内科英文病历材料模板
呼吸科英文病历范文
呼吸科英文病历范文
ENGLISHCASE700756(Respiratory department)
----------------------------Name: Liyuzhen `Age:42 yearsSex: FemaleRace: HanOccupation: Free occupationNationality: ChinaMarried status: married Addre: Qianjing Road No.16, Wuhan Hankou.
thDate of admiion: July 26, 2001
thDate of record: July 26, 2001
Present illne:
Two days ago the patient suddenly started to cough and feel
Her spirit,sleep,appetite were normal.stool and urine were
normal, too.
----------------------------PastHistory:
General health status: normal
Operation history: thyroidectomy.
Infection history: No history of tuberculosis or hepatitis.Allergic history: allergic to a lot of drugs such as sulfanilamideTraumatic history: No traumatic history
门诊病历英文模板
门诊病历英文模板
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
英语病历作文格式模板
英语病历作文格式模板英文回答：
Medical History Template。
Patient Information。
Name:
Date of Birth:
Address:
Phone Number:
Email:
Insurance Information:
Chief Complaint。
A brief summary of the patient's primary reason for the visit.
Example: "The patient presents with a 3-day history of fever and chills."
History of Present Illness。
A detailed description of the patient's symptoms, including:
Onset: When did the symptoms first appear?
Duration: How long have the symptoms been present?
Severity: How severe are the symptoms?
Location: Where are the symptoms located?
Associated symptoms: Any other symptoms that are present, such as nausea, vomiting, or headache.
Past Medical History。
偏瘫病历书写模板范文
偏瘫病历书写模板范文
英文回答：
Patient Name: [Patient's Name]
Gender: [Patient's Gender]
Age: [Patient's Age]
Date of Admission: [Date of Admission]
Date of Discharge: [Date of Discharge]
Chief Complaint:
The patient presented with a sudden onset of weakness on the right side of the body, along with difficulty in speaking and understanding speech.
History of Present Illness:
The patient's symptoms began [duration] ago. The weakness primarily affects the right upper and lower limbs, with significant difficulty in performing daily activities. The patient also experiences difficulty in speaking and understanding others. There is no history of trauma or other significant events preceding the onset of symptoms.
急性脑梗病历模板范文
急性脑梗病历模板范文
英文回答：
Acute Ischemic Stroke.
Case Presentation.
Chief Complaint: Sudden onset of left-sided weakness and numbness.
History of Present Illness: The patient is an 80-year-old male with a past medical history of hypertension and hyperlipidemia. He awoke this morning with sudden onset of left-sided weakness and numbness. He denies any other symptoms.
Past Medical History: Hypertension, hyperlipidemia.
Medications: Lisinopril 10 mg daily, simvastatin 20 mg daily.
Social History: Retired, lives alone.
Family History: Father had a stroke at age 75。
Physical Examination.
Vitals: Blood pressure 180/100 mmHg, heart rate 80 bpm, respiratory rate 16 breaths per minute, temperature 98.6 degrees Fahrenheit.
内科诊所门诊病历书写范文模板
内科诊所门诊病历书写范文模板英文版
Internal Medicine Clinic Outpatient Medical Record Writing Template
When it comes to writing medical records for outpatient visits at internal medicine clinics, it is important to be thorough and accurate. The following template can serve as a guide for healthcare professionals to ensure that all necessary information is included in the patient's medical record:
Patient Information:
Name:
Age:
Gender:
Date of Birth:
Address:
Phone Number:
Occupation:
Chief Complaint:
Briefly describe the reason for the patient's visit, including any symptoms or concerns they may have.
History of Present Illness:
Detail the patient's current symptoms, when they started, and any factors that may have contributed to their condition.
英文病历书写范例
英文病历书写范例（内科）
Medical Records for Admisson
Medical Number: 701721
General information
Name: Liu Side
Age: Eighty
Sex: Male
Race: Han
Nationality: China
Address: NO.35, Dandong Road, Jiefang Rvenue, Hankou, Hubei.
Tel: 857307523
Occupation: Retired
Marital status: Married
Date of admission: Aug 6th, 2001
Date of record: 11Am, Aug 6th, 2001
Complainer of history:patient’s son and wife
Reliability: Reliable
Chief complaint: Upper bellyache ten days, haematemesis, hemafecia and unconsciousness for fo ur hours.
