最新整理英文病历模版资料讲解
英文病历
POMR (Problem-Oriented Medical Records)表格式住院病历Biographical data:一般项目：Name Age Sex Marital status Nativity Race姓名年龄性别婚否籍贯民族Occupation Date of admission Informant History职业入院日期病史叙述者病史Chief complaint主诉History of present illness现病史Past history既往史：Previous health status: well ordinary bad Infectious diseases平素健康状况：良好一般较差传染病史Immunizations Allergies: N Y clinical manifestation预防接种史过敏史无有临床表现allergen: Trauma: Surgery:过敏原外伤史手术史Review of systems:(Tick if positive, cross out if negative. If postive, you should write down your disease history and brief course of diagnose and therapy)系统回顾：(有打√无打×阳性病史应在下面空间内填写发病时间及扼要诊疗经过) Respiratory system:呼吸系统Sore throat chronic cough sputum hemoptysis wheezing咽痛慢性咳嗽咳痰咯血哮喘dyspnea chest pain呼吸困难胸痛cadiovascular system:循环系统Palpitation dyspnea on exertion hemoptysis syncope心悸活动后气促咯血晕厥edema of lower limbs precordial pain hypertention下肢水肿心前区疼痛高血压Digestive system:消化系统Anorexia sour regurgitation belching nausea vomitting食欲减退反酸嗳气恶心呕吐abdominal distention abdominal pain constipation diarrhea腹胀腹痛便秘腹泻hematemesis melena hematochezia jaundice呕血黑便便血黄疸Urinary system:泌尿系统Lumbago frequent micturition urgent micturition urodynia腰痛尿频尿急尿痛dysuria hematuria nocturia polyuria oliguria facial edema排尿困难血尿夜尿多尿少尿面部水肿Hematopoietic system造血系统Fatigue dizziness blurred vision gingival bleedig乏力头昏牙龈出血subcutaneous hemorrhage ostealgia epistaxis皮下出血骨痛鼻衄Metabolic and endocrine system:代谢及内分泌系统Excessive appetite anorexia sweats cold intolerance食欲亢进食欲减退多汗畏寒polydipsia tremor hands change of character obvious obesity 多饮双手震颤性格改变显著肥胖emaciation hirsutism hair losing pigmentation消瘦多毛毛发脱落色素沉着chang of sexual function amenorrhea性功能改变闭经Musculoskeletal system肌肉骨骼系统Floating arthralgia arthraliga swelling of joints游走性关节痛关节痛关节红肿deformiteies of jionts myalgia atrophy of muscle关节变形肌肉痛肌肉萎缩Nervous system神经系统Dizziness headache vertigo syncope degeneration of memory 头昏头痛眩晕晕厥记忆力减退visual disturbance insomnia disturbance of consciousness视力障碍失眠意识障碍tremor spasm paralysis paresthesia颤动抽搐瘫痪感觉异常Personal history:个人史Birthplace Occupation sexual history smoking N Y出生地职业冶游史吸烟无有about years average pieces per day ceased for years约年平均支/日戒烟年alcohol intake N occasional frequent about years嗜酒无偶有经常约为年average ml per day others平均ml/日其他Marital history:婚姻史：Marrying age companion’s state of health结婚年龄配偶健康状况Menorrhea and Childbearing:月经及生育史Menarche age cycle lasting for days date of last period初潮每次持续时间末次月经时间(age of menopause)绝经年龄Amount of flow: little normal large menstrual pain: N Y经量少正常多痛经无有cycle: regular irregular pregnancy times natural labor经期规则不规则妊娠次顺产times abortions times premature delivery times胎流产胎早产胎stillbirths times difficult labor and its condition死产胎难产及病情Familly history (pay attention to the congenital diseases andcommunicable diseases and communicable dieases related to the paitent家族史（注意与患者现病有关的遗传病和传染性疾病）Father: still alive illness died cause of deaths mother:父：健在患病已故死因母still alive illness died cause of death siblings: others: 健在患病已故死因兄弟姐妹子女其他Physical examination体格检查Vital signs生命体征:Temperature体温pulse脉搏/min次/分respiration呼吸/min次/分B.P血压mmHgGeneral Appearance一般状况:Development发育:ortho-sthenic type正常asthenic type不良sthenic type超常nutrition营养:well良好fairly中等poor不良cachexia恶病质Facial features面容:normal无病容acute急性chronic慢性病容others其他Expression表情:natural自知painful痛苦anxious忧虑dreadful恐惧indifferent淡漠Position: active semi-recumbent others体位：自主半卧位其他Gait: normal abnormal步态正常不正常Conciousness: aware somnolence confusion stupor coma神志清楚嗜睡模糊昏睡昏迷delirium coppperatio; well badly谵妄配合检查合作不合作Mucocutaneous color: normal red pale cyaosis stainted皮肤粘膜色泽无病容潮红苍白紫绀yellow pigmentation lesions:N Y (type and distribution)黄染色素沉着皮疹无有（类型及分布）Subcutaneous hemorrhange: N Y(type and distribution)皮下出血无有（类型及分布）Hair: normal reduced edema: N Y(position and degree)头发分布正常减退水肿无有（部位及程度）Hepatic palm: N Y spider angionma:N Y（position numbers ）others:肝掌无有蜘蛛痣无有(部位数目) 其他Lymphnodes:淋巴结Superficial lymph nodes: non-swelling swelling(position and characteristics) 全身淋巴结肿大无肿大肿大（部位及特征）Head : cranium : size : normal large small deformity:头部头颅大小正常大小畸形N Y(coxycephaly squared skull deforming skull)无有（尖颅方颅变形颅）Others: tenderness mass sunk (position)其他异常：压痛包块凹陷（部位）Eyes eyelid: normal edema ptosis trichiasis conjunctive :眼睑正常水肿下垂倒睫结膜normal hyperemia edema hemrrhage正常充血水肿出血eye ball: normal proptosis depression tremor眼球正常突出凹陷震颤motion dysfunction(left right)运动障碍Sclera :normal yellow cornea : normal abnormal ( left right )巩膜无黄染有黄染角膜正常异常（左右）Pupils: equal roundness same size unequal left cm瞳孔等圆等大不等左cmreaction to light: normal delay (left right) disappear (left right) 对光反射正常迟钝（左右）消失（左右）Others:其他Ears: auricle :normal deformity fistula others (left right )耳耳廓正常畸形瘘管其他（左右）excretions of external auditory canal: N Y (left right feature)外耳道分泌物无有（左右性质）Tenderness of mastoid : N Y audation dysfunction: N Y (left right)乳突压痛无有听力粗试障碍无有（左右）Nose: shape : normal: abnormal ( ) other abnormalities:N Y鼻外形正常异常（）其他异常无有Nosalala flap obsruction excretions nasal sinus tenderness:鼻翼扇动鼻塞分泌物鼻旁窦压痛N Y (position )无有（部位）Mouth lips :red syanosis pale herpes fissure mucosa :normal口唇红润发绀苍白疱疹皲裂粘膜正常abnormal ( pale petechia)异常（苍白出血点）Opening of parotid gland duct: normal abnormal (swelling腮腺导管开口正常异常（肿胀suppurative excretions)脓性分泌物）Tongue:normal abnormal (coverings tremor leaning to left or right)舌正常异常（舌苔伸舌震颤向左、向右偏斜）Gums: normal swelling pus overflow hemorrhage pigments牙龈正常肿胀溢脓出血色素沉着lead line tooth:regular edentulous carious teeth铅线牙列齐缺牙—|—龋齿—|—Tonsils: pharynx: voice: normal hoarse扁桃体咽声音正常嘶哑Neck:resistence:N Y carotid artery pulsation: normal increased颈部抵抗感无有颈动脉搏动正常增强decreased (left right) jugular vein:normal distention减弱（左右）颈静脉正常充盈high distention trachea:middle deviation to (left right)怒张气管正中偏移（向左向右）Hepatojugular reflux:(-) (+) thyroid: normal swelling degree肝颈静脉回流征：（-）（+）甲状腺正常肿大度Symmetry 对称Dominance in one side: spreading nodular:soft hard others :N Y 侧为主弥漫性结节性质软质硬其他无有(tenderness tremor bruits)（压痛震颤血管杂音）Chest topography:normal barrel chest pigeon chest funnel chest 胸部胸廓正常桶状胸鸡胸漏斗胸flat chest bulging or retraction (left right )扁平胸膨隆或凹陷（左右）bulging in the precordial region tenderness of sternum心前区膨隆胸骨压痛Breast: normal symmetrical abnormal : left right(gynecomastia 乳房正常对称异常左右（男乳女化mass tenderness excretions of nipples)包块压痛乳头分泌物）Lung肺Inspection : movement of respiration : normal abnormal : left 视诊呼吸运动正常异常左right( increased decreased)右（增强减弱）Intercostal space :normal wide narrow(position)肋间隙正常增宽变窄（部位）Palpation : vocal fremitus:normal abnormal :left right (increased 触诊：语颤正常异常左右（增强decreased ) pluernal friction rubs: N Y（position）减弱胸膜摩擦感：无有（部位）Subcutaneous crepitus: N Y(posotion) percussion: resonance皮下捻发感无有（部位）叩诊正常清音abnormal dullness flatness hyperresonance tympany异常叩诊音浊音实音过清音鼓音Lower borders:scapular line: right intercostal space, left肺下界肩胛线右肋间左intercostal space Range of mobility: right cm , left cm肋间移动度右cm，左cmDusculation: breath regular irregular听诊呼吸规整不规整Breath sound: normal abnormal( feature, position )呼吸音正常异常（性质，部位描写）Rale: N Y ：ronchi: sonorous sibilant啰音：无有：干性鼾音哨笛音Moist rales: coarse medium fine rales crepitus湿性大中小水泡音捻发音Vocal conduction: normal abnormal: reduced increased(position)语音传导正常异常减弱增强（部位）Plueral friction rubs: N Y (position)胸膜摩擦音无有（部位）Heart 心Inspection:bulging in precordial region : N Y apex impulse:视诊心前区隆起无有心尖搏动normal unseen increased diffusing position: normal正常未见增强弥散心尖搏动位置正常deviation ( the distance from midclavicular line cm)移动（距左锁骨中线内外厘米）Other precordial pulsations: N Y (position)其他部位搏动无有（部位）Palpation:apex impulse:normal increased thrust unclear触诊心尖搏动正常增强抬举感触不清thrills :N Y (position period) percardial friction rubs:N Y震颤无有（部位时期）心包摩擦感无有Percussion:relative cardiac outline: normal shrink extant (right left ) 叩诊相对浊音界正常缩小扩大（右左）Ausculation: heart rate bpm/min rhythm(regular irregular听诊心率次/分心律（齐不齐）absolutly irrgelar) heart sound:S1 normal increased decreased绝对不齐心音S1 正常增强减弱split S2 normal increased decreased split分裂S2 正常增强减弱分裂S3 N Y S4 N Y A2 P2S3 无有S4 无有A2 P2Extra heart sound N gallop (diastolic presystotic summalion额外心音无奔马律（舒张期收缩前期重叠gallop) opening snap others murmurs: N Y (degree conduction)开瓣音其他杂音无有（图示并描述传导）Pericardial friction rubs N Y心包摩擦音无有Peripheral vessals: normal pistal shot of big arteries周围血管无异常血管征大血管枪击音Duroziez’s sign water hammer pulse capillary pulsation二重杂音水冲脉毛细血管搏动pulse deficit paradoxical pulse pulsus alternans other脉搏短绌奇脉交替脉其他Abdoman腹部Inspection: shape normal distention frog abdomen( size cm)视诊外形正常膨隆蛙腹（腹围厘米）scaphoid apical abdomen gastral pattern intestinal pattern舟腹尖腹胃型肠型peristalsis abdominal respiration:existance disappear umbilicus:蠕动波腹式呼吸存在消失脐normal protruding excretions others: N Y(venous distention of正常凸出分泌物其他异常无有（腹壁静脉曲张abdoman purple striae surgical scars hernia)条纹手术疤痕疝）Palpation: soft muscle tension position tenderness N Y触诊柔软腹肌紧张部位压痛无有rebound tenderness N Y fluidthtill N Y succussions plash N Y反跳痛无有液波震颤无有振水音无有Mass N Y(position size) discription of feature liver:can’t be 腹部包块无有（部位大小）特征描述肝未触及touched can be touched :subcostal cm under xipfoid process可触及肋下厘米剑突下discription of feature gallbladder: can’t be touched can be touched特征描述胆囊未触及可触及size cm tenderness N Y Murphy’s sign spleen: can’t be 大小厘米压痛无有Murphy征脾未触及touched