【分享】妇科手术记录表

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Gynecologic Surgical History
Identifying Data. 身份资料  Age年龄, gravida 孕妇(number of pregnancies受孕次数), Para (number of deliveries生产次数).
Chief Compliant主诉. Reason given by patient for seeking surgical care. 患者给出的寻求手术处理的原因。
History of Present Illness(HPI)当前疾病记录. Describe the course of the patient's illness, including when it began, character of the symptoms; pain onset (gradual or rapid), character of pain(constant, intermittent, cram ping, radiating); other factors associated with pain(urination, eating, strenuous activities); aggravating or relieving factors. Other related diseases; past diagnostic testing. 病程描述，包括何时生病，症状；疼痛发作（渐进还是急性），疼痛特征（持续，间歇，压痛，发射状）；与疼痛相关的其它因素（排尿，进食，紧张活动）；恶化还是减缓因素。其它相关疾病；过去诊断检查资料。
Obstetrical History. Past pregnancies, durations and outcomes, preterm deliveries,  operative deliveries. 产科记录：以往怀孕情况，持续时间和结果，早产，剖腹产。
Gynecologic History: Last menstrual period, length of regular cycle. 妇科记录：最后一次月经，月经周期
Past Medical History (PMH). Past medical problems, previous surgeries, hospitalizations, diabetes, hypertension, asthma, heart disease. 以往医学记录（PMH）；以往病史，以往手术，住院记录，糖尿病，高血压，哮喘，心脏病。
Medications. Cardiac medications, oral contraceptives, estrogen. 药物治疗。心脏药物，口服避孕药，雌激素
Allergies. Penicillin, codeine. 敏感症. 盘尼西林，可待因。
Family History. Medical problems in relatives. 家族病史. 亲属中生病情况。
Social History. Alcohol, smoking, drug usage, occupation. 社会记录： 酗酒，吸烟，药物使用，职业
Review of Systems(ROS): 各系统评价：
General: Fever, fatigue, night sweats. 一般：发热，疲劳，夜汗。
HEENT: Headaches, masses, dizziness. 头痛，晕眩
Respiratory: Cough, sputum, dyspnea. 呼吸系统：咳嗽， 吐痰，呼吸困难
Cardiovascular: Chest pain, extremity edema. 心血管系统：胸痛，严重浮肿。
Gastrointestinal: Vomiting, abdominal pain, melena 消化系统：呕吐， 腹痛，黑粪症（黑色大便）， 便血（鲜红血样便）
(black tarry stools), hematochezia (bright red blood per
rectum).
Genitourinary: Dysuria, hematuria, discharge.泌尿生殖系统：排尿困难，血尿，流驻
Skin: Easy bruising, bleeding tendencies. 皮肤：易擦伤，有出血倾向。

第一次翻译，限于水平，多有不准之处，与大家共勉。