英文病例
英文病例模版
discharges were found invetibulum nasi. Septum nasi was in midline. No
nares flaring. No tenderness in nasal sinuses.
Superficial lymph nodes：Superficial lymph nodes were not found enlarged.
Head:Cranium:Hair was black and white, well distributed.No deformities. No scars.No pain when we press on. No masses.No tenderness.
Kinetic system:No history of joint pain, numbness,red and swollen,
metallaxis,myalgia or myophagism.
Neural system:No history of long-term headache,dizziness and vertigo,
atage 46.
Marital history：She’s marriedat 28,her husband is heslth,and the relationship
between them were concord.
Childbearing history：G4P2,induced abortion twice,natural labourtwice,and they are heathy.
骨折病例报告范文
骨折病例报告范文（中英文实用版）English:Case Report: Fracture中文:病例报告：骨折English:This is a case report of a 45-year-old male who presented to the emergency department with a history of a fall from a height.The patient complained of severe pain in the right forearm and inability to move it.On examination, there was a deformed appearance of the forearm with tenderness and swelling.Radiographs revealed an open fracture of the distal radius with associated soft tissue damage.The patient was managed conservatively with immobilization and antibiotics, and had a good recovery.中文:这是一份45岁男性患者的病例报告，他因从高处坠落而来到急诊室。
患者抱怨右前臂剧烈疼痛且无法活动。
检查发现前臂有畸形、压痛和肿胀。
X光片显示radius 远端骨折伴有软组织损伤。
患者接受了保守治疗，包括固定和抗生素，并取得了良好的恢复。
English:Fractures are common injuries that can occur due to trauma, suchas falls, motor vehicle accidents, or sports injuries.The management of fractures depends on the type and location of the fracture, as well as the patient"s overall health.Treatment options include conservative management with immobilization and pain relief, or surgical intervention in more severe cases.中文:骨折是常见的损伤，可能由于外伤，如跌倒、交通事故或运动损伤等原因发生。
英文病例报告作文范文
英文病例报告作文范文英文：Case Report: A Patient with Abdominal Pain。
I recently saw a patient, a 35-year-old female, who presented with severe abdominal pain. She reported that the pain had started suddenly and was located in the lowerright quadrant of her abdomen. She also reported nausea and vomiting.Upon examination, I noted that her abdomen was tender to the touch and that she had rebound tenderness in the lower right quadrant. Based on these findings, I suspected that she had appendicitis.I ordered a CT scan of her abdomen, which confirmed my suspicion. The scan showed an enlarged appendix with signs of inflammation.I immediately admitted the patient to the hospital and consulted with a surgeon. The patient underwent an appendectomy, and her recovery was uneventful.This case highlights the importance of prompt diagnosis and treatment of appendicitis. If left untreated, appendicitis can lead to serious complications, such as a ruptured appendix and peritonitis.中文：病例报告，一位患有腹痛的患者。
湘雅二医院儿科英文病例
Physical examination
No jaundice, no cyanosis, no pigmentation, no skin eruption was seen. Several enlarged superficial lymph nodes were found in her neck but without tenderness.
Past history
The patient was healthy before. No history of surgery. No history of blood transfusion or contact with TB or HBV or other infective diseases. No allergy record of food or drug.
Although the fever was relieved, her leg pain got worse. Therefore, she was brought to our out-patient department and blood routine showed that the WBC was 50*10^9/L, PLT was 32*10^9/L, Hb was 50 g/L. She was suspected as “Acute Leukemia?” and admitted to our ward. She did not sleep well since onset and her appetite was not good. Defecation and urination were normal.
Admission Notes英文版病例 英语病历
Admission Notes (2)A 60-year-old married male was admitted on March 10,2010, with a two-month palpitation and a thoracalgia.Since this March, the patient has frequently felt palpitations a chest pain upon physical exertion, the latter radiating into the left shoulder and arm. One attack lasts about five minutes. He has a feeling of suffocation. It seems as if something heavy were pressing hard on his chest. He has a slight cough and expectorates a little mucous sputum during the attack.. Because he has not had any treatment before, the symptoms mentioned above have also deteriorated this week and his legs have been swollen as well, he came to the hospital for medical treatment.During his illness, he has been feeling weak but he has had a goodappetite, and his bowel motions and micturition have remained normal.He said that he had been perfectly healthy and had never had rheumatic fever or heart trouble previously.There is nothing particular in his family medical history.PE T: 36.7”C; P:100/min. R:20/min.;BP:140/80mmHg(19—11kPa).Well developed and nourished. In his right mind and in voluntary position. No dyspnea or cyanosis detected. No eruption or purpura over skin. Superficial lymph nodes impalpable. Skull and head organs not abnormal. Neck soft and supple and free of venous engorgement. Trachea in midline. Thyroid not enlarged. Chest symmetrical. Lungs clear. Heart enlarged and leftward without irregular beats. Heart rate 100/min. A grade—IIIharsh blowing systolic murmur heard at the apical area with no thrill felt or diastolic murmur heard. Abdomen flat with no tenderness. Liver felt 2 fb below costal margin. Hepatojugular reflux negative. Spleen not palpable. No shifting dullness over abdomen heard. Slight edema in both ankles present. Bilateral knee jerk reflexes active. No pathological neural reflex found.Chest fluoroscopy reveals general cardiac enlargement.ECG shows:1.sinus rhythm2.left ventricular hypertrophy3.chronic coronary insufficiency Diagnosis: Coronary Heart Disease Left V entricular HypertrophyAngina Pectoris Signature: Date:。
阑尾炎英文病例报告作文模板
阑尾炎英文病例报告作文模板英文回答：Appendicitis Case Report: A 17-Year-Old Male with Right Lower Quadrant Pain。
History of Present Illness:A 17-year-old male presents to the emergency department with a 24-hour history of progressively worsening right lower quadrant (RLQ) pain. The pain is described as sharp and stabbing, and it is associated with nausea and vomiting. The patient has no significant past medical history and is not taking any medications.Physical Examination:The patient is afebrile with a blood pressure of 120/80 mmHg, a heart rate of 80 beats per minute, and arespiratory rate of 18 breaths per minute. Abdominalexamination reveals mild tenderness and rebound tenderness in the RLQ. There is no guarding or rigidity.Laboratory Findings:Laboratory findings include a white blood cell count of 15,000 cells/mm3 with a predominance of neutrophils. Urinalysis is unremarkable.Imaging Studies:An abdominal ultrasound shows a distended and fluid-filled appendix with surrounding inflammation.Diagnosis:Appendicitis。
英文版病例汇报
Chest CT
Chest CT
2015.05.28 Pelvic CT
2015.05.28 Pelvic CT
Present diagnosis
Rectal cancer after resection pT4aN0M0 ⅡB
Liver metastasis
Harbin Medical University cancer hospital
Present history
Tumor marker after Chemotherapy
CEA CA199
2015.05.29
Before chemotherapy
113.2
168.2
135.3
157.7
CEA：0-5ng/ml CA199:0-37U/ml
2015.06.23
1 course later
Harbin Medical University cancer hospital
Present history
Recurrence
• 2015-06-01 Left liver lesion biopsy: Poorly differentiated carcinoma, consistent with metastatic carcinoma.