can be touched distance from costal margin cm可触及肋下厘米Kideny:can’t be touched can be touched size consistency肾未触及可触及大小硬度tenderness mobility tenderness of ureters: N Y (position)压痛移动度输尿管压痛点无有（部位）percussion: borders of liver dull(existance shrink obliteration )叩诊肝浊音界（存在缩小消失）Upper borders of liver on right midclavicular line intercostal space 肝上界位于右锁骨中线肋间shifting dullness N Y tenderness in renal region N Y (right left )移动性浊音无有肾区叩痛无有（右左）ausculation : borhorygmus normal increased decreased听诊肠鸣音正常增强减弱disappear gurgling N Y vessal bruits N Y (position)消失气过水声无有血管杂音无有（部位）Genitalia :not examined normal abnormal Rectum and Anus :生殖器未查正常异常肛门直肠not examined normal abnormal未查正常异常Spine and Extremities脊柱四肢Spine : normal deformities (lateral anterior posterior protruding)脊柱正常畸形（侧前后凸）Spinous process : tenderness pain while percussed ( position )棘突压痛叩痛（部位）Mobility : normal restricted extremeties: normal abnormal移动度正常受限四肢正常异常deformity swelling of joints joints stiffness畸形关节红肿关节强直tenderness of muscles atrophy of muscles肌肉压痛肌肉萎缩Venous distention of lower limbs (position and feature ) acropachy下肢静脉曲张（部位及特征）杵状指Nervus System神经系统Abdominal wall reflex ( normal ) muscle tone ( normal )腹壁反射（正常）肌张力（正常）Myodynamia ( degree ) paralysis of limbs N Y (left right肌力（级）肢体瘫痪无有（左右upper lower) biceps reflex left (normal) right (normal)上下）肱二头肌反射左（正常）右（正常）knee jerk left (normal) right( normal) achilles jerk left膝健反射左（正常）右（正常）跟腱反射左(normal) right ( normal )正常右（正常）Hoffmann’s dign left (+)(-) right(+)(-)Hoffmann征左（+）(-) 右（+）（-）Babinski’s sign left(+)（-）right(+)(-)Babinski 左（+）（-）右（+）（-）Kernig’s sign left(+)（-）right(+)(-) othersKernig征左（+）（-）右（+）（-）其他Laboratory findings实验室及器械检查结果（The important laboratory examination .X-ray . ECG and other result areincluded）(重要的化验、X线、心电图及其他有关化验) Nunber of X-rayX线片号Abstract病历摘要Diagnosis(impressions)入院诊断Recorder病史记录者Examiner并使审阅者Date of record记录日期第一章病人身份[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• [P lace 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 not ify (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*程试• [Medical security (Type of payment)] 医疗费用• [Ty pe 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 age 2、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[Leader (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] •***[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] •***人[Japane se] •英国人[Britisher] 5、医疗费用的表示方法• [Self pay (Individual medical care)] 自费• [Governm ent 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• [S ingle (Unmarried)] 未婚• [Diverced] 离婚• [Widow] 寡妇• [Wi dower] 鳏夫7、病史可*程度的表示方法• [Reliable] 可* • [Unreliable] 不可* • [Not entir ely] 不完全可* • [Unobtainable] 无法获得8、住址的表示方法•[NO.3,Qing Chun Road Eas t,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*** 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[1-10-200 2(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)] 一般第二章主诉[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 hemorrh age (bleeding)] 皮肤粘膜出血• [Dyspnea (Difficuly in b reathing;Respiratory difficulty;short of breath)] 呼吸困难• [Cough and expectoration (Sp utum;Phlegm)] 咳嗽和咯痰• [Hemoptysis] 咯血• [Cyanosis] 紫绀• [Palpitation] 心悸• [Chest discomfort] 胸闷• [Nausea (Retch;Dry Vomi ting)and Vomiting] 恶心和呕吐• [He matemesis (Vomiting of blood)] 呕血• [Hematochezia (Hemafecia)] 便血• [Diarrhea] 腹泻• [Constipation (Obstipation)] 便秘• [Vertigo (Giddiness; Dizziness)] 眩晕• [Jaundice (Icterus)] 黄疸• [Convulsion] 惊厥• [Disturbance of consciousn ess] 意识障碍• [Hemat uria] 血尿• [Frequent micturition,urgent micturition and dysuria] 尿频，尿急和尿痛• [Inc ontinence of urine] 尿失禁• [Retention of urine] 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 (I nanition)fever] 脱水热• [Drug fever] 药物热• [Functional hypothermia] 功能性低热• [A bsorption fever] 吸收热• [Central fever] 中枢性发热• [Fever type] 热型▲[Continuous fever] 稽留热▲[Remittent fever] 驰张热▲[Intermittent fever] 间歇热▲[Undulant f ever] 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 und etermined(unknown) origin, FUO] 不明原因发热• [Rigor (shivering;chill;shaking chill;agu e)] 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• [B ecome feverish (Have a temperature)] 发热• [Crisis] 骤降• [Lysis] 渐降• [Typhoid fev er] 伤寒热• [Rheumatic fever] 风湿热• [Cancerous fever] 癌性发热• [Fervescence peri od] 升热期• [Defervescence period] 退热期• [Persistent 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▲[Migrai ne 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 (Art hralgia)] 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• [Burning 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 pa in] 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• [Wandering 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• [Pe rsistent pain (Unremitting pain)] 持续性痛• [Constant pain] 经常性痛• [Intermittent pai n] 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• [Generaliz ed 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• [Pleural effusion (Hydrothorax)] 胸水• [Pericardial effusion (Hydropericardium)] 心包积液• [Bronchoedema] 支气管水肿• [Slight (M ild)] 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• [Dysp nea 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• [Bronchial asthma] 支气管性哮喘• [Hyperpnea] 呼吸深快• [Periodic breathing] 周期性呼吸• [Tachypnea (Rapid or fast breathing;accelerate d 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 (Errhy sis)] 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 (Nonproductive 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• [Mucopurulent 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 hemoptysis]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 (Macroscopic) 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• [Hemopericardi um] 心包积血• [Cerebral hemorrhage] 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• [Puls ating 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• [Vomiturition (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 diarrhea] 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• [Hab itual 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• [Hemol ytic] 溶血性• [Hepatocellular] 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; ur inate; 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*• [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• [Dis comfort (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 th e 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(P ass) 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 (Menorr hagia; 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• [A***uality (lack of libido)] 无性欲• [Hypo***uality] 性欲低下• [Hyper***uality] 性欲亢进• [Prospermia (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 appetite; hyperorexia; bulimia)] 多食• [Cold (Heat) intolerance] 怕冷（热）• [Dwarfism (Excessive height)] 身材矮小（高大）• [Excessive sweating] 多汗• [Hands tremble] 手抖• [Obesity (Fatty)] 肥胖• [Agitation (Anxiety;nervous irritability)] 焦虑（忧虑）•[Mania] 躁狂• [Hallucination] 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 sleepness;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) sensation] 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• [Dimi nution 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 fee ling 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• [Sneezing] 打喷嚏• [Snoring] 打鼾• [Hyposmia (Reduction of the sense of smell)] 嗅觉减退• [Anosm ia (Complete loss of sense 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 escape d] 破水• [Uterine contraction] 宫缩• [Acalculia] 计算不能• [Apathy] 情感淡漠• [Delusion] 妄想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。
英文病历之主诉的写法
主诉1.主诉的表示方法：症状+时间（Symptom+T ime）•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 day s` 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 (bleedin g)] 皮肤粘膜出血• [Dyspnea (Difficuly in breathing;Re spiratory difficulty;short of breath)]呼吸困难• [Cough and expectoration (Sputum;Ph legm)] 咳嗽和咯痰• [Hemoptysis] 咯血• [Cyanosis] 紫绀• [Palpitation] 心悸• [Chest discomfort] 胸闷• [Nausea (Retch;Dry Vomiting)and Vom iting] 恶心和呕吐• [Hematemesis (Vomiting of blood)]呕血• [Hematochezia (Hemafecia)] 便血• [Diarrhea] 腹泻• [Constipation (Obstipation)] 便秘• [Vertigo (Giddiness; Dizziness)] 眩晕• [Jaundice (Icterus)] 黄疸• [C onvulsion] 惊厥• [Disturbance of consciousness] 意识障碍• [Hematuria] 血尿• [Frequent micturition,urgent mictur ition and dysuria] 尿频，尿急和尿痛• [Incontinence of urine] 尿失禁• [Retention of urine] 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▲ [Continuous 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) ori gin, FUO] 不明原因发热• [Rigor (shivering;chill;shaking chi ll;ague)] 寒战• [Chilly Sensation (Fell chilly;cold fits;coldness)] 畏寒[Ultra-hyperpyrexia] 超高热• [Hyperthermia (A high fever;hyperpy rexia;ardent fever)] 高热• [Moderate fever] 中度发热• [Hypothermia (Low-grade fever;sligh t fever;subfebrile temperature)] 低热• [Become feverish (Have a temperatur e)] 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• [Persistent febrile period] 持续发热期（2）疼痛的表示方法• [Backache (Back pain)] 背痛• [Lumbago] 腰痛• [Headache] 头痛医学.全.在线.网.站.提供▲ [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•[Burning 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•[Wandering 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] 脑积水医学全.