门诊过程中以问话,体格检查和交流为主。因为在西方的文化中,当别人述说的时候,你长时间的记录或者目光不和患者进行交流,是不尊重他人的表现。在平均每个患者15-20分钟的门诊时间内,你必须耐心地听完患者的陈述甚至抱怨,全面体检,尽可能进行详细地解释他的疑问,有时还要对患者进行一定的心理辅导。所以在实际工作中,手写病历里描述的症状和皮损累及部位的做图往往都比较简单,甚至只有几句语法不通的短句。结束后由秘书(或本人)进行整理,撰写相对完整的病历,再交由医生修改、审核并签名,然后发给患者的社区医生或私人医生。但整理好的病历和原始手写记录是一并作为医疗档案保存的。

  以下病历由埃及皮肤科医生Dr.Mohammed Sallam整理并改写,参照美国门诊病历格式。


  Why the patient seeked for medication: This 26-year-old female presents today complaining of “acne” on both cheeks for more than 10 years.


  Location: She indicates the problem location is the cheeks and nose locally.

  Menses: Onset : 12 years old. Interval: 24-28 days. Duration: 4-6 days. Flow: light. Complications: none.

  Allergies: Patient has allergies from penicillin resulting in difficulty breathing.

  Medication History: Patient is currently having Lincomycin creams external use for 6 days, which was prescribed by doctor A.

  Past Medical History: Female Reproductive Hx: (+) birth control pills use.

  Childhood Illnesses: (-)chickenpox, (+) measles.

  Past Surgical History: No previous surgeries.

  Family History: She has a younger brother who also suffered from acne for a long time.


  Social History: Patient admits caffeine use, she consumes 3-5 servings per day, Patient admits alcohol use, Drinking is 
described as social, Patient admits good diet habits, Patient admits exercising regularly and she denies STD history.



  Review of Systems: Integumentary: (+) periodic reddening of face, (+) acne problems, Allergic / Immunologic: (-) allergic or immunologic symptoms, Constitutional Symptoms: (-) constitutional symptoms such as fever, headache, nausea, dizziness.


  Physical Exam:


  Patient is a 26-year-old female who appears pleasant, in no apparent distress, externally appearing as her given age, well
developed, well nourished and with good attention to hygiene and body habitus.


  Skin: Examination of scalp shows no abnormalities. Hair growth and distribution is normal.

  Inspection of skin outside of affected area reveals no abnormalities. Palpation of skin shows no abnormalities.

  Face shows keratotic papule and erythema around.

  Impression: Acne vulgaris.

  Plan: Since she is 26 years old, so Tetracycline is recommended.

  Continously Lincomycin creams are locally used.

  She understands acne treatment is usually long-term. Return to clinic in 2 weeks.

  Patient Instructions:

  Patient received literature regarding acne vulgaris.


  Discussed with the patient the prescription for Tetracycline and handed out information regarding the side effects and the proper method of ingestion.


  Prescriptions:

  Tetracycline Dosage: 250mg capsule Sig: BID Dispense: 60 Refills: 0 Allow Generic: Yes

  _______________________ A. Dermatol