Harbin Medical University cancer hospital
Present history
Clinical diagnosis based on the pathologic
stage Rectal adenocarcinoma after resection pT4aN0M0 ⅡB
Harbin Medical University cancer hospital
医学英语-英文病例-范文
Case HistoryName: Meretrix Gender: FemaleAge: 40 Occupation: NurseBirth Place: Washington DC Marital Status: MarriedAddress: #112, Main Avenue, Washington DCReliability: Reliable Supplier: Patient herselfDate of Admission: 10am, Aug. 6th, 2006Date of Record: Aug. 6th, 2006C.C.:Palpitation and breathlessness after exertion for 7 years; edema of lower extremities for 4 daysH.P.I.:The patient got palpitation and breathlessness after overexertion and going upstairs alleviating after having a rest 7 years ago. Then she saw her doctor, and the roentgenography showed an enlargement of the heart; but it was so negligible that she was not treated. She came to Washington 5 years ago because of frequent bad colds due to bad weather conditions with strong cough which didn’t ameliorate with the disappearance of the palpitation and breathlessness but with orthopnea at night. She was once hospitalized with an injection of penicillin and glucose and had a rest of 2 weeks, thus propelling the symptoms. She complains of a flatulence without edema of lower extremities in the recent 2 years. One month ago, she was admitted to our hospital with sore throat, cough, hemoptysis, palpitation, breathlessness, and orthopnea due to a bad cold resulting from exhaustion. Antitussive and penicillin have been employed but it was in vain. Edema of lower extremities came into being in the recent 3 days or so; urine is little with a dark color; feces are not amorphous with once a day; dyspepsia and nausea are overt. Digitalis has not been used and good in mental status with infrequent insomnia.P.H.:The patient has been and is weak with frequent sore throat since her childhood. Shegot malaria 11 years ago with a medication of quinine and thus symptoms disappeared a week after with a recurrence and a similar treatment resulting in good outcome; no migrant rash was found. No histories of allergy to drug or food, of trauma or surgery, of blood transfusion. And we are not informed of a history of inoculation.Pers. H.:The patient was a Shanghaier and came to Washington DC 5 years ago. No visiting history to other places. She was an undergraduate. The patient is a housewife with a gasto of reading. She is quiet and not addicted to smoke or wine. SheF.H.:She married at the age of 24 and her husband is 39 now. Parents, a girl aged 10, and a boy aged 6 are all living and well.Mens. H.:614——4028P.E.:T. 38.0℃. P. 70. R. 30. B.P. 100/70mmHg.The patient stayed in bed in semi-reclining position. She looked actually ill, but remained conscious, and was well oriented to time, place, and person.Skin and Lymph Node: N.A.D. (No abnormality detected.)Head: There was flaring of the nares, but otherwise normal.Neck: Negative.Chest: Excursion decreased on the right side of the chest. Trachea in the midline. Heart: Disseminated rales in the fundi of the two lungs, especially the right lung. Lungs: Slightly increased fremitus, dull percussion note, diminished breath sound, and fine moist inspiratory rales were present on the right bases. The rest of the chest showed nothing special.Abdomen: Soft. Liver felt 1.5 cm below L.C.M. (lower costal margin) on the mid-clavicular line. Spleen not felt. Murphy’s sign weakly positive, withno palpable gall-bladder. No tenderness or mass elsewhere.Spine, Extremities, Rectum and External Genitalia: Nothing remarkable. Neurological Reflexes: Physiological reflexes normal. No pathological reflexes elicited. O.P.D. Lab. Findings (Out-Patient Department Laboratory Findings):Blood:W.B.C. 14,000/cmmD.B.C. P.M.N.82%, Lymph. 16%, M.1%R.B.C. 3,900,000/cmmHgb. 11 gmFeces:Dark yellow, slightly cloudy, acidic.Density 1.019Protein (+)Glucose (-)W.B.C. 5/HPMajor Diagnostic Evidence:1.History of streptococcal infection and a weak body.2.Symptoms and signs of heart failure and pulmonary edema.3.W.B.C. of 14,000 with 82% polys.Impression:1. Rheumatic valvular disease.Mitral stenosis complicated with mitral regurgitationAtrial fibrillationGrade III heart failure2. Acute onset of a chronic tonsillitis.Date: Aug. 6th, 2006Attending Physician____________。
英文病例报告范文 低视力
英文病例报告范文低视力When examining a patient with low vision, it is essential to take a thorough medical history to ascertain the underlying cause of their visual impairment. This may involve asking about previous eye conditions, family history of eye diseases, and any other relevant medical issues that may contribute to the low vision.在检查视力低下的患者时，需要对其进行全面的病史调查，以确定视力受损的潜在原因。
这可能涉及询问之前的眼部状况、家族中是否有眼部疾病史以及可能导致低视力的其他相关医疗问题。
Furthermore, performing a comprehensive eye examination is crucial to assess the current visual abilities of the patient. This may involve testing visual acuity, visual fields, color vision, contrast sensitivity,and other parameters to determine the extent of the visual impairment and tailor appropriate management strategies.此外，进行全面的眼部检查对评估患者当前的视觉能力至关重要。
这可能涉及测试视力、视野、色觉、对比敏感度和其他参数，以确定视力受损的程度，并制定适当的管理策略。
湘雅二医院儿科英文病例模板
Xinrui Tan PhD
PEDIATRIC DEPARTMENT OF THE SECOND XIANGYA HOSPITAL
GENERAL INFORMATION
X, a four-year-old girl, admitted to our ward on July 31, 2016.
thorax [ˈθɔ:ræks] symmetric [sɪ'metrɪk] tactile fremitus [ˈtæktəl ˈfremitəs] pleural friction ['plʊrə ˈfrɪkʃn] vesicular resonance [viˈsikjulə ˈrezənəns] wheeze [wi:z]
PHYSICAL EXAMINATION
No jaundice, no cyanosis, no pigmentation, no skin eruption was seen. Several enlarged superficial lymph nodes were found in her neck but without tenderness.