在线网.站.提供•[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;hydroperiot oneum)] 腹水•[Pleural effusion (Hydrothorax)] 胸水•[Pericardial effusion (Hydropericardium)]心包积液•[Bronch oedema] 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•[Bronchial asthma] 支气管性哮喘•[Hyperpnea] 呼吸深快•[Periodic breathing] 周期性呼吸•[Tachypnea (Rapid or fast breathing;accel erated 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•[Spl inter 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 (Nonproductive cough;hackin g 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•[Mucopurulent 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 hemoptysis]戈耳斯坦氏咯血•[Massive hematemesis]大量呕血•[Epistasis (Nosebleed;Nasal bleeding; He morrhinia;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 (Macroscopic) hematuria] 肉眼血尿•[Microscopic hematuria] 镜下血尿•[Hematuria in the whole process of urin ation] 全程血尿•[Gingival bleeding (Ulaemorrhagia;gum b leeding)] 牙龈出血•[Hematochezia] 便血•[B loody 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 hemorrhage] 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 extractio n] 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•[V omiturition (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 diarrhea] 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•[Hepatocellular] 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; mictur ition)] 排尿•[Frequent micturition (Frequency of mict urition; 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; distur bance of micturition)] 排尿困难•[Small urinary stream] 尿线细小•[V oid with a good stream] 排尿通畅•[Guttate emiction (Dribbling following ur ination;terminal d ribbling)] 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; debilitatin g)] 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; dif ficult swallowing; acataposis)] 吞咽困难•[Epigastric (Upper abdominal) discomfort]上腹部不适•[Anorexia (Sitophobia)] 厌食•[Poor appetite (Loss of appe tite)] 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] 月经过少医学全.在线提供•[Excessive menstruation (Menorrhagia; m enometrorrhagia; 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•[Hype rsexuality] 性欲亢进•[Prospermia (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 appetite; hyperore xia; bulimia)] 多食•[Cold (Heat) intolerance] 怕冷（热）•[Dwarfism (Excessive height)] 身材矮小（高大）•[Excessive sweating] 多汗•[Hands tremble] 手抖•[Obesity (Fatty)] 肥胖•[Agitation (Anxiety;nervous irritability)] 焦虑（忧虑）•[Mania] 躁狂•[Hallucination] 幻觉•[Aphasia (Logopathy)] 失语•[Amnesia (Poor memorization;memory de terioration)] 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 sleepness;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 v ision; dimness of vision)]视物模糊•[Burning (Dry) sensation] 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-ac he)] 耳痛•[Stuffy feeling in the ear] 耳闭气•[Tinnitus] 耳鸣医学全在.线提供•[Outophony] 自声过强•[Nasal obstruction (blockage)] 鼻塞•[Dryness of the nose] 鼻干燥•[Rhinorrhea (Snivel;Nasal discharge)] 流鼻涕•[Sneezing] 打喷嚏•[Snoring] 打鼾•[Hyposmia (Reduction of the sense of s mell)] 嗅觉减退•[Anosmia (Complete loss of sense of sm ell)] 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 contraction] 宫缩•[Acalculia] 计算不能•[Apathy] 情感淡漠•[Delusion] 妄想4、时间的表示方法（1）月（Month）•[January,Jan.] 一月•[February,Feb.] 二月•[March,Mar.] 三月•[April,Apr.] 四月•[May] 五月•[June,Jun.] 六月•[July,Jul.] 七月•[August,Aug.] 八月•[September,Sept.] 九月•[October,Oct.] 十月•[November,Nov.] 十一月•[December,Dec.] 十二月（2）周（Week）• [Monday] 星期一• [Tuesday] 星期二• [Wednesday] 星期三• [Thursday] 星期四• [Friday] 星期五• [Saturday] 星期六• [Sunday] 星期日（3）年（Year）和日[Day]•[1st (First) year] 第1年•[2nd (Second) year] 第2年•[3rd (Third)year] 第3年•[4th (Forth) year] 第4年•[One year (day)] 1年（天）•[Two years (days)] 2年（天）•[Whole year] 整年•[1st (First)] 1日•[2rd (Second)] 2日•[3rd (Third)] 3日•[5th (Fifth)] 5日•[Today] 今天•明天[Tomorrow]•昨天[Yesterday]•前天[The day bdfore yesterday]•后天[The day after tomorrow]•大前天[3 days ago]•大后天[3 days hence]•今晚[Tonight]•昨晚[Last night]•明晚[Next nigh t]•通宵[All night]•整天[All day (the whole day)]（4）季节[Season]和时节[Solar terms] •春季[Spring]•夏季[Summer]•秋季[Autumn]•冬季[Winter]•立春（夏、秋、冬）[the Beginning of Spi ring (Summer;Autumn;Winter)]•小暑（雪、寒）[Slight Heat (Snow;Cold)] •大暑（雪、寒）[Great Heat (Snow;Cold)] •雨水[Rain Water]•惊蛰[the Waking of Insects]•春（秋）分[the Spiring (Autumnal) Equin ox]•清明[Pure Brightness]•谷雨[Grain Rain]•小满[Grain Full]•芒种[Grain in Ear]•夏（冬至）[the Summer (Winter) Solstice] •处暑[the Limit of Heat]•白（寒）露[White (Cold) Dew]•霜降[Frost’s Descent]（5）时间的表示方法•In[在……内（后）]▲在2003年[In 2003]▲在3月[In March(Mar.)]▲在去年10月[In last Oct.]▲在早晨[In the morning]▲在上午[In the forenoon]▲在下午[In the afternoon]▲在晚上[In the evening]▲在近5天[In the past 5 days]▲在10分钟后[In 10 minutes]▲在秋季[In autumn]▲在这2～3天内[In a couple of days]•Within[在……中]▲在近8个月中[Within the last 8 mont hs]▲在过去的2年中[Within the preceding 2 years]•On[在……时候]医学全在.线提供www. ▲在2002的9月18日[On the 18th of September,2002(英国)or On sept.18th,2002 (美国)▲在星期三[On Wednesday]▲在本月7日[On 7th instant]•At[在……时]▲在中午[At noon]▲在晚上[At night]▲在昨晚[At last (preceding;previous )ni ght]▲在半夜[At midnight]▲在上午10点钟[At 10AM]▲在5岁时[At the age of five]▲在2000年底（中、初）[At the end (mid dle;beginning) of 2000]•For[计……时间]▲一周[For one week]▲近2个月来[For the past 2 months]▲几乎（整整）一年[For nearly a mont h (a full month)]▲3个月左右[For 3 months or so]▲至少3个月[For at least 3 months]▲3个月以上[For more than 3 months]▲3个月或以上[For 3months or more]▲时间不详[For an unknown(indefinite) period (time)]•Of[在……时期]▲10年内[Of 10 years` duration]▲期间[Length of time]▲6月6日[The 6th of June]•Dring[在……期间]▲在2000-2005年的几年中[During the y ears form 2000 to 2005]▲在这4年中[During four years]▲在过去的几周中[During the past(Last) couple of weeks]▲在夜间[Dur ing the night]▲整天[During the entire day]•About [约]▲约1个半小时[About one and half an hour]▲大约半年[About half a year]•To[至；在……之前]▲从今下午点至明上午8点[Form 6 PM today to 8 AM tomorrow]▲6点45分[At fifteen to seven]•From[从……起]▲从14岁至52岁[From 14 to 52 year-old]▲从上午7点30分开始[Form 7:30AM] ▲从周一至周五[From Monday through Friday]•Past[过去；超过]▲在过去的3周中[In the past 3 weeks] ▲8点10分[ten minutes past eight]•Through or throughout[在……整个期间] ▲通宵值班[Be on duty through the nig ht]▲从一月到六月[From January through June]▲熬过明晚[Through the next nigut]▲整天（晚）[Throughout the day (night)] •Over[在……期间]▲在过去的2个月内[Over the past t wo months]▲一夜间[Overnight]（6）其他表示方法•每月（年、日）一次[Monthly (Yearly; dai ly)]•整整一年[Yearlong (Year-round)]•满周岁[Yearling]•工作日[Weekday]•周末[Weekend]•每周末[Weekends]•8小时工作日[An eight-hour day]•整天[Daylong]•白天[Daytime]•昼夜[Nighttime]•日常的[Day-to-day]•夏令时间[Daylight saving time]•每晚[Nightly]•黄昏[Nighfall]•过期的[Overdue]•前天晚上（一夜间）[Overnight]•After [在……之后]▲婚后[After one`s marriage]▲七点十分[Ten after (past) seven]▲住（出）院后[After admission (discharge)] ▲起病后2天[2 days after the onset(attack) of symptoms]•Before[在……之前]▲ 7点50分之前[Before seven fifty]▲医生到达前[Before the doctor come]▲以前未有种症状[Have had not the same symptom before]Ago[以前]▲ 5年前[5 years ago]▲直到一个月前[Up to one month ago]▲大前天[Three days ago]•Prior to[在……之前]▲入（出）院前[Prior to admission (discha rge)]▲前天之前[Prior to the day before yester day]•Up to[直到]▲直到3周前[Up to 3 weeks ago]▲直到现在（出院）[Up to now (discharge)] •Until or till[直到]▲直到80岁[Until 80 years old]▲直到今晨8点[Until 8 o`clock this moni ng]▲直到医生查完房[Until the doctor have f inished the ward round]▲直到3年以前[Until 3 years ago]▲直到出院前一天[Until 1 day prior to di scharge]•By[在……之前] ▲下午点钟前[By 5 PM] ▲下个月之前[By next month]•Since[从……开始]▲自从去年术后[Since operation was perfo rmed last year]▲前天起[Since the day before yesterday] ▲从2002年6月起[Since June 2002]•超时(加班)[Overtime]•上午8点[8：00AM]•下午2点30分[2：30PM]•7点50分[Seven fifty (Ten to eight)]•9点20分[Nine twenty(Twenty past or aft er nine)]术前[Pre-operation]•术后[Post-operation]现病史[History of present illness 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。
病历书写英文
英文病历书写常用句式与表达
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英文病历书写注意事项
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实例三：糖尿病病历
Symptoms：Itching, skin redness and scalingMedical history：None significantFamily history：None contributoryReview of systems：NegativePhysical examination：Multiple small red patches and scaling on the skin of the upper back and upper armsDiagnostic studies：Skin scrapings showed positive fungal elementsDiagnosis：DermatitisPlan：Patient was advised to apply topical corticosteroid cream twice daily and follow up in 1 week
实例二：高血压病历
Symptoms：Polyuria, polydipsia, unexplained weight lossMedical history：Known diabetes mellitus for 2 years, taking metformin hydrochlorideFamily history：None contributoryReview of systems：NegativePhysical examination：Blood pressure 130/85, pulse 90 beats/minute, respiration rate 18 breaths/minute, weight 150 poundsDiagnostic studies：Random blood glucose level of 250 mg/dL, HbA1c of 7.5%Diagnosis：Diabetes mellitusPlan：Patient was advised to continue current medications, receive education on diabetes self-management, lose weight, reduce glucose intake, and follow up in 3 months
英文病历全攻略
