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一、主要調查項目:
1.主訴chief complaint:weakness, malaise, chills, fever, sleep, pain, headache, appetite, weight, stomach and bowels, nausea and vomiting, diarrhea, urine, genitalia, neuropsychiatric disorders, respiration, shortness of breath, bleeding or discharge, etc.
2.現症歷present illness:onset(date, mode), duration before present entry, exciting cause and environmental influences, prodromal symptoms, general symptoms, course or progress( location, duration, severity, continuity, intermission, radiation, treatment), aggravating and alleviating factors, loss of weight, appetite and strength, sleep, bowel movement, frequency of urination, menstruation, etc.
3.既往歷past history:
1)former places of residence, previous stage of health( 健壯的robust,纖弱的delicate), experience with similar disease, immunity to infectious disease
2)previous illness:麻疹measles, 腮腺炎mumps, 水痘chicken-pox, 百日咳pertussis, 流行性感冒influenza, 猩紅熱scarlet fever, 白喉diphtheria,傷寒typhoid fever, 支氣管炎bronchitis, 肺炎pneumonia,腦炎encephalitis,腦膜炎meningitis,破傷風tetanus,小兒麻痺poliomyelitis,赤痢dysentery,霍亂cholera, 胸膜炎pleurisy,天花small-pox,瘧疾malaria,結核病tuberculosis,黃疸病jaundice,過敏性反應allergy,etc
3)venereal disease:specific symptoms, signs, and the disease by name, treatment.
4)Accidents( date, any disability, sequelae), operation and hospitalization (date , procedure, name of hospital , physician, complications, bleeding tendency)
4.家族歷family history:family tendency, presence of hereditary disorders, cancer, tuberculosis, mental disorder and nervous affection, rheumatism, diabetes, hypertension, cerebral vascular accident, hemophilia, syphilis, tumor, epilespsy, allergy, contact with diseased individuals, relationship of patient’s childhood and adult life, age, health condition, and cause of death of parents, grandparents, self , spouse, siblings , or relatives.
5.個人歷personal history:
1)Social history:fears, metal status, education, financial condition, number of dependents, family harmony or fractious , hygienic condition at home
2)Marital history:duration of marriage, 1st or 2nd marriage, age and death of spouse and children , cause and age at time of death, number of children , pregnancies, 流產次數miscarriages, 死產數 stillbirths
3)occupational history:duration of employment, past work, exact nature of work, exposure to occupational hazards, whether work is satisfactory or not.
4)Habits:alcohol, tobacco, narcotic, coffee, tea, appetite, food habits, regularity of meals, rapidity of eating , bowel movements, sleep, exercise, interests, etc.
6.系統檢查system review:
1)General:nutrition, fever, night sweats, tremor, weight gain or loss, weakness, allergy.
2)Skin:蕁蔴疹hives, rash, eczema
3)Head:trauma, headache, loss of hair
4)Eyes:vision, pain glasses diplopia.
5)Ears:pain, discharge, deafness, tinnitus.
6)Nose:obstruction, discharge, epistaxis, rhinitis.
7)Mouth:teeth, lips, gums, tongue, disturbance in taste.
8)Throat.:sore throat, tonsillitis, 膿性扁桃腺炎quinsy, dysphagia
9)Neck:adenitis, goiter , rigidity
10)Cardiorespiratory:palpitation, tachycardia, blood pressure, chest pain, dyspnea, cough , hemoptysis , seasonal cold, expectoration.
11)Gastrointestinal:appetite, nausea, vomiting, distress(before or after meals), melena, colic, jaundice, fullness, hernia, hemorrhoid, constipation, diarrhea, frequency of bowel movement , heartburn, idiosyncrasies, relation of symptoms to eating, type and quantity of food
12)Genito-urinary:dysuria, urinary frequency, dribbling , hematuria, pyuria, nocturia and volume, enuresis, incontinence, sores about external genitalia, symptoms suggestive of syphilis(mucous patches, falling hair), urethral discharge, exposure to venereal infection, obstetric history, catamenia(age of onset, date of last period, cycle and amount, periodicity , dysmenorrheal, menopause) leucorrhea, associated headache
13)Neuromuscular:神經過敏nervousness, emotional stress, weakness, muscle or joint pains, convulsion, numbness, neuralgia, anesthesia, muscular atrophies or dysatrophies, deformities.
二、病歷與時態
1.現症歷(present illness):
1)A.現在式:表示一般的真理、職業、人格、習慣和現在的事實、動作或狀態。
例1:Sedentary habits often interfere with health
例2:He is mentally deranged and disoriented as to time, place, and person
例3:He gets up at 6 every morning.
B.現在進行式(Be+ pres. p.)表示現在某動作正在進行中。
例1:Both his parents are still living and well.
例2:The patients is getting worse and worse.
例3:The patients is progressively doing well.
C.表「經常的習慣」也用進行式,通常與always, constantly等副詞連用。
例1:He is always taking a nap in class.
例2:He is constantly forgetting peoples’ names.
例3:He is for ever complaining of headaches.
D.通常不用進行式的動詞。
a)不隨意動詞( Verbs of involuntary actions):
-知覺( perception):feel, hear, notice, see, smell等。
例1:Whenever he has a cold, he can neither taste nor smell.
-知識(knowledge):believe, (dis)agree, doubt, find, forget, know, mind, remember, think, understand等。
例1:She does not remember specific scratches which might have preceded the present lesions.