Present illness:
The patient felt upper bellyache about ten days ago. He didn’t pay attention to it and thought heha date something wrong. At 6 o’cloc k this morning he fainted and rejected lots of blood and gore. T hen hemafecia began. His family sent him to our hospital and received emergent treatment. So the patient was accepted because of “upper gastrointestine hemorrhage and exsanguine shock”. Since the disease coming on, the patient didn’t urinate. Past history
肿瘤内科病历中英文对照
Xie Yanhua
Xie yanhua, bed 38,female, 40 years old, was born in Fuyang, Anhui province.The patient was admitted to our department for gastric cancer for more than 2 years and pelvic metastasis for more than 10 months. The patient was treated at the people's hospital of Taihe county for "six years of abdominal pain and eight days of melena",On May 28, 2014.She underwent radical operation of gastric cancer at the People’s Hospital of Taihe County on June,2014. The pathology report:Gastric ulcer type adenocarcinoma, partially signet-ring cell carcinoma, invading muscular layer, size of 3cm x 3cm; the upper and lower margin negative;4 of 10 lymph nodes positive around lesser curvature and 3 of 3 lymph nodes positive around greater curvature.After the operation, the patient underwent 6 courses of PCF regimen chemotherapy in this hospital, which is not clear enough.The patient was admitted to radiotherapy and chemotherapy department of our hospital on December 14th,2016 for pelvic mass after gastric cancer surgery .CA199 was slightly elevated in the local hospital, and there was
心内科英文病历
Medical Records for Admisson
Medical Number: 701721 General information
Name:Liu Side
Age: Eighty
Sex: Male
Race:Han
Nationality:China Address: Occupation: Retired Marital status: Married Date of admission:Aug 6th, 2001
Date of record: 11Am, Aug 6th, 2001
Complainer of history: patient’s son and wife Reliability: Reliable
Chief complaint: Upper bellyache ten days, haematemesis, hemafecia and unconsciousness for four hours.
Present illness:
The patient felt upper bellyache about ten days ago. He didn’t pay attention to it and thought he had ate something wrong. At 6 o’clock this morning he fainted and rejected lots of blood and gore. Then hemafecia began. His family sent him to our hospital and received emergent treatment. So the patient was accepted because of “upper gastrointestine hemorrhage and exsanguine shock”.
英文完全病历模板-详细版
Admission Record
Name：* Nativity: * district, * city
Sex:male Race: Han
Age:55 Date of admission:2020-09-07 14:30 Marital status: be married Date of record:2020-09-07 15:23 Occupation:teacher Complainer:patient himself Medical record Number: * Reliability: reliable
Present address: NO*, building*, * village,* district, *city, *province
Chief complaint: cough and sputum for more than 6 years, worsening for 2 weeks
History of present illness: The patient complained of having paroxysmal cough and sputum 6 years ago. At that time, he was diagnosed as “COPD” in another hospital and no regular treatment was applied. Cough and sputum worsened and were accompanied by tachypnea 2 weeks ago with no inducing factors. Small amounts of white and mucous sputum were hard to cough up. Compared to daytime, tachypnea worsened in the night or when sputum can’t be cough up. The patient can’t lie flat at the night because of prominent tachypnea and prefer a high pillow. He had no fever, no chest pain, no dizziness, no diarrhea, no abdominal pain, no obvious decrease of activity tolerance. On 20*-0*-*, the patient went to *Hospital for medical consultation. CT lung imaging indicated: lesion accompanied by calcification in the superior segment, the inferior lobe of the right lung, the possibility of obsolete tuberculosis; emphysema, bullae formation and sporadic inflammation of bilateral lung; calcified lesion in the inferior lobe of the left lung; arteriosclerosis of coronary artery.
英文病例模版
insomnia.Never coma.No deterioration of the memory,visual disorder,disturbance of consciousness.No history of paralysis,hyperspasmia and abnormal sensation.
Nose:The appearanceis normal,aerationis well.No abnormal
discharges were fowk.baidu.comnd invetibulum nasi. Septum nasi was in midline. No
nares flaring. No tenderness in nasal sinuses.
Chief complaint:One lump prolapse out of vagina for 4+months.
冠心病入院病历书写模板范文
冠心病入院病历书写模板范文英文回答：
Medical Record Template for Coronary Heart Disease Admission.
Patient Information:
Name: [Patient's Name]
Age: [Patient's Age]
Gender: [Patient's Gender]
Date of Admission: [Date]
Chief Complaint:
The patient presented with chest pain and shortness of breath upon exertion.
History of Present Illness:
The patient had been experiencing chest pain for the past week, which was initially intermittent but gradually became more frequent and severe. The pain was described as a squeezing sensation in the chest, radiating to the left arm. The patient also reported shortness of breath during physical activity. There were no associated symptoms of nausea, vomiting, or diaphoresis. The patient sought medical attention due to the persistence and worsening of symptoms.
2、心内科常用英文病历模板
第二节心内科常用英文病历模板
熟练地阅读和书写英文病历是一名临床医师需要具备的基本外语技能。对英文病历的熟练掌握对于阅读英文文献和撰写英文论文都有很大的帮助。本章主要介绍心内科常见疾病英文病历的格式和基本模板。英文病历的书写格式大致与中文病历相似，主要包括以下部分：
1.General information（一般情况）
2.Chief complaint（主诉）
3.Present illness（现病史）
4.Past history（既往史）
5.Personal history（个人史）
6.Family history（家族史）
7.Physical examination（体格检查）
8.Investigation（辅助检查）
9.History summary（病史特点）
10.Impression（印象、初步诊断）
11.Signature（签名）
鉴于不同疾病的病历之间存在共性，本章按照病历的通用部分和心血管内科部分逐一进行介绍。
第一部分通用部分
1. General information（一般情况）
这一部分包括name（姓名），age（年龄），sex（性别），race（民族），nationality（国籍），address（地址和电话），occupation（职业），marital status（婚姻状况），date of admission（入院日期），date of record（记录日期），complainer of history（供史者）和reliability（可信度）等12项内容。基本格式如下：
英文病历报告作文模板
英文病历报告作文模板英文：
Medical Record Report。
Name: John Smith。
Age: 35。
Gender: Male。
Date of Admission: 05/01/2021。
Date of Discharge: 05/07/2021。
Chief Complaint:
The patient complained of a persistent cough and shortness of breath.