英文病历全攻略一、主要调查项目：1.主诉chief complaint：weakness, malaise, chills, fever, sleep, pain, headache, appetite, weight, stomach and bowels, nausea and vomiting, diarrhea, urine, genitalia, neuropsychiatric disorders, respiration, shortness of breath, bleeding or discharge, etc.2.现症历present illness：onset(date, mode), duration before present entry, exciting cause and environmental influences, prodromal symptoms, general symptoms, course or progress( location, duration, severity, continuity, intermission, radiation, treatment), aggravating and alleviating factors, loss of weight, appetite and strength, sleep, bowel movement, frequency of urination, menstruation, etc.3.既往历past history：1)former places of residence, previous stage of health( 健壮的robust，纤弱的delicate), experience with similar disease, immunity to infectious disease2)previous illness：麻疹measles, 腮腺炎mumps, 水痘chicken-pox, 百日咳pertussis, 流行性感冒influenza, 猩红热scarlet fever, 白喉diphtheria，伤寒typhoid fever, 支气管炎bronchitis, 肺炎pneumonia，脑炎encephalitis,脑膜炎meningitis，破伤风tetanus,小儿麻痹poliomyelitis,赤痢dysentery，霍乱cholera, 胸膜炎pleurisy,天花small-pox，疟疾malaria,结核病tuberculosis，黄疸病jaundice，过敏性反应allergy,etc3)venereal disease：specific symptoms, signs, and the disease by name, treatment.4)Accidents( date, any disability, sequelae), operation and hospitalization (date , procedure, name of hospital , physician, complications, bleeding tendency)4.家族历family history：family tendency, presence of hereditary disorders, cancer, tuberculosis, mental disorder and nervous affection, rheumatism, diabetes, hypertension, cerebral vascular accident, hemophilia, syphilis, tumor, epilespsy, allergy, contact with diseased individuals, relationship of patient’s childhood and adult life, age, health condition, and cause of death of parents, grandparents, self , spouse, siblings , or relatives.5.个人历personal history：1)Social history：fears, metal status, education, financial condition, number of dependents, family harmony or fractious , hygienic condition at home2)Marital history：duration of marriage, 1st or 2nd marriage, age and death of spouse and children , cause and age at time of death, number of children , pregnancies, 流产次数miscarriages, 死产数stillbirths3)occupational history：duration of employment, past work, exact nature of work, exposure to occupational hazards, whether work is satisfactory or not.4)Habits：alcohol, tobacco, narcotic, coffee, tea, appetite, food habits, regularity of meals, rapidity of eating , bowel movements, sleep, exercise, interests, etc.6.系统检查system review：1)General：nutrition, fever, night sweats, tremor, weight gain or loss, weakness, allergy.2)Skin：荨麻疹hives, rash, eczema3)Head：trauma, headache, loss of hair4)Eyes：vision, pain glasses diplopia.5)Ears：pain, discharge, deafness, tinnitus.6)Nose：obstruction, discharge, epistaxis, rhinitis.7)Mouth：teeth, lips, gums, tongue, disturbance in taste.8)Throat.：sore throat, tonsillitis, 脓性扁桃腺炎quinsy, dysphagia9)Neck：adenitis, goiter , rigidity10)Cardiorespiratory：palpitation, tachycardia, blood pressure, chest pain, dyspnea, cough , hemoptysis , seasonal cold, expectoration.11)Gastrointestinal：appetite, nausea, vomiting, distress(before or after meals), melena, colic, jaundice, fullness, hernia, hemorrhoid, constipation, diarrhea, frequency of bowel movement , heartburn, idiosyncrasies, relation of symptoms to eating, type and quantity of food12)Genito-urinary：dysuria, urinary frequency, dribbling , hematuria, pyuria, nocturia and volume, enuresis, incontinence, sores about external genitalia, symptoms suggestive of syphilis(mucous patches, falling hair), urethral discharge, exposure to venereal infection, obstetric history, catamenia(age of onset, date of last period, cycle and amount, periodicity , dysmenorrheal, menopause) leucorrhea, associated headache13)Neuromuscular：神经过敏nervousness, emotional stress, weakness, muscle or joint pains, convulsion, numbness, neuralgia, anesthesia, muscular atrophies or dysatrophies, deformities. 二、病历与时态1．现症历(present illness)：1)A.现在式：表示一般的真理、职业、人格、习惯和现在的事实、动作或状态。
英文病历报告作文模板
英文病历报告作文模板Patient Information- Name: [Patient's Full Name]- Gender: [Male/Female]- Age: [Patient's age]- Date of Admission: [MM/DD/YYYY]Chief ComplaintThe patient presented with [specific symptoms/complaints] which started [duration].History of Present IllnessThe patient reported [detailed description ofsymptoms/complaints]. The symptoms worsened over the past [duration]. The patient experienced [associated symptoms] and tried [any self-medication or home remedies] but noticed no improvement. There was no history of trauma or injury.Past Medical HistoryThe patient has a history of [chronic/acute medical conditions, if any] which includes [specific conditions]. The patient has taken[previous medications/treatments] for these conditions.Social HistoryThe patient has a [specific occupation] and lives in [specific area]. The patient does [specific habits] such as smoking or drinking alcohol [frequency]. There is no significant family medical history.Physical Examination- Vital Signs:- Blood Pressure: [value] mmHg- Heart Rate: [value] bpm- Respiratory Rate: [value] bpm- Temperature: [value]C- General Appearance:The patient appears [general appearance of the patient].- Systemic Examination:- Cardiovascular: [specific findings]- Respiratory: [specific findings]- Gastrointestinal: [specific findings]- Neurological: [specific findings]- Musculoskeletal: [specific findings]Laboratory and Imaging Findings- Blood Test Results:- Complete Blood Count: [values]- Biochemical Profile: [values]- Others: [specific findings]- Imaging:- [Specific imaging tests performed]- Results: [specific findings]DiagnosisAfter evaluating the patient's medical history, physical examination, and laboratory/imaging findings, the following diagnosis was made:[Primary Diagnosis]Treatment and ManagementThe patient was started on [specific treatment plan] which includes [medications, therapies, or procedures]. The patient wasadvised to [specific instructions] and scheduled for [follow-up tests/appointments, if any].Follow-upThe patient will be followed up in [specific time frame] to assess the response to treatment and manage any complications that may arise. The patient was given contact information for any urgent concerns or changes in symptoms.Discussion and ConclusionThis case report highlights the presentation, evaluation, and management of a patient with [specific condition]. The patient's symptoms were appropriately addressed through a systematic approach involving history taking, physical examination, and laboratory/imaging investigations. The provided treatment plan aims to address the underlying cause and improve the patient's overall well-being. Continuous monitoring and follow-up will guide further management decisions.Note: This medical case report is fictional and serves as a template for educational purposes. Any resemblance to actualpatients is purely coincidental.。
英文完全病历模板-详细版
Admission RecordName：* Nativity: * district, * citySex:male Race: HanAge: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: reliablePresent address: NO*, building*, * village,* district, *city, *provinceChief complaint: cough and sputum for more than 6 years, worsening for 2 weeksHistory 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.Pulmonary function tests indicated:d obstructive ventilation dysfunction; bronchial dilation test was negative2.moderate decrease of diffusion function, lung volume, residual volume and the ratio of lungvolume; residual volume were normalThe patient was diagnosed as “AECOPD” and prescribed cefoxitin to anti-infection for a week, Budesonide and Formoterol to relieve bronchial muscular spasm and asthma,amb roxol to dilute sputum, and traditional Chinese medicine (specific doses were unknown).The patient was discharged from the hospital after symptoms of cough and sputum slightly relieved with a prescription of using Moxifloxacin outside the hospital for 1 week. Cough and sputum were still existing, thus the patient came to our hospital for further treatment and the outpatient department admitted him in the hospital with “COPD”. His mental status, appetite, sleep, voiding, and stool were normal. No obvious decrease or increase of weight.Past history: The patient was diagnosed as type 2 diabetes 1 years ago and take Saxagliptin (5mg po qd) without regularly monitoring the levels of blood sugar. The patient denies hepatitis, tuberculosis, malaria, hypertension, mental illness, and cardiovascular diseases. Denies surgical procedures, trauma, transfusion, food allergy and drug allergy. The history of preventive inoculation is not quite clear.Personal history: The patient was born in *district, * city and have lived in * since birth. He denies water contact in the schistosome epidemic area. Smoking 10 cigarettes a day for 20 years and have stopped for half a month. Denies excessive drinking and contact with toxics.Marital history: Married at age of 27 and have two daughters. Both the mate and daughters are healthy.Family history: Denies familial hereditary diseases.Physical ExaminationT: 36.5℃ P：77bpm R: 21 breaths/min BP：148/85mmHgGeneral condition：normally developed, well-nourished, normal facies, alert, active position, cooperation is goodSkin and mucosa: