【正文】 The writing of clinical record A patient’ s health record plays many important roles and provides a view of the patient’ s health history/status The basic requirement of clinical records In writing up the history and the physical examination, the examiner should obey the following rules: ? Record all pertinent (相關的） data, avoid extraneous （無關的） data ? Use standard format ? Describe prehensively, use mon terms, avoid nonstandard abbreviations（縮寫） The basic requirement of clinical records ? Written in an allround way, all items should be filled, the hand writing should be clear, not scratchy（潦草） or be altered ? Be objective(客觀） , use diagram（圖表） when indicated Types , formats and contents of clinical records Clinical records during hospitalization ? The clinical records should be written during hospitalization ? It includes: Case record First record of admission Record of the course of disease Record of consultation Record for transferring to new department Record of discharge Record of death Record of surgery Case record The case record should be written systemically and pletely within 24 h by intern Formats and contents of case record ? Case record Name Sex Age Marital status Nation Profession Native place Current address Data of admission Data of case record Source Reliability ? Chief pliant ? History of present illness ? Past illness ? Systemic review ? Personal history ? Marriage ? Reproductive and Gynecologic history ? Family history Physical examination Temperature Pulse Respiratory Blood Pressure ? General appearance: development, nutrition (well, moderate, poor) facial expression (acute or chronic, suffering expression, anxiety, fear, calm) position, gait mental status: alert, obscure（ 不清楚的 ） , lethargy（ 昏睡 ） , a cooperative Physical examination Skin and mucous: color (reddish, paler, cyanosis, yellowish, pigmentation) swelling, moisture, elasticity, bleeding, rashes, subcutaneous nodular, spider angioma（蜘蛛痣） , ulceration, scar. The location, size and shape should be recorded. Lymph note: systemic or localized lymph notes (submaxillary, 下顎 ； posterior auricular, 耳后的 ； neck, armpit, 腋窩 ； groin， 腹股溝 ). Its size, number, tenderness, hardness, mobility, fistula（漏管） , scar etc. Physical examination Head and ans Head: its size, shape, tenderness, mass, hair Eye: eyebrow（眉毛） , eyelash（睫毛） , eyelid,（眼瞼） eyeball (protrude/突出 , sunk/凹陷 , movement, tremble/震動 , strabismus/斜視 ), conjunctiva（結膜） , sclera(鞏膜） , cornea/角膜 (size, shape, symmetry, light reflex, near reflex). Ear: discharge, hearing, mastoid（ 乳突 ） . Nose: abnormality。 tenderness of maxillary sinus（上頜竇） , ethmoid sinus（篩竇） , frontal sinus（額竇） 。 exudation（分泌） , bleeding. Physical examination ?Oral cavity: odor, lips (color, swelling, ulceration, herpes simplex, pigmentation)。 teeth。 gingival（ 齒齦 ） 。 tongue (mass, ulceration， coating of the tongue, mucus (rash, bleeding, ulceration)。 tonsils（ 扁桃腺 ） 。 pharynx（ 咽 ） etc. ?Neck: symmetry。 texture (slightly flexed and cradled in the examiner’ s hands)。 thyroid gland (size, hardness, tenderness, nodular, tremble, murmur)。 superficial venous distention。 the position of the trachea. Physical examination ?Chest: configuration。 symmetry。 local protrude。 tenderness。 respiratory rate and pattern。 abnormal pulsate（ 異常搏動 ） 。 breast (size, mass)。 venous distention Physical examination ?Lung: Inspection: respiratory movement。 interspace of ribs。 Palpation: the extent of chest excursion（ 移動 ） 。 vocal fremitus （ 語顫 ） 。 Speech creates vibrations that can be heard when one listens to the chest and lungs. These vibrations are termed vocal fremitus. When one palpates the chest wall while an individual is speaking, these vibrations can be felt and are termed tactile fremitus（ 觸覺語顫 ） . Pleura friction（ 胸膜摩擦音 ） 。 subcutaneous crepitus（ 捻發(fā)音 ） . Physical examination ? Percussion: resonance tympany hyperresonance dullness flatness diaphrag