jaundice [ˈdʒɔ:ndɪs] cyanosis [ˌsaɪə'nəʊsɪs] pigmentation [ˌpɪgmenˈteɪʃn] eruption [ɪ'rʌpʃn] superficial [ˌsu:pəˈfɪʃl] lymph nodes [lɪmf nəʊds]
PHYSICAL EXAMINATION
supplementary foods [ˌsʌplɪˈmentri] vaccination [ˌvæksɪ'neɪʃn]
病例报告英文范文医护英语
病例报告英文范文医护英语English:The patient, a 45-year-old male, presented to the emergency department complaining of severe chest pain radiating to his left arm and shortness of breath. On examination, his blood pressure was 180/110 mmHg, heart rate 110 bpm, and oxygen saturation 92% on room air. ECG revealed ST-segment elevation in leads II, III, and aVF, consistent with an inferior myocardial infarction. He was promptly started on aspirin, clopidogrel, and sublingual nitroglycerin. Intravenous morphine was administered for pain relief. He was transferred to the coronary care unit for further management, where he underwent emergent coronary angiography showing complete occlusion of the right coronary artery. Percutaneous coronary intervention (PCI) was performed, resulting in successful revascularization. The patient's symptoms improved, and he was discharged home with instructions for cardiac rehabilitation and secondary prevention measures, including dual antiplatelet therapy, statin, beta-blocker, and angiotensin-converting enzyme inhibitor therapy.Translated content:患者为45岁男性，就诊于急诊科，主诉严重胸痛放射至左臂，呼吸急促。
低蛋白血症病例模板范文
低蛋白血症病例模板范文英文回答：Low proteinemia, also known as hypoalbuminemia, is a medical condition characterized by low levels of protein in the blood. This condition can be caused by various factors, including inadequate dietary protein intake, malabsorption, liver disease, kidney disease, and certain types of cancer.One common symptom of low proteinemia is edema, whichis the accumulation of fluid in the tissues. This canresult in swelling in the legs, ankles, and feet. Other symptoms may include fatigue, weakness, and a decrease in muscle mass.To diagnose low proteinemia, a blood test called serum albumin level is usually performed. A normal albumin levelis typically between 3.5 and 5.5 grams per deciliter (g/dL). If the level is below this range, it indicates low proteinemia.Treatment for low proteinemia focuses on addressing the underlying cause. This may involve dietary changes to increase protein intake, such as consuming more lean meats, fish, eggs, and dairy products. In severe cases, intravenous protein supplementation may be necessary.It is important to address low proteinemia as it can lead to complications if left untreated. For example, the decreased protein levels in the blood can affect the body's ability to heal wounds and fight infections. Additionally, low proteinemia can contribute to the development of malnutrition and muscle wasting.中文回答：低蛋白血症，也被称为低白蛋白血症，是一种血液中蛋白质水平过低的医学状况。
英文病例写作范文阅读带翻译
英文病例写作范文阅读带翻译病例写作是医生日常的工作，英文的病例该如何写呢，接下来店铺为大家整理英文病例写作范文，希望对你有帮助哦!英文病例写作范文篇一Name: Joe Bloggs (姓名：乔。
伯劳格斯)Date: 1st January 2000(日期：2000年1月1日)Time: 0720(时间：7时20分)Place: A&E(地点：事故与急诊登记处)Age: 47 years(年龄：47岁)Sex: male(性别：男)Occupation: HGV(heavy goods vehicle ) driver(职业：大型货运卡车司机)PC(presenting complaint)(主诉)4-hour crushing retrosternal chest pain(胸骨后压榨性疼痛4小时)HPC(history of presenting complaint)(现病史)Onset: 4 hours of “crushing tight” retrosternal chest pain, radiating to neck and both arms, gradual onset over 5-10 minutes.(起病特征：胸骨后压榨性疼痛4小时，向颈与双臂放射，5-10分钟内渐起病)Duration: persistent since onset(间期：发病起持续至今)Severe: “worst pain ever had”(严重性：“从未痛得如此厉害过)Relieving/exacerbating factors缓解与恶化因素GTN(glyceryl trinitrate) provided no relief although normally relieves pain in minutes, no other relieving/exacerbating factors.(硝酸甘油平时能在数分钟内缓解疼痛，但本次无效，无其它缓解和恶化因素。
英文病例范文
英文病例范文(中英文版)English Sample Medical Case:John Doe, a 35-year-old male, presented to the emergency department with a chief complaint of severe abdominal pain. The pain started suddenly two hours prior to his arrival and was described as sharp and radiating to his back. Upon examination, his vital signs were stable, but he appeared pale and diaphoretic. The abdomen was tender to palpation, particularly in the upper right quadrant. Laboratory investigations revealed an elevated white blood cell count and increased liver function tests. A diagnosis of acute cholecystitis was suspected, and an ultrasound was ordered to confirm the presence of gallstones.张三，35岁男性，因剧烈腹痛到急诊科就诊。
疼痛在就诊前两小时突然开始，表现为尖锐并向背部放射。
检查时，他的生命体征稳定，但面色苍白且出汗。
腹部触诊时，尤其右上象限区域明显疼痛。
实验室检查显示白细胞计数升高和肝功能测试异常。
眼科英文病例模板(myself)(可编辑)