no jaundiceSuperficial lymph nodes: no enlargementHead organs: normal shape of headEyes:no edema of eyelids; no exophthalmos; eyeballs move freely; no bleeding spots of conjunctiva; no sclera jaundice; cornea clear; pupils round, symmetrical in size and acutely reactive to light.Ears: no deformity of auricle; no purulent secretion of the external canals; no tenderness over mastoidsNose: normal shape; good ventilation;no nasal ale flap; no tenderness over nasal sinus; Mouth: no cyanosis of lips; no bleeding spots of mouth mucosa; no tremor of tongue; glossy tongue in midline; no pharynx hyperemia; no enlarged tonsils seen and no suppurative excretions; Neck: supple without rigidity, symmetrical; no cervical venous distension; Hepatojugular reflux is negative; no vascular murmur; trachea in midline; no enlargement of thyroid glandChest: symmetrical; no deformity of thoraxLung:Inspection：equal breathing movement on two sidesPalpation: no difference of vocal fremitus over two sides;Percussion: resonance over both lungs;Auscultation: decreased breath sounds over both lungs; no dry or moist rales audible; no pleural friction rubsHeart:Inspection: no pericardial protuberance; Apex beat seen 0.5cm within left mid-clavicular at fifth intercostal space;Palpation: no thrill felt;Percussion: normal dullness of heart bordersAuscultation: heart rate 78bpm; rhythm regular; normal intensity of heart sounds; no murmurs or pericardial friction sound audiblePeripheral vascular sign: no water-hammer pulse; no pistol shot sound; no Duroziez’s murmur; no capillary pulsation sign; no visible pulsation of carotid arteryAbdomen:Inspection: no dilated veins; no abnormal intestinal and peristaltic waves seenPalpation: no tenderness or rebounding tenderness; abdominal wall flat and soft; liver and spleen not palpable; Murphy's sign is negativePercussion: no shifting dullness; no percussion tenderness over the liver and kidney regionAuscultation: normal bowel sounds.External genitalia: uncheckedSpine: normal spinal curvature without deformities; normal movementsExtremities: no clubbed fingers(toes); no redness and swelling of joints; no edema over both legs; no pigmentation of skins of legsNeurological system: normal muscle tone and myodynamia; normal abdominal and bicipital muscular reflex; normal patellar and heel-tap reflex; Babinski sign(-);Kerning sign(-) ; Brudzinski sign(-)Laboratory DataKey Laboratory results including CT imaging and pulmonary function test have been detailed in the part of history of present illness.Abstract*, male, 55 years old. Admitted to our hospital with the chief complaint of cough and sputum for more than 6 years, worsening for 2 weeks. Cough and sputum worsened and were accompanied by tachypnea 2 weeks ago. The patient can’t lie flat in the night because of prominent tachypnea and prefer a high pillow.Physical Examination: T: 36.5℃,P: 77bpm, R: 21 breaths per minute, BP:148/85mmHg. Decreased breath sounds over both lungs; no dry or moist rales audible.Laboratory data: CT lung imaging indicates: lesion accompanied by calcification in superior segment, inferior lobe of right lung, possibility of obsolete tuberculosis; emphysema, bullae formation and sporadic inflammation of bilateral lung; calcified lesion in inferior lobe of left lung. Pulmonary function tests indicate: mild obstructive ventilation dysfunction, bronchial dilation test was negative moderate decrease of diffusion function.Primary Diagnosis:1.AECOPD2.Type 2 Diabetes3.Primary Hypertension Doctor’s Signature:。
英语简要病历报告作文
英语简要病历报告作文Title: Patient Medical Report: A Case of Respiratory Infection。
Date: April 16, 2024。
Patient Information:Name: [Patient Name]Age: [Age]Gender: [Gender]Date of Admission: [Date]Admitting Physician: Dr. [Physician Name]Chief Complaint:The patient presents with symptoms of cough, fever, shortness of breath, and fatigue.History of Present Illness:The patient, [Patient Name], a [Age]-year-old [Gender], presented to the emergency department with complaints of cough, fever, shortness of breath, and fatigue for the past five days. The cough was productive, with yellowish-green sputum. The fever was intermittent and associated with chills. The patient also reported experiencing mild chest pain exacerbated by coughing.Past Medical History:The patient has a past medical history significant for asthma, for which they use an inhaler as needed. There are no known allergies to medications.Medications:The patient takes [Medication Name] for asthma asneeded.Social History:The patient is a non-smoker and denies any history of alcohol or illicit drug use. They work as a [Occupation] and have no recent travel history.Family History:There is no significant family history of respiratory illnesses.Physical Examination:On physical examination, the patient was febrile with a temperature of [Temperature], tachycardic with a heart rate of [Heart Rate], and tachypneic with a respiratory rate of [Respiratory Rate]. Oxygen saturation was [Oxygen Saturation]% on room air. Lung auscultation revealed coarse crackles in the lower lung fields bilaterally. There was no evidence of cyanosis, clubbing, or peripheral edema. 。
英文病历标准模版
英文病历标准模版Patient ProfileName: Si RuihuaDepartment: ___ Power ___Sex: FemalePresent Address: Electric Power Bureau Age: 80 yearsDate of n: May 17.2003nality: Chinese XinjiangDate of Record: May 17.2003Marital Status: MarriedReliability: Reliablen: Family ___History of Allergy: None reportedChief Complaints___。
breathlessness。
and precordial pain for the last hour。
There were no precipitating factors。
and the fort could not be relieved by rest。
As a result。
she came to the hospital for help。
She did not experience syncope。
cough。
headache。
diarrhea。
or vomiting during the course of the illness。
Her appetite。
sleep。
voiding。
and stool were normal.Medical History___.______。
___ distress。
She had a heart rate of 120 beats per minute and a blood pressure of 160/90 mmHg。
Her respiratory rate was 28 breaths per minute。
and her oxygen n was 90% on room air。
英语病历范文
英语病历范文Patient Information:- Name: [Not Specified]- Age: [Not Specified]- Date: [Not Specified]- Doctor: [Not Specified]Chief Complaint:The patient presents with a persistent cough, accompanied by mild fever and body aches for the past three days.History of Present Illness:The patient first noticed the symptoms on [Date], with a dry cough that gradually worsened. The fever started as low-grade but has been increasing, reaching up to 38.5 degrees Celsius.Past Medical History:The patient has no significant past medical history. No previous hospitalizations or chronic illnesses are reported.Medications:The patient has not taken any medications for the current illness, nor are they on any regular medication.Allergies:No known allergies to medications or environmental factors.Physical Examination:Vital signs: Temperature 38.3°C, Puls e 92 bpm, Respiratory rate 20 breaths per minute, Blood pressure 120/80 mmHg. The patient appears fatigued but in no acute distress. Lungs are clear to auscultation with no wheezing or crackles. The throat is slightly red without exudates.Assessment:Based on the symptoms and physical examination, the patient is likely suffering from a viral upper respiratory infection.Plan:1. Hydration and rest are recommended.2. Over-the-counter fever reducers and cough suppressants may be used as needed for symptomatic relief.3. If symptoms persist or worsen, the patient should return for further evaluation and potential testing for influenza or COVID-19.Follow-up:The patient is advised to follow up in one week if symptoms have not improved or if new symptoms develop.Instructions:- Increase fluid intake to prevent dehydration.- Avoid contact with others to prevent the spread of the infection.- Monitor for signs of worsening condition, such as difficulty breathing, persistent high fever, or chest pain.Note: This is a hypothetical patient case and should not be used as a substitute for professional medical advice, diagnosis, or treatment.。
英语作文病历模板
英语作文病历模板英文回答：Medical History Template。
Patient Information。
Name:Date of Birth:Gender:Address:Phone Number:Email Address:Reason for Visit。
What brings you to the clinic today?Medical History。
Past Medical History。
Do you have any past medical conditions?Have you ever been hospitalized or had surgery?Do you currently take any medications?Do you have any allergies?Family Medical History。
Do any of your close family members have any medical conditions?Have any of your close family members passed away at a young age due to illness?Social History。
What is your occupation?Are you currently married or in a relationship? Do you have any children?Do you smoke, drink alcohol, or use drugs?Physical Examination。
General Appearance:Height:Weight:BMI:Vital Signs:Blood pressure: Pulse:Respiratory rate: Temperature:Cardiovascular:Heart rate:Heart sounds:Blood pressure: Respiratory:Respiratory rate: Lung sounds:Abdomen:Girth:Soft and non-tender: Liver span:Musculoskeletal:Range of motion:Strength:Reflexes:Skin:Color:Texture:Turgor:Assessment。
