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    英文病历如何书写(四)-个人史

       作者:古龙   2009-07-04
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            四、个人史
           1.吸烟:
           例1:History revealed that he started smoking 10 years before, at the age of 23, and has smoked ever since. At first he smoked only a few cigarettes a day but gradually increased this to three-fourths of a package per day, his present rate.
           例2:He now smokes an average of 2 packages of cigarettes daily and has averaged this amount for the past 7 years.
           2.饮酒:
           例1:The patient admitted to excessive use of alcohol for years with a grossly inadequate dies.
           例2:He customarily consumed up to 2 bottles of beer a day on weekends but denied long period of alcoholic excess or the daily use of alcohol.
           3.饮食:
           例1:The boy never ate any fresh fruits or vegetables and did not like milk.
           例2:She took supplemental multivitamins daily and used a variety of mouthwashes.
           4.工作:
           例1:The patient’s occupation ( for more than five years) necessitated his breathing acid fumes.
           例2:His complaints persisted, and he was unable to resume his regular work.
           5.分娩:
           例1:The history relative to her pregnancy suggested that she was in her 5th month of gestation ( pregnancy).
           例2:She is a 30-year-old primigravida with long-standing sterility (infertility).
           6.其它(卫生、习惯等):
           例1:He spent 3 months visiting Taipei in early 1960 and denied travel outside of Taiwan after that time.
           例2:The pt. related that she has always lived in Peitou expect for 8 months during 1958~1959 when she temporarily moved to Tienmoo.
           例3:The house was located in a river valley and , therefore, was in a damp, foggy area.
           例4:The families of both parents were long residents in the same rural area in Taitung prefecture.
           例5:He was born in a small village of illiterate and primitive parents.
           例6:The family had a sick kitten and also kept dogs at the time of the present illness.
           例7:He preferred the supine position partially rotated to the right side.
           例8:The patient stated that he was in the habit of spending a great deal of time at the beach during the summer.
           例9:She lacked outside interests and was apathetic.
           例10:His interests and activities centered mainly on his job.
           例11:The patient is not in a good term with his boss.
           例12:His income was somewhat above the average for the area in which he lived, and he was well satisfied with his present occupation.
           来源:医学全在线

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