眼科英文病例模板（myself）Medical Records for AdmissonMedical Number: 701721General informationName: Liu XiaojingAge:56Sex: MaleNationality: ChinaMotherland:ChongqingAddress:Occupation: workerMarital status: MarriedDate of admission:Date of record:Complainer of history: himselfReliability: ReliableChief complaint:Present illness: Contain: main symptoms e g. The patient felt…; symptoms for differential diagnosis e g. without vomiting;examination and therapeutic proceduree g. drugs、surgery;Is he going well or worse?; So why he came to our hospitale g. for further treatment;the diagnosis in outpatient clinicPast history:Contain: Is the patient healthy before? History of infective diseasee g. hepatitis B,TB ; History of HBP、DM、CHD; History of trauma and surgery; Allergy history of food and drugse g. penicillin、sulfamide; History of blood transfusion; History of vaccinatione g. he was inoculated according to the national plan Systems review:Head and neck: no history of deaf, tinnitus, vertigo, headache, epistaxis, gum hemorrhage and hoarseness.Respiratory system: No history of respiratory diseaseCirculatory system: No history of precordial pain.Alimentary system: No history of regurgitation.Genitourinary system: No history of genitourinary diseaseHematopoietic system: No history of anemia and mucocutaneous bleedingEndocrine system: No acromegaly. No diabetes mellitusKinetic system: No history of confinement of limbsNeural system: No history of headache or dizziness.Personal history:e g. He was born in Chongqing on Nov 19th, 1921 and lived in Chongqing. His living conditions were good. He has never been to malaria, paragonmiasis, and schistosoma prevalent areas. He works as worker, and has college education. He never smokes, drinks, or has any drug abuses.No bad personal habits and customs.Menstrual and Obstetrical history: He is a male patient.Family history: No history of special hereditary disease and infective disease are found in his family. His parents are both healthy.Physical examinationT 36.5℃,P 80/min,R 20/min, BP 100/60mmHg He is well developedand moderately nourished. Active position. His consciousness was clear. His face was sanguine and the skin was not stained yellow. No cyanosis. No pigmentation. No skin eruption. Spider angioma was not seen. No pitting edema. Superficial lymph nodes were not found enlarged.Head Cranium: Hair was black and well distributed. No deformities. No scars. No masses. No tenderness Ear: Bilateral auricles were symmetric and of no masses. No discharges were found in external auditory canals. No tenderness in mastoid area. Auditory acuity was normal Nose: No abnormal discharges were found in vetibulum nasi. Septum nasi was in midline. No nares flaring. No tenderness in nasal sinuses Eye:The details is in the “special examination” Mouth: Oral mucous membrane was smooth, no ulcer can be seen. Tongue was in midline. Pharynx wasn’t congestive. Tonsils were not enlargedNeck: Symmetric and of no deformities. No masses. Thyroid was not enlarged. Trachea was in midline.ChestChestwall: Veins could not be seen easily. No subcutaneous emphysema. Intercostal space was neither narrowed nor widened. No tenderness Thorax: Symmetric bilaterally. No deformities Breast: Symmetric bilaterally Lungs: Respiratory movement was bilaterally symmetric with the frequency of 20/min. thoracic expansion and tactile fremitus were symmetric bilaterally. No pleural friction fremitus. Resonance was heard during percussion. No abnormal breath sound was heard. No wheezes. No rales Heart: No bulge and no abnormal impulse or thrills in precordial area. The point of imum impulse was in 5th left intercostal space inside of the mid clavicular line and not diffuse. No pericardialfriction sound. Border of the heart was normal. Heart sounds were strong and no splitting. Rate 80/min. Cardiac rhythm was regular. No pathological murmurs.Abdomen: Flat and soft. No bulge or depression. No abdominal wall varicosis. Gastralintestinal type or peristalses were not seen. Tenderness was obvious around the navel and in upper abdoman. There was not rebound tenderness on abdomen or renal region. Liver and spleen was untouched. No masses. Fluidthrill negative. Shifting dullness negative. Borhorygmus not heard. No vascular murmurs.Extremities: No articular swelling. Free movements of all limbs.Neural system: Physiological reflexes were existent without any pathological ones.Genitourinary system: Not examed.Rectum: not exanedEye exam Right eye Left eyeVisual Acuity:Visual acuity - uncorrected: OD: 20/200OS: 20/100Refraction:Lenses - final:OD: +6.00 +4.50 X 90 Prism 4.00 →20/100; OS: +6.00 +3.50 X 125 Prism 4.00 →20/20 IOP: 10mmHg10mmHgMotility: Ocular motility exam reveals gross orthotropia with full ductions and versions bilateral.Lids/Orbit: Bilateral eyes reveal normal position without infection. Bilateral eyelids reveals white and quiet.Conjunctiva:Cornea:Anterior angle chamber:Pupils: Pupil exam reveals round and equally reactive to light and accommodation.Iris:Visual Fields: Confrontation VF exam reveals full to finger confrontation OU.Slit Lamp: Corneal epithelium is intact with normal tear film and without stain. Stroma is clear and avascular. Corneal endothelium is smooth and of normal appearance.Anterior Segment: Bilateral anterior chambers reveal no cells or flare with deep chamber.Lens: Bilateral lenses reveals transparent lens that is in normal position.Posterior Segment: Posterior segment was dilated bilateral. Bilateral retinas reveal normal color,contour, and cupping.Retina: Bilateral retinas reveals flat with normal vasculature out to the far periphery. Bilateral retinasreveal normal reflex and color.Test Results: No tests to report at this timeImpression: Eye and vision exam normal.Plan: Return to clinic in 12 months.InvestigationBlood-Rt: Hb 69g/L RBC 2.70T/L WBC 1. 