英文病历示例
英文病历示例患者，李华，男，69岁，退休教师，因心悸一年，加重5个月于1989年6月6日入院。
一年前患者健康。
1988年5月感到轻微心悸，在工作劳累，快走及上楼时感气短，傍晚下肢浮肿，休息后则减轻。
近5个月来，心悸气短明显加重。
以致不能行走，亦不能平卧，不得不坐着度过整夜，有时咳嗽，咳少量白色粘液，无血。
患者无寒战、发热、胸痛或关节疼痛，排尿正常。
系统复习无特殊，1949年曾患“大叶肺炎”，无药物过敏史。
个人史：生在西安，曾去过中国南方，但无疫水接触史，抽烟一天10支，1945年结婚，其妻健康，有一女孩亦健康，其父死于胃癌，其母健在。
查体：体温36.8℃，脉搏90次/分，呼吸28次/分，BP23.5/13.3kPa，发育良好，营养中等，体胖、半卧位，颜面苍白，全身浮肿，神智清楚，查体合作。
皮肤无红斑、黄疸、紫瘢。
淋巴结未触及。
头部、眼、鼻、耳、口正常，但口唇紫绀。
颈软，颈静脉无充盈，甲状腺未触及，无细震颤或搏动，气管正中。
胸廓两侧对称，呼吸动度对称，无异常浊音区，但在两肺底部可闻一些湿罗音。
心尖搏动所见，触诊时在第5肋间，距正中线14cm处，无细震颤，心浊音界如图：心率90次/分，律齐，心尖部可闻Ⅱ级柔和的吹风样收缩期杂音，P2＞A2，无胸膜磨擦音，腹软，无压痛及反跳痛，肝可触及，在肋下2cm，轻度压痛，脾未触及；无移动性浊音，其他正常。
右（cm）左（cm）1.5 Ⅱ2.02.0 Ⅲ 4.03.0 Ⅳ8.0Ⅴ14.0Ⅵ14.0正中线至左锁骨中线距离10cm初步诊断：1.高血压心脏病2.Ⅲ度心衰AN EXAMPLE OF MEDICAL CASE RECORD IN ENGLISH Patient Li Hua, mate,69 years old, a retired teacher, was admitted on June 6,1989,because of palpitation for one year and becoming worse in recent 5 months.The patient was quite well until one year before May,1988, He felt slight palpitation and dyspnia during hard work, fast walk , or climbing stairs, There was swelling of legs in the evening but he felt better after having a rest. In recent 5months, palpitation and dyspnia became so serious that he could neither walk nor lie down. He had to sit up during the whole night, Sometimes he coughed with small amounts of sputum, but without blood. He had no chill, fever, chest pain or sore joints. The urinating was normal.There was nothing else abnormal in the case history review except a cured lobor pneumoniain 1949. He had no history of drug allergy.Personal history：The patient was born in Xi’an in 1923. He had been to the south of China but did not contact contaminated water. He smoked a bout 10 cigarettes daily. He got married in 1945. His wife was healthy .They had a daughter who was also healthy. His father died of stomach cancer. His mother was well.Physical Examination：T.36.8C, P. 96/min, R. 28/min, BP.23.5/13.3kPa. The patient, an old fatty man who developed well and moderately nourished, was lying in bed with a semifallous position. He looked pale and suffered from general edima. He was mentally normal and cooperative in the examination. There was no eruption, no jaundice, no purpura on the skin, and the lymphnodes were not palpable. The head, eyes, nose, ears, mouth were normal while the lips were cyanotic. The neck was soft, there was no venous engorgement. Thyroid glands were not palpable, there were no thrill or brunt. The trachea was in midline. The chest and respiratory movements were symmetrical. There was no abnormal dullness but some moist rales were heard in the base areas of the both lungs. The points of maximal impulse (PMI) were not visible but palpable in the 6 thcostal interspace, 14cm form the middle line, there was no thrill. The cardiac dullness, 14cm from the middle line, there was no thrill. The cardiac dullness were as follows;Right （cm）I nterspaces Left (cm)1.5 Ⅱ2.02.0 Ⅲ 4.03.0 Ⅳ8.0Ⅴ10.0Ⅵ14.0The distance from midsternal line to midclavicular line was 10cm.The heart rate was 96/min, regular. There was a grade Ⅱsoft blowinglike systolic murmurat the apex,P2>A2, but no pericardium friction sound was heard. Abdominal wall was soft without tenderness. The liver was palpable 2cm below the costal margin with slight tenderness. The spleen was not palpable and there was no shifting dull ness. The rest was normal.Impression：disease with：1. hypertensive heart disease2.degreeⅢheart failureSignature：×××。
英语写病历作文模板
英语写病历作文模板 Patient History Template。
英文回答：General Information。
Name:Age:Gender:Occupation:Address:Phone number:Emergency contact:Medical History。
Past medical history: List any previous illnesses, surgeries, hospitalizations, or accidents.Family medical history: Note any history of chronic diseases, such as heart disease, cancer, or diabetes, in the patient's family.Allergies: List any known allergies to medications, foods, or other substances.Medications: List all current medications, including prescription drugs, over-the-counter medications, and herbal supplements.Social history: Discuss the patient's lifestyle, including diet, exercise, smoking, alcohol use, and drug use.Present Illness。
Chief complaint: State the patient's primary reasonfor seeking medical attention.History of present illness: Describe the onset, duration, severity, and progression of the patient's symptoms.Physical Examination。
英文病历范文
英文病历范文Title: English Medical Record Sample (Creating and Expanding on a Matching Content)Medical RecordNa John SmithDate of Birth: February 15, 1985Gender: MaleNationality: AmericanOccupation: AccountantChief Complaint:The patient presented with a complaint of persistent cough, shortness of breath, and chest pain for the past week.History of Present Illness:The symptoms initially started as a mild cough, which gradually worsened over the week. The patient also experienced shortness of breath, especially during physical activities. He reported occasional chest pain, which was sharp in nature and intensified during deep breaths. The patient denied any fever, night sweats, or weight loss.Past Medical History:The patient has a history of asthma since childhood and has been using an inhaler as needed. He had a similar episode ofpersistent cough and shortness of breath six months ago, which resolved with a course of oral steroids. No other significant medical history was reported.Social History:The patient is a non-smoker and denies any alcohol or illicit drug use. He lives with his wife and two children in a smoke-free environment. The patient works as an accountant and does not have any known occupational exposures.Family History:There is no significant family history of respiratory diseases or any chronic illnesses.Review of Systems:The review of systems was unremarkable except for the respiratory symptoms mentioned above.Physical Examination:On examination, the patient appeared to be in no acute distress. Vital signs were within normal limits. Auscultation of the lungs revealed mild wheezing bilaterally. Heart sounds were normal, and there were no signs of peripheral edema or cyanosis. Other systemic examinations were within normal limits.Investigations:Laboratory investigations, including complete blood count, liver and kidney function tests, and electrolyte levels, were all within normal range. Chest X-ray showed hyperinflation of lungs and no evidence of infiltrates or consolidation.Assessment and Plan:Based on the history, clinical findings, and investigations, the patient's symptoms and past medical history suggest asthma exacerbation. Initial management includes a trial of short-acting bronchodilators, oral corticosteroids, and close monitoring of symptoms. The patient was educated about proper inhaler technique and advised to follow up in one week for reassessment.Education and Counseling:The patient was counseled on the importance of adherence to the prescribed medication and the need to avoid triggers for asthma exacerbation, such as allergens and respiratory infections. He was also provided with a written asthma action plan for self-management and advised to seek medical attention if symptoms worsen or do not improve within a week.Follow-up:The patient will be scheduled for a follow-up visit in one week to reassess symptoms, evaluate response to treatment, andadjust the management plan accordingly.This medical record documents the patient's chief complaint, history of present illness, past medical history, social and family history, physical examination findings, investigations, diagnosis, and treatment plan. It serves as a comprehensive guide for healthcare professionals involved in the patient's care.。
英文病历撰写手记
英文病历撰写手记病历是医生记录患者病情和诊疗过程的重要文档。
对于医生来说，准确、清晰地撰写英文病历至关重要。
本手记将介绍英文病历的撰写方法和注意事项。
1. 病历组成部分1.2 现病史（Present Illness）现病史应详细记录患者的主要症状、起病时间、发展情况以及辅助检查结果等。
应使用客观、中立的语言描述。
例如：Patient presents with fever, cough, and shortness of breath for the past week. Chest X-ray shows infiltrates in both lungs.1.3 既往史（Past Medical History）既往史包括患者过去的疾病、手术、药物过敏等情况。
应尽量提供详细信息，如果无则注明“无”。
例如：Patient has a history of hypertension and diabetes. No known drug allergies.1.4 家族史（Family History）家族史包括患者家庭成员的疾病情况，特别是与患者当前问题相关的疾病。
例如：Patient's mother has a history of breast cancer.1.5 个人史（Social History）个人史包括患者的生活方式、吸烟、饮酒、嗜好、职业等信息。
例如：Patient is a non-smoker and consumes alcohol occasionally.1.6 体格检查（Physical Examination）体格检查应记录医生对患者进行的全面检查，包括体温、脉搏、呼吸、血压等指标。
应详细描述发现的异常情况。
例如：Vital signs: temperature 37.5°C, heart rate 82 bpm, respiratory rate 18 breaths per minute, blood pressure 120/80 mmHg. Chest auscultation reveals decreased breath sounds in the lower left lung field.1.7 辅助检查（Laboratory and Diagnostic Tests）1.8 诊断（Diagnosis）1.9 治疗（Treatment）治疗部分应详细记录医生针对患者病情制定的治疗计划，包括药物治疗、手术、物理疗法等。
英语病历
