由Nallamothu, Padma医生修改审定
很多欧洲国家的病历格式里没有主诉，代之以一段话，中心意思为“患者这次为什么来就诊?”。有部分医生认为：
1、对有些复杂的疾病，没法一下子提炼出合适的主诉。
2、避免了由于主诉的主观倾向性(因字数限制，书写者需要按照其对患者病情描述的理解二次提炼而成)而干扰患者病情的诊断，就是避免先入为主。
以上只是有争议的学术观点，相当多的国家(如美国)的病历体系里也是有主诉的。
为尊重患者隐私，所有患者相关信息全部略去。阅读下述病历，有读者可能会发现其中行文非常简单，native
speaker的写法，我们大部分人只要能看懂就行了，很难模仿(但他们也会有拼写错误，语法错误)。这是为了提高工作效率，在查房记录中，很多记录只是单词、短语和缩写，只求让同行看懂。但是写给患者的出院小结，则会非常详细，并且行文使用简单的词汇和句式，保证即使文化不高的患者及家属也能理解。在此呈现真实工作病历给读者，供参考
。
Why she came here:
The assignment of Mrs. G was exacerbated for further clarification of
eczematous skin lesions for 3 weeks to Pat.schulung,intensification of therapy
and ECT.
Akutell for 3 weeks progressive, pruritic skin lesion on the lower legs,
starting with the spread on the entire body, especially arms, accompanied by
night-time itching. They've tried various topical agents, including Optiderm
cream and body wash pruriens-med, but none of them have led to any improvement.
She stood in front of our clinic last week, beginning here with a local therapy
plus Sicorten. Moreover, even antihistamines (cetirizine), only here at
improvement of the itching.
Past Derm History:
In 2001, the patient suffered from allergic contact dermatitis, ranging
from jewelry-exposed areas. It was from Dr. Suter, FMH Dermatology, Biel, a
patch test. Here were allergies found in wool wax alcohols, cobalt, nickel,
calendula ointment. They also reported an allergy of Zoloft and Augmentin, each
with it a rash.
Already in 2003 the patient suffered a lower leg eczema, which was why it
Dr. Krahenbuhl, FMH Dermatology visited in Biel. This topically treated with
steroids and phototherapy, including a history it was never a complete healing
of the lesions come.
Exposure History:
New house for 4 years. Cat for several years. New mattress for about 4
ye
Nolong stay abroad. Lives alone. Hobby paint posts.
Social History:
Divorced, one son, former gallery owner, currently unemployed, lives
alone.
Allergies / intolerances:
wool wax alcohols, cobalt, nickel, calendula ointment, drug allergy:
sertraline; Amoxicillin and enzyme inhibitor, Alcohol: 1 bottle of red wine per
day, nicotine:
Stop 1978 cumulatively about 10 py, no stays abroad: Except for France.
Review of symptoms:
No B symptoms. No angina symptoms. Stress incontinence, bowel movements
normal.
Physical Exam: Status of 05.09.2011
58-year-old woman in an orderly and adipose general nutritional status.
Afebrile.
Cor: heart sounds clear, no abnormal noises. Ankle edema bilaterally.
Pulmo: well-vesicular breath
sounds.
Abdomen:Significantly increased panniculus, soft, assessed the extent of
obesity no organomegaly Lien. Normal bowel sounds.
Lymph nodes: submandibular, cervical, supraclavicular and infraclavicular,
axillary, and inguinal lymph nodes not enlarged palpable.
Skin Status:
Generalized skin type II, emphasizes above all extremities sometimes sharp
z.T. poorly demarcated, eczematous lesions, excoriations on the lower leg.
Xerosis. Partly tongue turns black. Nails normal.
Diagnoses：
First Exacerbated Atopic Dermtitis with / at:
Atopic diathesis with rhinoconjunctivitis, wool intolerance
Epicutaneous testing: multiple type IV sensitizations Contact (balsam of
Peru, cobalt (II) chloride,
Wool wax alcohols, nickel (II) sulfate, fragrance mix II, oxybenzone)
PRICK testing: Type I sensitization to grass, rye, birch, hazel, alder,
ash,
Cat hair, dust mites)
Second Allergy / drug intolerance to Zoloft and Augmentin
Third Hyperchromic macrocytic blood picture
A history of alcohol consumption by at least one bottle of red wine per
day
4th Elevated transaminases and gGT
Pre-existing
Treatment:
ECT beginning today, Pat has not brought their ointments
Tel HA tomorrow, regarding pre-existing conditions and topical agents ...
(Eiseninfusionen. ...)
Prick any Neurodermititsschulung
TSH and iron
Tel Krahenbuhl (Derma / FMH) with respect to skin lesions in 2010.
Checking Patient Record:
Day 1 CA visit:
HV significantly better!