1G/L PLT 120G/LHistory summaryPatient was male, 80 years oldUpper bellyache ten days, haematemesis, hemafecia and unconsciousness for four hoursNo special past history.Physical examination: T 37.5℃, P 130/min, R 23/min, BP 100/60mmHg Superficial lymph nodes were not found enlarged. No abdominal wall varicosis. Gastralintestinal type or peristalses were not seen. Tenderness was obvious around the navel and in upper abdoman. There was not rebound tenderness on abdomen or renal region. Liver and spleen was untouched. No masses. Fluidthrill negative. Shifting dullness negative. Borhorygmus not heard. No vascular murmurs. No other positive signs.investigation information:Blood-Rt: Hb 69g/L RBC 2.80T/L WBC 1.1G/L PLT 120G/L Impression: upper gastrointestine hemorrhageExsanguine shockSignature: He Lin 95-10033。
感冒病例书写范文
感冒病例书写范文（中英文版）英文文档：Cold Case Writing SampleIntroduction:This document serves as a sample for writing a cold case report specifically related to a patient diagnosed with a common cold.The case report will include a detailed patient history, physical examination findings, diagnostic tests performed, and treatment recommendations.Patient History:The patient, a 30-year-old female, presented to the emergency department with complaints of a sore throat, runny nose, and mild fever.She reported that these symptoms had started approximately 2 days prior and had been progressively worsening.The patient mentioned that she had been exposed to a known case of the common cold within the past week.Physical Examination:On examination, the patient appeared uncomfortable and had a temperature of 38.2°C.Her throat was sore, and she had a persistent runny nose with some congestion.Her lungs were clear, and there was no palpable lymphadenopathy.The patient"s heart rate was slightly elevated, and her extremities were warm.Diagnostic Tests:To confirm the diagnosis of a common cold, a rapid influenza diagnostic test (RIDT) and a throat swab for streptococcal pharyngitis were performed.The RIDT result was negative for influenza A and B, and the throat swab did not show any group A streptococci.Treatment Recommendations:Based on the patient"s clinical presentation and test results, the following treatment recommendations were made:1.Supportive care: The patient was advised to rest, maintain hydration, and use over-the-counter pain relievers as needed for symptom relief.2.Antiviral therapy: Oseltamivir (Tamiflu) was prescribed at a dosage of 75 mg twice daily for 5 days, as the patient"s symptoms were consistent with influenza, even though the RIDT was negative.3.Cough medication: If the patient developed a cough, she was recommended to use a non-sedating cough suppressant.4.Follow-up: The patient was scheduled for a follow-up appointment in 3-5 days to reassess her symptoms and adjust treatment as necessary.Conclusion:This document provides a sample of a cold case report for a patient diagnosed with a common cold.It includes a patient history, physical examination findings, diagnostic tests performed, and treatmentrecommendations.This sample can be used as a reference for writing future cold case reports.中文文档：感冒病例书写范文引言：本文作为一份感冒病例报告的样本，特别针对被诊断为普通感冒的患者。
英文病例翻译
英文病例翻译第一部分病人身份[Identification]• [Name] 姓名• [Sex] 性别• [Age] 年龄• [Occupation] 职业• [Date of birth] 出生日期• [Marriage （Marital status）] 婚姻• [Race] 民族• [Place of birth (Birth place)] 籍贯• [Identification No.(code of ID card No.)] 身份证号码• [Department of work and TEL. No. (Unit and Business phone No.)] 工作单位及电话• [Home address and phone No.] 家庭住址及电话• [Post code] 邮政编码• [Person to notify (Correspondent) and phone No.] 联系人及电话• [Source (Complainer;offerer;supplier;provider) of history] 病史陈术者• [Reliability of history] 病史可靠程试• [Medical security (Type of payment)] 医疗费用• [Type of admission (Patient condition)] 住院类别（入院时病情）• [Medical record No.] 病历号• [Clinic diagnosis] 门诊诊断• [Date of admission (admission date)] 入院日期[Date of record] 记录日期1、年龄的表示方法（以36岁为例）•36 years old (y/o)•Age 36•36 year-old•The age of 36•36 years of age2、性别的表示方法• [Male,♂] 男性• [Female,♀] 女性3、职业的表示方法•工人[Worker] •退休工作[Retired worker]•农民[Farmer (peasant)] •干部[L eader (cadre)]•行政人员[administrative personnel (staff)]•职员[staff member] •商人[Trader (Businessman)]•教师[Teacher] •学生[Student] •医生[Doctor]•药剂师[Pharmacist]•护士[Nurse] •军人[Soldier] •警察[Policeman]•工程师[Engineer] •技术员[Technician] •家政人员[Housekeeper]•家庭主妇[Housewife] •营业员[Assistant] •服务员[Attendant]•售票员[Conductor]4、民族的表示方法•汉[Han] •回[Hui] •蒙[Meng] •藏[Tibetan]•朝鲜[Korean]•美国人[American] •日本人[Japanese] •英国人[Britisher]5、医疗费用的表示方法• [Self pay (Individual medical care)] 自费• [Government insruance (Public medical care)] 公费• [Insurance] 保险• [Local insurance] 本地医保• [Non-local in surance] 外地医保• [Labor protestion care] 劳保6、婚姻状况的表示方法• [Married] 已婚• [Single (Unmarried)] 未婚• [Diverced] 离婚• [Widow] 寡妇• [Widower] 鳏夫7、病史可靠程度的表示方法• [Reliable] 可靠• [Unreliable] 不可靠• [Not entirely] 不完全可靠• [Unobtainable] 无法获得8、住址的表示方法•[NO.3,Qing Chun Road East,Hangzhou, Zhejiang] 浙江省杭州市庆春东路3号•[XinDong Cun, Cheng Guan Town, Zhu Ji municipality, zhejiang province.] 