1 病历case histroy一般事项date of admission /marital status /present address /correspondence / occupatio n主诉chief complaints现病史present illness / history of present illness既往史past medical history家族史family history个人病史personal history / social history曾用药物medications过敏史allergies系统回顾system review / review of system体检physical examination一般资料physical data 生理指标physical signs一般状况或全身状况general appearance头眼与耳鼻喉head ,eyes,ear,nose,throat ,略作heent.胸部与心肺CHEST,heart,and lungs腹部abodoms四肢extremities神经系统nervous system,Neurological,略作CNC或Neuro,骨骼肌系统Musculoskeletal泌尿生殖系统Genitourinary化验室资料laboratory data/ studies /diagnosis血液检查blood test化学7项指标chem.-7心脑电图electrocardiogram / electroencephalogram , 略作EKG/EEGX线检查与x光片X-ray examination, x-ray slides,计算机X线断层扫描与核磁共振扫描资料computerized x-ray tomography and nuclear mag netic resonance spectroscopy dta. CT AND NMR其他检查资料other lab data印象与诊断impression and diagnosis住院治疗情况hospital course出院医嘱discharge instructions / recommendations出院后用药discharge medications2 看病时用英文1) 一般病情:He feels headache, nausea and vomiting. (他覺得頭痛、噁心和想吐。
英语病历模板范文
英语病历模板范文Chief Complaint:The patient presents with a persistent cough and chest tightness for the past 2 weeks. He also reports feeling fatigued and experiencing shortness of breath during physical activities.History of Present Illness:The patient reports a history of smoking for 20 years, with a 10-pack-year smoking history. He denies any recent travel or exposure to sick contacts. He has been taking over-the-counter cough medicine for symptomatic relief withlimited improvement.Past Medical History:The patient has a history of hypertension and hyperlipidemia, for which he takes medication regularly. Healso reports a past history of seasonal allergies and occasional sinus infections.Family History:There is a family history of cardiovascular disease, with the patient's father suffering from a heart attack at the age of 55.Physical Examination:Vital signs on presentation were stable with a blood pressure of 130/80 mmHg, pulse rate of 80 beats per minute, respiratory rate of 18 breaths per minute, and oxygen saturation of 98% on room air. Lung auscultation revealed bilateral scattered wheezes and diminished breath sounds in the lower lung fields.Assessment and Plan:Based on the patient's presenting symptoms and physical examination findings, the working diagnosis is exacerbationof chronic obstructive pulmonary disease (COPD). The plan includes initiating bronchodilators, corticosteroids, and supplemental oxygen therapy. A chest X-ray will be ordered to rule out any acute pathology. Patient education on smoking cessation will be provided, and a follow-up appointment in 2 weeks for reassessment of symptoms will be scheduled.。
英文病历书写范例
英文病历书写范例（内科）Medical Records for AdmissonMedical Number: 701721General informationName: Liu SideAge: EightySex: MaleRace: HanNationality: ChinaAddress: NO.35, Dandong Road, Jiefang Rvenue, Hankou, Hubei.Tel: 857307523Occupation: RetiredMarital status: MarriedDate of admission: Aug 6th, 2001Date of record: 11Am, Aug 6th, 2001Complainer of history:patient’s son and wifeReliability: ReliableChief 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 historyThe patient is healthy before.No history of infective diseases. No allergy history of food and drugs.Past history Operative history: Never undergoing any operation. Infectious history: No history of s evere infectious disease. Allergic history: He was not allergic to penicillin or sulfamide. Respirator y system: No history of respiratory disease. Circulatory system: No history of precordial pain. Ali mentary 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 sys tem: No history of headache or dizziness. Personal historyHe was born in Wuhan on Nov 19th, 1921 and almost always lived in Wuhan. His living condition s were good. No bad personal habits and customs.Menstrual history: He is a male patient. Obstetrical history: NoContraceptive history: Not clear.Family history: His parents have both deads. Physical examinationT 36.5℃, P 130/min, R 23/min, BP 100/60mmHg. He is well developed and moderately nourished.Active position. His consciousness was not clear. His face was cadaverous and the skin was not sta ined yellow. No cyanosis. No pigmentation. No skin eruption. Spider angioma was not seen. No pi tting edema. Superficial lymph nodes were not found enlarged. HeadCranium: Hair was black and white, well distributed. No deformities. No scars. No masses. No ten derness.Ear: Bilateral auricles were symmetric and of no masses. No discharges were found in external au ditory 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 nare s flaring. No tenderness in nasal sinuses. Eye: Bilateral eyelids were not swelling. No ptosis. No e ntropion. Conjunctiva was not congestive. Sclera was anicteric. Eyeballs were not projected or dep ressed. Movement was normal. Bilateral pupils were round and equal in size. Direct and indirect p upillary reactions to light were existent.Mouth: Oral mucous membrane was not smooth, and there were ulcer can be seen. Tongue was in midline. Pharynx was congestive. Tonsils were not enlarged.Neck: Symmetric and of no deformities. No masses. Thyroid was not enlarged. Trachea was in mi dline. ChestChestwall: Veins could not be seen easily. No subcutaneous emphysema. Intercostal space was nei ther narrowed nor widened. No tenderness.Thorax: Symmetric bilaterally. No deformities. Breast: Symmetric bilaterally.Lungs: Respiratory movement was bilaterally symmetric with the frequency of 23/min. thoracic e xpansion 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 maximum imp ulse was in 5th left intercostal space inside of the mid clavicular line and not diffuse. No pericardi al friction sound. Border of the heart was normal. Heart sounds were strong and no splitting. Rate 150/min. Cardiac rhythm was not regular. No pathological murmurs.Abdomen: Flat and soft. No bulge or depression. No abdominal wall varicosis. Gastralintestinal ty pe or peristalses were not seen. Tenderness was obvious around the navel and in upper abdoman. T here 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 mur murs. 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 exanedInvestigationBlood-Rt: Hb 69g/L RBC 2.70T/L WBC 1. 1G/L PLT 120G/L History summary1. Patient was male, 80 years old2. Upper bellyache ten days, haematemesis, hemafecia and unconsciousness for four hours.3. No special past history.4. Physical examination: T 37.5℃, P 130/min, R 23/min, BP 100/60mmHg Superficial lymph node s 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 ne gative. Shifting dullness negative. Borhorygmus not heard. No vascular murmurs. No other positive signs. 5. investigation information:Blood-Rt: Hb 69g/L RBC 2.80T/L WBC 1.1G/L PLT 120G/LImpression: upper gastrointestine hemorrhage Exsanguine shock出院小结（DISCHARGE SUMMARY）， ===============Department of GastroenterologyChanghai Hospital，No.174 Changhai Road Shanghai, China Phone: 86-21-25074725-803 DISCHARGE SUMMARYDA TE OF ADMISSION: October 7th, 2005 DA TE OF DISCHARGE: October 12th, 2005 ATTE NDING PHYSICIAN: Yu Bai, MD PA TIENT AGE: 18ADMITTING DIAGNOSIS:V omiting for unknown reason: acute gastroenteritis?BRIEF HISTORYA 18-year-old female with a complaint of nausea and vomiting for nearly one month who was see n at Department of Gastroenterology in Changhai Hospital, found to have acute gastroenteritis and non-atrophic gastritis. The patient was subsequently recovered and discharged soon after medicati on.REVIEW OF SYSTEMShe has had no headache, fever, chills, diarrhea, chest pain, palpitations, dyspnea, cough, hemopty sis, dysuria, hematuria or ankle edema.PAST MEDICAL HISTORYShe has had no previous surgery, accidents or childhood illness.SOCIAL HISTORY: She has no history of excessive alcohol or tobacco use.FAMIL Y HISTORYShe has no family history of cardiovascular, respiratary and gastrointestinal diseases. PHYSICAL EXAMINA TIONTemperature is 37, pulse 80, respirations 16, blood pressure 112/70. General: Plump girl in no app arent distress. HEENT: She has no scalp lesions. Her pupils are equally round and reactive to light and accommodation. Extraocular movements are intact. Sclerae are anicteric. Oropharynx is clear. There is no thyromegaly. There is no cervical or supraclvicular lymphadenopathy. Cardiovascular: Regular rate andrhythm, normal S1, S2. Chest: Clear to auscultation bilateral. Abdomen: Bowel sounds present, no hepatosplenomagaly. Extremities: There is no cyanosis, clubbing or edema. Neurologic: Cranial n erves II-XII are intact. Motor examination is 5/5 in the bilateral upper and lower extremities. Sens ory, cerebellar and gait are normal.LABORATORY DATAWhite blood cells count 5.9, hemoglobin 111g/L, hematocrit 35.4. Sodium 142, potassium 4.3, chl oride 106, CO2 25, BUN 2.6mmol/L, creatinine 57μmol/L, glucose 4.1mmol/L, Albumin 36g/L. Endoscopic ExamChronic non-atrophic gastritisHOSPITAL COURSEThe patient was admitted and placed on fluid rehydration and mineral supplement. The patient im proved, showing gradual resolution of nausea and vomiting. The patient was discharged in stable c ondition.DISCHARGE DIAGNOSIS Acute gastroenteritisChronic non-atrophic gastritisPROGNOSISGood. No medications needed after discharge. But if this patient can not get used to Chinese food, she had better return to UK as soon as possible to prevent the relapse of acute gastroenteritis. The patient is to follow up with Dr. Bai in one week. ___________________________ Yu Bai, MD D: 12/10/2005。