-感情( emotion):desire, despise, disgust, fear, hate, hope, (dis)like, love, prefer, want等。
例1:He likes lobster, but it disagrees with him.
b)表示繼續狀態的動詞( Verbs of continuous state):表示存在、所有等動
詞:appear, be, belong, consist, flow, have, hold, live, look, possess, resemble, seem等。
例1:Her fingers and hands are stiff and cyanotic.
例2:He has no discomfort and eats well.
2)A.現在完成式( Have+ p.p)
a)表示動作的完了(completion of an action)或其結果的現在狀態(present state of things):
例1:The patient has passed the crisis. = The patient is out of danger now.
例2:He has caught cold. = He has a cold now.
註:常用的連用副詞為:all this while, (not) yet, already , just, now, by this time, today, this week( or month, year, etc.), hitherto, till now, up to( till) now, recently, lately, of late等。
比較:過去式僅表示過去的動作狀態;現在完成式則以表示現在為主。
例1:He had no appetite for food. (過去式)→表示過去某時有過食慾不振
例2:Lately he had had no appetite for food. (現在完成式)→表示現在仍然胃口不佳。
b)表示截至現在為止的經驗( experience):
例1:He has seldom consulted a doctor in his life.
例2:He has never been treated by a doctor since he was born.
註:表示經驗時,常用的副詞為:ever, before, once, many times, (very) often, seldom, sometimes, in one’s time等副詞。比較:同一動詞有時表示完了,有時表示經驗,視其所連用的副詞而決定。
例1:He has just undergone a nephrectomy.→表示動作完了。
例2:He has undergone a nephrectomy once.→表示經驗。
c)表示截至現在為止的動作或狀態的繼續(continuance)
例1:He has been deaf in the left ear since the age of 18 and has experienced slight dizziness on stooping.
例2:Except fro a slight loss of energy, he has always felt well.
例3:For the past 10 years he has had persistent and high-pitched tinnitus in his left ear, consisting a buzzing sensation and, occasionally, the sounds of bells.
註:常用的連用副詞為:since, always, from, for, these, how long?
B.現在完成進行式( Have been +~ing)
a)表示以前開始的動作繼續到現在的狀態:
例1:He came here 2 weeks ago, and has been lying sick with a cold since then.
例2:The patient has recently had experience of memory loss and of spells of dizziness. For the preceding 5 years she has been receiving treatment for hypertension.
b)表示「習慣」:
例1:The patient has been smoking excessively.
例2:She has been chewing a wad of bubble gum all day.
註:常用的連用副詞為:since, for, how long?,these, form, always等。
比較:
例1:He has been learning medicine for 5 years. (繼續)
例2:He has learned medicine for 5 years. (經驗)
2.既往歷(past history):大半用過去式,但發生過去某一定時間以前者,宜用過去完成式;如果疾病發生的前後關係甚明顯,或以年代順序記載時,仍可用過去式。
1)A.過去式:用以表示過去的動作、狀態、習慣等且與現在的情形毫無關聯。
a)發生於過去某時者:
例1:An unknown number of years ago he was said to have pneumonia.
例2:In addition to the above symptoms, he noted some vague abdominal pain for a couple of months in the past.
例3:At that time she had a slight nonproductive cough and mild exertional dyspnea.
例4:Before therapy, she was unable to swallow anything but small sips of water.
b)過去某時以後的狀態:
例1:In the previous month she noticed that the stools were greatly flattened. Subsequently she became aware of a bearing-down pain the rectum.
例2:Menarche occurred at age 13, thereafter menses were regular, every 28 days, lasting 3 to 4 days each time.
例3:The patient had tinnitus in his left ear 10 years before being discharged for the military service. Several year later, he noted loss of hearing on the left.
例4:In June 1956, a sterilizing operation was performed at a hospital. For the ensuing 5 months the patient was troubled with intermittent attacks of vague abdominal pain.
例5:Two years after this episode she had one short attack of vertigo but has been attack-free for 2 years.
註1:過去式常用的連用副詞:ago, last night, yesterday, the day before yesterday, the other day, this morning , just now等。
註2:現在完成和過去兩者都可用的連用副詞:just, ever, lately, recently,
once, always, already, this morning, today, every night, this week, these few days, for the last few days, since last week, before, yet等。
B.表示過去的習慣時,須用used to , was (were) accustomed to ~或had the habit to ~等。用would來表示過去的習慣時,大抵與often, sometimes等副詞連用。
例1:He used to work far into the night.
例2:He would sometimes come home drunk, and beat his wife.
C.過去進行式( Be 動詞的過去式+ pres. p.):表示在過去某一時間正在進行 的動作:
例1:One sister was suffering from active tuberculosis.
例2:He was having mild symptoms of fever and nausea at the time he was seen.
例3:He was raising large amounts of purulent sputum at that time.
D.過去完成式( Had + p.p.):表示截至過去某一時間為止的動作的完了、經驗、繼續等。
a)完了( completion):
例1:The patient had already expired when he came.
例2:By that time he had immunized against smallpox.
連用副詞:already, by that time, (not) yet, only just等。
b)經驗(experience):
例1:Till then he had never seen so-called bone-setter.
例2:He could not repeat what he had said before.
c)繼續(continuance):
例1:He had long been ill in bed.
例2:He had been ill in bed for a long time.
E.過去完成進行式(Had been + pres. p.):表示繼續過去某一時間的動作。
例1:Up to that time, he had been drinking mush wine.
例2:Due to her increasing constipation, she had been taking laxatives daily for one year before admission.
比較:
例1:I was sleeping when he came. (過去進行式)
例2:I had been sleeping for an hour before he came.(過去完成進行式) |
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