浙江省诸暨市（县）城关镇新东村9、病史陈述者的表示方法• [Patient himself (herself)] 患者本人• [Her husband] 患者的丈夫• [His wife] 患者的妻子• [Patient`s colleague] 患者的同事• [Patient`s neighbor] 患者的邻居• [Patient`s Kin (Mother; Son; daughter;brother;Sister)] 患者的亲属(父亲、母亲、儿子、女儿、兄弟、姐妹)• [Taximan] 出租车司机• [Traffic police] 交通警察10、日期的表示方法•2002年10月1日[10-1-2002(10/1/2002; Oct.1,2002; Oct.lst,2002)](美国)•2002年10月1日[1-10-2002(1/10/2002; 1 Oct.,2002; 1st of Oct.,2002)] (英国)11、住院类别的表示方法• [Emergent (Emergency call)] 急诊• [Urgent] 危重• [Elective (General)] 一般（普通）12、入院时病情的表示方法• [Stable] 稳定• [Unstable] 不稳定• [Relative stable] 相对稳定• [Critical (Imminent)] 危重• [Fair (General)] 一般第二部分主诉[Chief Complaint]1、主诉的表示方法：症状+时间（Symptom+Time）•症状+for+时间如：[Chest pain for 2 hours] 胸痛2小时•症状+of+时间如：[Nausea and vomiting of three days` duration] 恶心呕吐3天•症状+时间+in duration如：[Headache 1 month in duration] 头痛1月•时间+of+症状如：[Two-day history of fever] 发热2天2、常见症状• [Fever] 发热• [Pain] 疼痛• [Edema] 水肿• [Mucocutaneous hemorrhage (bleeding)] 皮肤粘膜出血• [Dyspnea (Difficuly in breathing;Respiratory difficulty;short of breath)] 呼吸困难• [Cough and expectoration (Sputu mhlegm)] 咳嗽和咯痰• [Hemoptysis] 咯血• [Cyanosis] 紫绀• [Palpitation] 心悸• [Chest discomfort] 胸闷• [Nausea (Retch;Dry Vomiting)and Vomiting] 恶心和呕吐• [Hematemesis (Vomiting of blood)] 呕血• [Hematochezia (Hemafecia)] 便血• [Diarrhea] 腹泻• [Constipation (Obstipatio n)] 便秘• [Vertigo (Giddiness; Dizziness)] 眩晕• [Jaundice (Icterus)] 黄疸• [Convulsion] 惊厥• [Disturbance of consciousness] 意识障碍• [Hematuria] 血尿• [Frequent micturition,urgent micturition and dysuria] 尿频，尿急和尿痛• [Incontinence of urine] 尿失禁• [Retention of u rine] 尿潴留（1）发热的表示方法• [Infective (Septic)fever] 感染性发热• [Non-infective (Aseptic)fever] 非感染性发热• [Dehydration (Inanition)fever] 脱水热• [Drug fever] 药物热• [Functional hypothermia] 功能性低热• [Absorption fever] 吸收热• [Central fever] 中枢性发热• [Fever type] 热型• [Co ntinuous fever] 稽留热• [Remittent fever] 驰张热• [Intermittent fever] 间歇热• [Undulant fever] 波状热• [Recurrent fever] 回归热• [Periodic fever] 周期热• [Irregular fever] 不规则热• [Ephemeral fever] 短暂热• [Double peaked fever] 双峰热• [Fever of undetermined(unknown) orig in, FUO] 不明原因发热• [Rigor (shivering;chill;shaking chill;ague)] 寒战• [Chilly Sensation (Fell chilly;cold fits;coldness)] 畏寒• [Ultra-hyperpyrexia] 超高热• [Hyperthermia (A high fever;hyperpyrexia;ardent fever)] 高热• [Moderate fever] 中度发热• [Hypothermia (Low-grade fever;slight fever;subfebrile temperature)] 低热• [Become feverish (Have a temperature)] 发热• [Crisis] 骤降• [Lysis] 渐降• [Typhoid fever] 伤寒热• [Rheumatic fever] 风湿热• [Cancerous fever] 癌性发热• [Fervescence period] 升热期• [Defervescence period] 退热期• [Per sistent febrile period] 持续发热期（2）疼痛的表示方法• [Backache (Back pain)] 背痛• [Lumbago] 腰痛• [Headache] 头痛• [Vasomotor headache] 血管舒缩性头痛•[Post-traumatic headache] 创伤后头痛•[Migraine headache] 偏头痛• [Cluster headache] 丛集性头痛• [Chest pain] 胸痛• [Precardial pain] 心前区痛• [Retrosternal pain] 胸骨后痛• [Abdominal pain (Stomachache)] 腹痛• [Acrodynia (pain in limbs)] 肢体痛• [Arthrodynia (Arthralgia)] 关节痛• [Dull pain] 钝痛• [Sharp pain] 锐痛• [Twinge pain] 刺痛• [Knife-like pain (Piercing pain)] 刀割（刺）样痛• [Aching pain] 酸痛• [Bur ning pain] 烧灼痛• [Colicky (Griping;cramp) pain] 绞痛• [Colic] 绞痛• [Bursting pain] 胀痛（撕裂痛）• [Hunger pain] 饥饿痛• [Tic pain] 抽搐痛• [Bearing-down pain] 坠痛• [Shock-like pain] 电击样痛• [Jumping pain] 反跳痛• [Tenderness pain] 触痛（压痛）• [Girdle-like pain] 束带样痛• [Wa ndering pain] 游走性痛• [Throbbing pain] 搏动性痛• [Radiating pain] 放射性痛• [Cramping pain] 痉挛性痛• [Boring pain] 钻痛• [Intense pain] 剧痛• [Writhing pain] 痛得打滚• [Dragging pain] 牵引痛• [Labor pain] 阵痛• [Cancerous pain] 癌性疼痛• [Referred pain] 牵涉痛• [Persistent pain (Unremitting pain)] 持续性痛• [Constant pain] 经常性痛• [Intermittent pain] 间歇性痛（3）水肿的表示方法• [Mucous edema (Myxedema)] 粘液性水肿• [Cardiac (Cardiogenic) edema] 心源性水肿• [Nephrotic (renal) edema] 肾源性水肿• [Hepatic edema] 肝源性水肿• [Alimentary (Nutritional) edema] 营养不良性水肿• [Angioneurotic edema] 血管神经性水肿• [Pitting] 凹陷性• [Nonpitting] 非凹陷性• [Localized (Local) edema] 局限性水肿• [Generalized edema (Anasarca)] 全身性水肿• [Hydrops] 积水• [Elephantiasic crus] 橡皮肿• [Cerebral(Brain) edema] 脑水肿• [Pulmonary edema (Hydropneumonia0] 肺水肿• [Hydrocephalus] 脑积水• [Edema of endoscrinopathy] 内分泌病性水肿• [Invisible (Recessive) edema] 隐性水肿• [Frank edema] 显性水肿• [Inflammatory edema] 炎性水肿• [Idiopathic edema] 特发性水肿• [Cyclical edema] 周期性水肿• [Ascites (Abdominal effusion;hydroperiotoneum)] 腹水• [P leural effusion (Hydrothorax)] 胸水• [Pericardial effusion (Hydropericardium)] 心包积液• [Bronchoedema] 支气管水肿• [Slight (Mild)] 轻度• [Moderate] 中度• [Serious] 重度• [Transudate] 漏出液• [Exudate] 渗出液（4）呼吸困难的表示方法• [Cardiac dyspnea] 心原性呼吸困难• [Inspiratory] 吸气性• [Expiratory] 呼气性• [Mixed] 混合性• [Obstructive] 梗阻性• [Dyspnea at rest] 静息时呼吸困难• [Dyspnea on exertion] 活动时呼吸困难• [Dyspnea on lying down] 躺下时呼吸困难• [Paroxysmal nocturnal dyspnea,PND] 夜间阵发性呼吸困难• [Orthopnea] 端坐呼吸• [Asthma] 哮喘• [Cardiac asthma] 心源性哮喘• [Bro nchial asthma] 支气管性哮喘• [Hyperpnea] 呼吸深快• [Periodic breathing] 周期性呼吸• [Tachypnea (Rapid or fast breathing;accelerated breathing;short of breath)]气促• [Bradypnea (Slow breathing)] 呼吸缓慢• [Irregular breathing] 不规则呼吸（5）皮肤粘膜出血的表示方法• [Bleeding spots in the skin] 皮肤出血点• [Petechia] 瘀点• [Eccymosis] 