On the arm of small vesicles and poorly demarcated erythema -> subacute
eczema
To the U.S. -> more nummular eczema
Day 2
ECT is Response to cold cream to rise above the reddening in the
antecubital area
-> Stop Cold Cream
Day 3
Increased pre-existing liver, most likely due to C2-
-> The HA under control C2-waiting and possibly recommend further
investigations (Sono)
Discharge any Monday
for the WE:
Experiment with cold cream and half a body other side of Essex pomade
sosnt nothing special
ECT - Evidence of various contact sensitization
Prick: detection of various types of immediate reactions
On cold-cream with discreet 2xlig increased redness and itching on the arm
responds subjetiv the patient had the feeling that CC would do her good
With Elocom - HV exzematose significantly better
Discharge letter: Assessment, treatment and course
The hospitalization of Mrs. G was exacerbated due for 3 weeks, generalized,
eczematous skin lesions and intensification of therapy and implementation of an
epicutaneous and skin prick testing.
Due to a history of (recurrent eczema in the past, seasonal rhinitis),
clinical (generalized limb-stressed eczematous skin lesions, some
lichenification) and blood chemistry (elevated total IgE (131 kU / l) and sx1
(27 kU / l, RAST class IV)), we presented findings, the diagnosis of atopic
dermatitis exacerbated.
Due to the application of various topical agents with worsening of skin
lesions, we performed a epicutaneous testing. Here were various contact
sensitization (cobalt (II) chloride, ¬ wool wax alcohols, nickel (II)-sulfate)
were detected, so surely a contact allergic component to the exacerbation of
atopic dermatitis is playing a role.
The patient was given an allergy-pass and she was instructed accordingly,
continue with topical ingredients mentioned above no longer apply.
Furthermore, we have performed a skin prick test, here are immediate-type
reactions found on grasses, rye, birch, hazel, alder and ash, and a little to
Dermatophagoides pteronyssinus and cat hair . As Mrs. Gimmel has a cat, we have
advised her not close contact with the cat.
Therapeutically, she had with topical corticosteroids (Elocom cream) and
treated with nourishing cold cream. Among them there was a marked improvement
over the course of the cutaneous findings and the complete cessation of the
itching.
We also have the patient to participate in the neuro-dermatitis training at
our premises lession recommended. Corresponding dates in November 2011 were
submitted to the patient already.
Laboratory investigations on admission was a hyper-chromic, macrocytic
blood picture as well as increased trans on Amina and gamma-GT. The ferritin was
mixed with 620 mg / l also significantly above the norm. With a history of
regular alcohol
consumption of at least one bottle of red wine per day, we
interpreted these laboratory chemical change in the context of regular alcohol
consumption. We have informed the patient to the effect and recommended her to
suspend the alcohol consumption. We ask the doctor to control these parameters
and if necessary to further investigations.
We could dismiss Mrs. G on 12.09.2011 in good general condition and with
clearly improved skin findings home.
Medication / topical therapy at discharge
Morning Afternoon Evening Night remark
- Cold cream - - - - for skin care
- Elocom Cream - - - - 1xtgl. for 1 week, then 2 / W. for 2 weeks, then
stop
- Dermed - - - - for washing
- Atarax 25mg - - - - in reserve in case of itching, max 2x/Tag
Procedure
topical therapy as listed- above.
follow-up to our outpatient clinic (eczema-hours) in 4 weeks.
The patient will participate in our atopic training in November 2011.
liver monitoring by family physicians.
Best Regards
Prof. Dr. XXX
Chief Medical Officer
electronic targeting, MD YYY
Hospital Specialist
electronically targeting Dr. ZZZ
Assistant Physician
targeting electronically
Here are some cases written by students. We left them as original
version.
Case 1
Chief complaint: Skin eruption on the palate for one month
Present illness: The patient developed erythema and maculae located on her
two palate without any obvious predisposing
causes one month ago, no pain, no
itching. With the time going, the skin eruption went to be two red patch. And
she felt the patch feeling hard. Then she went to the local hospital, where she
was impresstioned as “paederia dermatitis” with berberine cetirizine and
bactroban .But the patch continued without any change. So she went to our
resident department given some extermal remdy .Days later the color of patch
changed dark but still there, So she came here again .With some examination
result ANA:1:1000、SSA(+)、SSB(+) diagnosed as“SLE”. With no ulcer in her mouth,
no joint pain, no heartomyositis. Since the disease coming on, the patient’s
general condition is fair ,no somnipathy, have a ordinary appetite, stool and
urination is easy and smooth, body
weight is stable.
Case 2
Chief complaint: erythema and vesicles on the left temporale area for five
days, edema on the left eyelid for three days.
Present illness: the patient developed erythema and vesicles on the left
temporale area without any obvious predisposing causes five days ago, no pain,
no itching. But he didn’t receive any treatment. Three days later, there was
edema around the left eye. Then he came to our hospital, diagnosed as “herpes
zoster” admitted to resident department for the further treatment. Since the
disease coming on, the patient’s general condition is fair ,no somnipathy, have
a ordinary appetite, stool and urination is easy and smooth, body weight is
stable.
Past history: the patient has suffered from “hypertension” for 15 years.
now the blood pressure is stable. no history of infective diseases as “hepatits”
and “tuberculosis”. history of preventive inoculation not in detail. no allergy
history of drugs, no history of operative and trauma, no history of using
particular drugs, no history of transfusio sanguinis, no history of contacting
bad materials.