特殊情况下主诉书写的探讨

主诉通常由两个要素组成,即症状或体征和持续时间.所谓的特殊情况是指不具备主诉两要素的临床病例（或就医者）,大致可归纳为4种：（1）症状或体征一过性出现;（2）原有症状或体征经治疗后已消失,后续治疗需求;（3）无症状或体征,医技检查发现异常;（4）无症状或体征,也无医技检查异常,但有就医需求.通过对上述4种特殊情况主诉书写案例的分析,提出在特殊情况下主诉书写时,特别要遵循具体问题、具体分析原则.对于特殊情况下主诉的书写,临床医师只有重视它、创新性地研究它,且不断积累书写经验,特殊情况下主诉书写才能由“难写”转变为“易写”.

Study on the Writing of Chief Complaint in Special Situation

Chief complaint is usually composed of two elements,the symptom or sign and duration.The so-called special situations refer to the clinical cases （or clients） which do not have two elements of chief complaint.It can be classified into 4 types：（1） The patients whose symptoms or signs transiently took place.（2） The original symptoms or signs had disappeared after treatment and follow-up treatment was needed.（3）The patients who had no symptoms or signs and whose results of medical examination were abnormal.（4） The clients who had no symptoms or signs and normal medical examination results,but demand the medical attention.By analyzing the special situations of the writing of chief complaint,it was suggested that the writers should follow the principle of the specific analysis of specific problems.For the writing of chief complaint in special situations,only clinicians attend importance to it,study it innovatively and accumulate their writing experience,could the writing of the chief complaint can change from ‘ difficult to write’ to‘ easy to write’.