History of Present Illness:
The patient had a persistent cough and shortness of breath for two weeks. He tried to treat himself with over-the-counter medication but his symptoms did not improve. He decided to seek medical attention when his cough became more severe and he started to experience chest pain.
Past Medical History:
The patient has a history of asthma and seasonal allergies. He has been hospitalized in the past for asthma exacerbations.
英文病历模板
Past history
Operative history: Never undergoing any operation.
Infectious history: No history of severe infectious disease.
Allergic history: She was not allergic to penicillin or sulfamide.
Respiratory system: No history of respiratory disease.
Circulatory system: No history of precordial pain.
Alimentary system: No history of regurgitation.
Genitourinary system: No history of genitourinary disease.
Hematopoietic system: No history of anemia and mucocutaneous bleeding.
Endocrine system: No acromegaly. No excessive sweats.
Kinetic system: No history of confinement of limbs.
Neural system: No history of headache or dizziness.
Personal history
She was born in Wuhan on Nov 19th, 1957 and almost always lived in Wuhan. She graduated from senior high school. Her living conditions were good. No bad personal habits and customs.
内科英文病历实用模板
HUAZHONG UNIVERSITY OF SCIENCE AND TECHNOLOGY
TONGJI MEDICAL COLLEGE ACCESSORY TONGJI HOSPITAL Hospitalization Records for None-operation Division Division: __________ Ward: __________ Bed: _________ Case No. ___________
Name: ______________ Sex: __________ Age: ___________ Nation:
___________
Birth Place: ________________________________ Marital
Status:____________
Work-organization & Occupation:
_______________________________________
Living Address & Tel:
_________________________________________________
Date of admission: _______Date of history taken:_______
Informant:__________
Chief Complaint:
___________________________________________________
History of Present Illness:
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HUAZHONG UNIVERSITY OF SCIENCE AND TECHNOLOGY TONGJI MEDICAL COLLEGE ACCESSORY TONGJI HOSPITAL
Hospitalization Records for None-operation Division Division: __________ Ward: __________ Bed: _________ Case No. ___________
Name: ______________ Sex: __________ Age: ___________ Nation: ___________ Birth Place: ________________________________ Marital Status:____________ Work-organization & Occupation: _______________________________________ Living Address & Tel: _________________________________________________ Date of admission: _______Date of history taken:_______ Informant:__________ Chief Complaint: ___________________________________________________
History of Present Illness:
___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________
Past History:
General Health Status: 1.good 2.moderate 3.poor
Disease history: (if any, please write down the date of onset, brief diagnostic
and therapeutic course, and the results.)
Respiratory system:
1. None
2.Repeated pharyngeal pain
3.chronic cough
4.expectoration:
5. Hemoptysis
6.asthma
7.dyspnea
8.chest pain
_______________________________________________________________ Circulatory system:
1.None
2.Palpitation
3.exertional dyspnea
4..cyanosis
5.hemoptysis
6.Edema of lower extremities
7.chest pain
8.syncope
9.hypertension
_______________________________________________________________ Digestive system:
1.None
2.Anorexia
3.dysphagia
4.sour regurgitation
5.eructation
6.nausea
7.Emesis
8.melena
9.abdominal pain 10.diarrhea
11.hematemesis 12.Hematochezia 13.jaundice
_______________________________________________________________ Urinary system:
1.None
2.Lumbar pain
3.urinary frequency
4.urinary urgency
5.dysuria
6.oliguria
7.polyuria
8.retention of urine
9.incontinence of urine
10.hematuria 11.Pyuria 12.nocturia 13.puffy face
_______________________________________________________________ Hematopoietic system:
1.None
2.Fatigue
3.dizziness
4.gingival hemorrhage
5.epistaxis
6.subcutaneous hemorrhage
_______________________________________________________________ Metabolic and endocrine system:
1.None
2.Bulimia
3.anorexia
4.hot intolerance
5.cold intolerance
6.hyperhidrosis
7.Polydipsia
8.amenorrhea
9.tremor of hands 10.character change 11.Marked obesity
12.marked emaciation 13.hirsutism 14.alopecia
15.Hyperpigmentation 16.sexual function change
_______________________________________________________________ Neurological system:
1.None
2.Dizziness
3.headache
4.paresthesia
5.hypomnesis
6. Visual disturbance
7.Insomnia
8.somnolence
9.syncope 10.convulsion 11.Disturbance of consciousness
12.paralysis 13. vertigo
_______________________________________________________________ Reproductive system:
1.None
2.others
_______________________________________________________________