英文病例书写(6)

英文病例书写

例2：His grandfather 87, is still hale and healthy.

4.家族有~病：

例1：He is the only member of a family of 5 have Hodgkin's disease.

例2：Family history showed chronic gastrointestinal symptoms in a maternal cousin.

5.家族有~倾向：

例1：There was a strong family history of hemophilia；6 members of the present generation were affected.

例2：There was a high incidence of gallbladder disease in the family.

6.过敏：

例1：He had no history of penicillin sensibility, however, he once noted petechiae after taking aspirin.

例2：No asthma, hives or any idiosyncrasy to foods.

7.因~而死：

例1：His father's death was coincidental with the patient's illness.

例2：His eldest brother died of pneumonia at the age of 28 in the preantiboitic era.

四、个人历

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.