瘀斑• [Purpura] 紫癜• [Splinter hemorrhage] 片状出血• [Oozing of the blood (Errhysis)] 渗血• [Blood blister (Hemophysallis)] 血疱• [Hemorrhinia (Nasal bleeding)] 鼻衄• [Ecchymoma] 皮下血肿（6）咳嗽与咯痰的表示方法• [Dry cough (Nonproduc tive cough;hacking cough)] 干咳• [Sharp cough] 剧咳• [Wet cough (Moist cough)] 湿咳• [Productive cough (Loose cough)] 排痰性咳• [Chronic cough] 慢性咳嗽• [Irritable cough] 刺激性咳嗽• [Paroxysmal cough] 发作性（阵发性）咳嗽• [Cough continually] 持续性咳嗽• [Spasmodic cough] 痉挛性咳嗽• [Whooping cough] 百日咳• [Winter cough] 冬季咳• [Wheezing cough] 喘咳• [Short cough] 短咳• [Distressed cough] 难咳• [Shallow cough] 浅咳• [Droplet] 飞沫• [Frothy sputum] 泡沫样痰• [Bloody sputum] 血痰• [Mucous (Mucoid) sputum] 粘液样痰• [Purulent sputum] 脓痰• [Mucopurule nt sputum] 粘液脓性痰• [White (Yellow,green) sputum] 白（黄,绿）痰• [Fetid (Foul) sputum] 恶臭痰• [Iron-Rust (Rusty) sputum] 铁锈色痰• [Chocolate coloured sputum] 巧克力色痰• [Thick sputum] 浓痰• [Thin sputum] 淡痰• [Viscous sputum] 粘痰• [Transparent sputum] 透明痰• [Much (Large amounts of) sputum] 大量痰• [Moderate amounts of sputum] 中等量痰• [Not much (Small amounts of ) sputum] 少量痰（7）内脏出血的表示方法• [Goldstein’s hemopty sis]戈耳斯坦氏咯血• [Massive hematemesis]大量呕血• [Epistasis (Nosebleed;Nasal bleeding; Hemorrhinia;rhinorrhagia)]鼻衄• [Hematuria] 血尿• [Initial hematuria] 初血尿• [Idiopathic hematuria] 特发性血尿• [Painless hematuria] 无痛性血尿• [Terminal hematuria] 终末性血尿• [Gross (Macro scopic) hematuria] 肉眼血尿• [Microscopic hematuria] 镜下血尿• [Hematuria in the whole process of urination] 全程血尿• [Gingival bleeding (Ulaemorrhagia;gum bleeding)] 牙龈出血• [Hematochezia] 便血• [Bloody stool] 血便• [Black stool (Melena)] 黑便• [Tarry stool] 柏油样便• [Bleeding following trauma] 外伤后出血• [Spontaneous bleeding] 自发性出血• [Bleeding Continuously] 持续出血• [Occult blood,OB] 隐血• [Hematobilia] 胆道出血• [Hemathorax] 血胸• [Hemarthrosis] 关节积血• [Hematocoelia] 腹腔积血• [Hematoma] 血肿• [Hemopericardium] 心包积血• [Cerebral he morrhage] 脑出血• [Subarachnoid hemorrhage(SAH)] 蛛网膜下腔出血• [Excessive (Heavy) menstrual flow with passage of clots] 月经量多伴血块• [Mild (Moderate) menses] 月经量少（中等）• [Painless Vaginal bleeding] 无痛性阴道出血• [Postcoital bleeding] 性交后出血• [Pulsating bleeding] 搏动性出血• [Post-operation wound hemorrhage] 术后伤口出血• [Excessive bleeding after denal extraction] 拔牙后出血过多（8）紫绀的表示方法• [Congenital cyanosis] 先天性紫绀• [Enterogenous] 肠源性• [Central] 中枢性• [Peripheral] 周围性• [Mixed] 混合性• [Acrocyanosis] 指端紫绀（9）恶心与呕吐的表示方法• [Vomituriti on (Retching)] 干呕• [Feel nauseated] 恶心感• [Postprandial nausea] 饭后恶心• [Hiccup] 呃逆• [Sour regurgitation] 返酸• [Fecal (Stercoraceous) vomiting] 吐粪• [undigested food Vomiting] 吐不消化食物• [Bilious Vomiting] 吐胆汁（10）腹泻与便秘的表示方法• [Moning diarrhea] 晨泻• [Watery (Liquid)diarrhea] 水泻• [Mucous diarrhea] 粘液泻• [Fatty diarrhea] 脂肪泻• [Chronic (Acute)] 慢性（急性）• [Mild diarrhea] 轻度腹泻• [Intractable (Uncontrolled)diarrhea] 难治性腹泻• [Protracted diarrhea] 迁延性腹泻• [Bloody stool] 血梗• [Frothy stool] 泡沫样便• [Formless (Formed)stool] 不成形（成形）便• [Loose (Hard) stool] 稀（硬）便• [Rice-water stool] 米泔样便• [Undigested stool] 不消化便• [Dysenteric diarrhea] 痢疾样腹泻• [Inflammatory diarrhea] 炎症性腹泻• [Osmotic] 渗透性• [Secretory] 分泌性• [Malabsorption] 吸收不良性• [Lienteric] 消化不良性• [Pancreatic diarr hea] 胰性腹泻• [Tenesmus] 里急后重• [Pass a stool (Have a passage; open or relax the bowel)] 解大便• [Have a call of nature] 便意• [Fecal incontinence (Copracrasia)] 大便失禁• [Functional constipation] 功能性便秘• [Organic constipation] 器质性便秘• [Habitual constipation] 习惯性便秘• [Have a tendency to be constipated] 便秘倾向（11）黄疸的表示方法• [Latent (occult) jaundice] 隐性黄疸• [Clinical jaundice] 显性黄疸• [Nuclear icterus] 核黄疸• [Physiologic icterus] 生理性黄疸• [Icterus simplex] 传染性黄疸• [Toxemic icterus] 中毒性黄疸• [Hemolytic] 溶血性• [Hepatocell ular] 肝细胞性• [Obstructive] 阻塞性• [Congenital] 先天性• [Familial] 家族性• [Cholestatic] 胆汁淤积性• [Hematogenous] 血源性• [Malignant] 恶性• [Painless] 无痛性（12）意识障碍的表示方法• [Somnolence] 嗜睡• [Confusion] 意识模糊• [Stupor] 昏睡• [Coma] 昏迷• [Delirium] 谵妄• [Syncope (swoon; faint)] 晕厥• [Drowsiness] 倦睡（13）排尿的表示方法• [Enuresis (Bed-wetting)] 遗尿• [Anuria] 无尿• [Emiction interruption] 排尿中断• [Interruption of urinary stream] 尿线中断• [Nocturia] 夜尿• [Oliguria] 少尿• [Polyuria] 多尿• [Pass water (Make water; urinate; micturition)] 排尿• [Frequent micturition (Frequency of micturition; fruquent urination;Pollakiuria)] 尿频• [Urgent micturition (Urgency of urination or micturition)] 尿急• [Urodynia (Pain on micturition; painful micturition; alginuresis; micturition pain)] 尿痛• [Dysuria (Difficulty in micturition; disturbance of micturition)] 排尿困难• [Small urinary stream] 尿线细小• [Void with a good stream] 排尿通畅• [Guttate emiction (Dribbling following urination;terminal dribbling)] 滴尿• [Bifurcation of urination] 尿流分叉• [Residual urine] 残余尿• [Extravasation of urine] 尿外渗• [Stress incontinence] 压力性尿失禁• [Overflow incontinence] 溢出性尿失禁• [Paradoxical in continence] 反常性尿失禁3．