20xx年醫(yī)學(xué)專題—病史采集(英文)(參考版)
2024-11-12 12:02本頁(yè)面
【正文】 Summary,第三十七頁(yè)，共三十七頁(yè)。Biopsychosocial medical approach。ng)總結(jié),History Taking。,內(nèi)容(n232。 summarize ages state of health Age and cause of death (if applicable) of family members – parents, siblings, spouse, and children Inquire about any similar symptoms or signs in family members if patient presents with inheritable symptoms or signs Example: thyroid disorders, cancers, diabetes,2011/09/06,第三十五頁(yè)，共三十七頁(yè)。,Marrital History,married or unmarried marriage age relations of couple,2011/09/06,第三十四頁(yè)，共三十七頁(yè)。,Personal history,place of birth current residence educational background economic status living conditions professional working conditions Smoking __ Packs for__ years, quitting for__ year Drinking Illicit drugs Heroin, Travel,2011/09/06,第三十二頁(yè)，共三十七頁(yè)。,Admission Notes Systems Review,General : weakness, fatigue, anorexia, fever, insomnia Integument (skin, hair, nails): changes in color (pigmentation, jaundice, cyanosis), pruritus, rash, hair loss HEENT: Head: headache, dizziness, vertigo Eyes: visual acuity, color vision, corrective lenses, photophobia, diplopia, pain Ears: pain, discharge, hearing loss, tinnitus Nose: epistaxis, discharge, stuffiness, sense of smell Throat: status of teeth, gums, dentures, taste, soreness, hoarseness, lump Respiratory: cough, sputum, hemoptysis, wheezing CV: dyspnea(on exertion, at rest, paroxysmal nocturnal dyspnea, orthopnea), edema, chest distress/pain, palpitation, intermittent claudication, cold limbs,2011/09/06,第三十頁(yè)，共三十七頁(yè)。,Allergy history,Allergy Describe not only what the patient is allergic to, but also the manifestation of that allergy Side effect or allergy,2011/09/06,第二十八頁(yè)，共三十七頁(yè)。,Past Medical History:,Preventive Health: Current immunization status – will depend on age of patient amp。 Queens hospital in New York by Dr. Carter, length of stay of 3 days. General anesthesia without reaction. No complications. Laparoscopic cholecystectomy in 1988。 number or use a separate paragraph if more than one surgical procedure,2011/09/06,第二十五頁(yè)，共三十七頁(yè)。,Past Medical History:,Ask about any significant care or other hospitalizations not covered. Ask about toxic and/or Industrial expo
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