少见症状• [Weekness( Debility; asthenia; debilitating)] 虚弱（无力）• [Fatigue (Tire; lassitude)] 疲乏• [Discomfort (Indisposition; malaise)] 不适• [Wasting (thin; underweight; emaciation; lean)] 消瘦• [Night sweating] 盗汗• [Sweat (Perspiration)] 出汗• [Cold sweat] 冷汗• [Pruritus (Iching)] 搔痒• [Asthma] 气喘• [Squeezing (Tightness; choking; pressing) sensation of the chest] 胸部紧缩（压榨）感• [Intermittent claudication] 间歇性跛行• [Difficulty in swallowing( Dysphagia; difficult swallowing; acataposis)] 吞咽困难• [Epigastric (Upper abdominal) discomfort] 上腹部不适• [Anorexia (Sitophobia)] 厌食• [Poor appetite (Loss of appetite)] 纳差• [Heart-burn( Pyrosis)] 胃灼热• [Stomachache( Pain in stomach)] 胃部痛• [Periumbilial pain] 脐周痛• [Belching (Eructation)] 嗳气• [Sour regurgitation] 返酸• [Abdominal distention(bloating)] 腹胀• [Pass gas( Break wink)] 肛门排气• [Small(Large) stool] 大便少（多）• [Expel(Pass) worms] 排虫• [Pain over the liver] 肝区痛• [Lumbago] 腰痛• [Pica(Parorexia; allotriophagy)] 异食癖• [Dysmenorrhea] 痛经• [Menoxenia (Irregular menstruation)] 月经不调• [Polymenorrhea (Epimenorrhea)] 月经过频• [Oligomenorrhea] 月经过少• [Excessive menstruation (Menorrhagia; menometrorrhagia; hypermenorrhea)] 经量过多• [Hypomenorrhea (Scantymenstruation)] 经量过少• [Menopause (Menostasia; menostasis)] 绝经• [Amenorrhea (Menoschesis)] 闭经• [Leukorrhagia] 白带过多• [Asexuality (lack of libido)] 无性欲• [Hyposexuality] 性欲低下• [Hypersexuality] 性欲亢进• [Prospe rmia (Ejaculatio praecox)] 早泄• [Impotency (impotence)] 阳萎• [Nocturnal emission (Spermatorrhea)] 遗精• [Lack of potency] 无性交能力• [Hair loss] 脱发• [Joint pain (Arthralgia; arthrodynia)] 关节痛• [Polydipsia (Excessive thirst)] 多饮（烦渴）• [Polyphagia (Excessive a ppetite; hyperorexia; bulimia)] 多食• [Cold (Heat) intolerance] 怕冷（热）• [Dwarfism (Excessive height)] 身材矮小（高大）• [Excessive sweating] 多汗• [Obesity (Fatty)] 肥胖• [Agitation (Anxiety;nervous irritability)] 焦虑（忧虑）• [Mania] 躁狂• [Hallucin ation] 幻觉• [Aphasia (Logopathy)] 失语• [Amnesia (Poor memorization;memory deterioration)] 记忆力下降• [Hemianesthesia] 偏身麻木• [Formication] 蚁走感• [Tingling] 麻刺感• [Hyperpathia] 痛觉过敏• [Hypalgesia] 痛觉减退• [Illusion] 错觉• [Hemiplegia] 半身不遂• [Insomnia (Poor slee pness;sleeplessness)] 失眠• [Nightmare] 多梦• [Numbness] 麻木• [Pain in limbs (Acrodynia)] 肢体痛• [Limitation of motion] 活动受限• [Tetany] 手足抽搐• [Discharge of pus] 流脓• [Blurred vision(Hazy vision;blurring of vision; dimness of vision)]视物模糊• [Burning (Dry) sen sation] 烧灼（干燥）感• [Tearing (Dacryorrhea;Lacrimation)] 流泪• [Double vision (Diplopia)] 复视• [Strabismus] 斜视• [Hemianopia] 偏盲• [Tired eyes (Eyestrain)] 眼疲劳• [Foreign body sensation] 异物感• [Lose the sight (Lose of vision)] 失明• [Diminution of vision] 视力减退• [Nictition] 眨眼• [Ophthalmodynia (Eye-ache;ocular pain)] 眼痛• [Photophobia] 畏光• [Spots before the eyes] 眼前黑点• [Deafness(Anacusia)] 耳聋• [Auditory dysesthesia] 听力减退• [Otalgia (Otodynia;pain in the ear ;ear-ache)] 耳痛• [Stuffy feeling in the ear] 耳闭气• [Tinnitus] 耳鸣• [Outophony] 自声过强• [Nasal obstruction (blockage)] 鼻塞• [Dryness of the nose] 鼻干燥• [Rhinorrhea (Snivel;Nasal discharge)] 流鼻涕• [Snoring] 打鼾• [Hyposmia (Reduction of the sense of smell)] 嗅觉减退• [Anosmia (Complete loss of se nse of smell)] 嗅觉丧失• [Dysphonia] 发音困难• [Hoarseness] 声嘶• [Pain on swallowing] 吞咽痛• [Saliva dribblies from the mouth] 流涎• [Troaty voice] 声音沙哑• [Stridor] 喘鸣• [Red and swollen] 红肿• [Scurf] 头皮屑• [Show] 见红• [Amniotic fluid escaped] 破水• [Uterine contra ction] 宫缩• [Acalculia] 计算不能• [Apathy] 情感淡漠• [Delusion] 妄想第三部分现病史[History of present illness (HPI/PI)]现病史书写的重点包括：一、主诉中症状的详细描述；二、疾病的发展过程；三、诊疗经过；四、目前的一般情况。
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CC: lower anterior teeth trauma two days ago
Ph: some of the lower anterior teete of them
were loose as a result of patient's carelessly falling down upon ground
soft diet delivered
Referral to dental clinic two weeks later
检查:71及81Ⅱ度松动,72及82脱落,73及83稳,x-ray示:71及81牙根完好,31及41位于71及81根方;32及42存于牙槽骨中.其余检查未见明显异常.
诊断:①71及81外伤Ⅱ度松动
②72及82缺失
设计①71,81,73,83正畸托槽及不锈钢钢丝固定
最近,本人接了一个外国病人,要求写英文病例可以将来带到国外继续治疗,现将中文病历写在下面,各位能帮忙翻译一下吗?
病人是个外国小女孩,三岁.中文病历如下:
主诉:下前牙外伤2天
现病史:患者于昨日不小心摔倒在地致使部分下前牙脱落,部分前牙松动,现来我院就诊.
2.one month later ,use a space maintainer to keep the space of 72 and 82
TREATMENT:
1.we adhesived brackets on 71.81.73.83,fixed them with 0.016 mil SS wire
Treatment Plan: 71, 81, 73, 83 fixed with stainless steel wire as well as
orthodontic brackets
72, 82 space maintained by space keeper one month later
Treatment: Orthodontic brackets bonded to 71, 81, 73, 83 respectively
Fixed with 0.016 inch round steel wire
Advice for patients: Oral hygiene methods highlighted,
83 are still steady. X- ray film shows that 31 and 41 position on the root
of 71 and 81.32 and 42 is in the alvelor bone.
DIAGNOSIS:1.71and 81 are traumatic and moderate loosed
2:72 and 82 are lost
TREATMENT PLANING:
1.we plan to adhere orthodontic brakets on 71.81.73.83and fix these teeth
with stainless steel.
history :this patient slipped down yesterday and had some lower incisors
lost ,some
loosed
EXAMINATION: 71and 81 are moderate loosed,72 and 82 are falled off,73 and
PE: 71, 81 mobility class II
72, 82 missing
73, 83 stable
X ray: Root intact for 71 and 81
31, 41 teeth germ right beneath the roots of 71,81 respectively
②一个月后行缺隙保持器保持72及82间隙
处理:①71,81,73,83粘托槽,用0.016英寸不锈钢圆丝固定,嘱注意事项(注意口腔卫生及进软食),2周复诊.
chief complaint: lower front teeth broken for two days
32, 42 teeth germ intact
other teeth no positive finding upon examination
Diag: 71, 81 trauma, mobility class II
72, 82 missing
and instructed her the cautions.(pay attention to her oral hygiene,and eat
some soft diet) and return visit for an examination 2 weeks later.