英文病历格式
发一份英文病历格式，希望对大家有用。
CASE HISTORYName……………..Age…………….Sex……………………..Maritalstatus ……………Race …………….Nationality …………………. Occupation …………Residence: ……………………………………………………………………………………………………………………………Chiefcomplaint: ……………………………………………………………………………………………………………………….Presentillness: …………………………………………………………………………………………………………………………Past history:General health up to onset of present illness, immunization, exposure to tuberculosis and other infections.Previous illness: Influenza, scarlet fever, diphtheria, typhoid fever, bronchitis, asthma, pneumonia, pleurisy, tonsillitis, rheumatism or sheumatic fever, cholera, tuberculosis, malaria or any other severe disorders. Operations: Date of each operation, nature, anesthetics used, complications and length of time patient incapacilted.Injuries: Details concerning any severe injuries .Personal history: Birth place, former places of residence, habits.Marital history:Family history:Social history:Physical examination:Temperature………… pulse rate……….respiratory rate …………blood pressure……….height ………… weight …………..General appearance:Appearance …………physicaldevelopment ……………..nutrition………………..status………….posture…………..gait…Tremors or other abnormal movements.Mental status:degree of consciousness…………….cooperation…………….orientation…………emotional state…………………Skincolor…………..texture…………….moisture………..hair-distribution…………character of scalp………………..Face:appearance…………color………..tenderness………………abnormal movements………………Eyes:Brows……….lids………..vision…………….eyeballmotion ………….prominence……………..tension……conjunctivae………sclerae……..corneae………..irises………….pupils……………..size……………shape………….regularity ……………….reactions……………fields………………fundi……………Ears:appearance……hearing…….tenderness………….discharge……….drums ……………canals…………….postauricular swelling or tenderness………………………..Nose:appearance ……..discharge………………nasal cavity …………septum………….transillumination……………..smell…….Mouth:Breath……………lips …………color…………fissure………….lesions…………………Tongue:tremor…..deviation………..color……..moisture……….texture……………..Gingivae:color…………….texture……….recession…………bleeding…………….Lesions:Teeth-number………….condition…………dentures…………….buccal mucus color………….eruptions…….lesions……Throat:palate and uvula ……………….pillars………..tonsils…………poster ior pharynx………larynx…………..Neck:lymphnodes…………….scars………thyroid……….salivaryglands……….position……….motion………veins…..pulsation…edema……..trachea……………..Shoulder girdle:deformity……….swelling………….tenderness………….freedom of movements………….muscle spasm……………….supraclavicular or infraclavicular lymphnodes………………………Arms and Hands:position……..deformities…………color………………….tenderness……………muscle strength………………. abnormal motions……………..joints: edema………… freedom of movements…….temperature…………moisture………..local swellings……….vessels ………….epitrochlear lymphnodes………fingers………….nails …………..reflexes………………..Breasts:size………contour……….tenderness…………….masses……….glandular consistency………nipples…………skin color……………texture……………retraction………..Axillae:skin……….hair……..lymphnodes……….Back:deformities………freedom of movements…….skin ……….swelling…….tenderness…………muscle spasm………..scapulae………..Thorax:shape……..respiratory movements……….swelling….pulsation……………Heart:apex impulse location…………character………..thrill…………..measurements: right border…….left border……….supracardiac dullness………..mid clavicular ilne………souds-rate…..rhythm………..intensity……..quality of murmurs………..pulses………..character……….condition of temporal, brachial, radial vessels……………….Lungs:resonance………..diaphragmatic excursion……………tactile fremitus……….. breath sounds………….whispered voic sounds……..spoken voice sounds……rales………..Abdomen:size………shape…….scars …………tension…….percussion note……………masses tenderness……….spasm………….pulsation……….umbilicus…….fluid wave………..shifting dullness………liver-dulness……….edge……..spleen ………….kidneys………..costovertebral tenderness………herniae ……………peristalsis: audible …..visible……bladder-dulness………..palpable distension……inguinal lymphnodes…..reflexes……Legs and Feet:Position…………deformities……….color……………..tenderness…………muscle strength………….abnormal motions………..freedom of movements….joints ……edema……..temperature…………moisture…………local swellings………ulcerations…………vessels…………arches……….toes..Nails…….reflexes……..clonus………Kerning…….Romberg…….Male Genitalia:Pubic hair………penis………..scrotum………testicles…….epididymis……….cords………………..Female Genitalia:pubic hair…..vulva……..vagina…….perineum……..cervix………..fundus…………..vaults…….Rectum:anal orifice….sphincter tone…..fissures…………hemorrhoids………..tenderness……………internal obstruction …..masses…….prostate…..tenderness….Other abnormal findings:…………Recapitulation of important variants:……….Impression…….Signature………………。
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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.poorDisease history: (if any, please write down the date of onset, brief diagnosticand therapeutic course, and the results.)Respiratory system:1. None2.Repeated pharyngeal pain3.chronic cough4.expectoration:5. Hemoptysis6.asthma7.dyspnea8.chest pain_______________________________________________________________ Circulatory system:1.None2.Palpitation3.exertional dyspnea4..cyanosis5.hemoptysis6.Edema of lower extremities7.chest pain8.syncope9.hypertension _______________________________________________________________ Digestive system:1.None2.Anorexia3.dysphagia4.sour regurgitation5.eructation6.nausea7.Emesis8.melena9.abdominal pain 10.diarrhea11.hematemesis 12.Hematochezia 13.jaundice_______________________________________________________________ Urinary system:1.None2.Lumbar pain3.urinary frequency4.urinary urgency5.dysuria6.oliguria7.polyuria8.retention of urine9.incontinence of urine10.hematuria 11.Pyuria 12.nocturia 13.puffy face_______________________________________________________________ Hematopoietic system:1.None2.Fatigue3.dizziness4.gingival hemorrhage5.epistaxis6.subcutaneous hemorrhage_______________________________________________________________ Metabolic and endocrine system:1.None2.Bulimia3.anorexia4.hot intolerance5.cold intolerance6.hyperhidrosis7.Polydipsia8.amenorrhea9.tremor of hands 10.character change 11.Marked obesity12.marked emaciation 13.hirsutism 14.alopecia15.Hyperpigmentation 16.sexual function change_______________________________________________________________ Neurological system:1.None2.Dizziness3.headache4.paresthesia5.hypomnesis6. Visual disturbance7.Insomnia8.somnolence9.syncope 10.convulsion 11.Disturbance of consciousness12.paralysis 13. vertigo_______________________________________________________________ Reproductive system:1.None2.others_______________________________________________________________ Musculoskeletal system:1.None2.Migrating arthralgia3.arthralgia4.artrcocele5.arthremia6.Dysarthrosis7.myalgia8.muscular atrophy_______________________________________________________________ Infectious Disease:1.None2.Typhoid fever3.Dysentery4.Malaria 4.Schistosomiasis4.Leptospirosis 7.Tuberculosis 8.Epidemic hemorrhagic fever9.others_______________________________________________________________ Vaccine inoculation:1.None2.Yes3.Not clearVaccine detail __________________________________________ Trauma and/or operation history:Operations:1.None2.YesOperation details:_______________________________________ Traumas:1.None2.YesTrauma details:_________________________________________ Blood transfusion history:1.None2.Yes ( 1.Whole blood 2.Plasma3.Ingredient transfusion)Blood type:____________ Transfusion time:___________Transfusion reaction1.None2.YesClinic manifestation:_____________________________ Allergic history:1.None2.Yes3.Not clearallergen:________________________________________________clinical manifestation:_____________________________________Personal history:Custom living address:____________________________________________ Resident history in endemic disease area:_____________________________ Smoking: 1.No 2.YesAverage ___pieces per day; about___yearsGiving-up 1.No 2.Yes (Time:_______________________) Drinking: 1.No 2.YesAverage ___grams per day; about ___yearsGiving-up 1.No 2.Yes(Time:________________________) Drug abuse:1.No 2.YesDrug names:_______________________________________ _______________________________________________________________Marital and obstetrical history:Married age: __________years old Pregnancy ___________timesLabor _______________times(1.Natural labor: _______times 2.Operative labor: ________times3.Natural abortion: ______times4.Artificial abortion: _______times5.Premature labor:__________times6.stillbirth__________times)Health status of the Mate:1.Well2.Not fineDetails: _______________________________________________ Menstrual history:Menarchal age: _______ Duration ______day Interval ____daysLast menstrual period: ____________ Menopausal age: ____years oldAmount of flow: 1.small 2. moderate 3. largeDysmenorrheal: 1. presence 2.absence Menstrual irregularity 1. No 2.Yes Family history: (especially pay attention to the infectious and hereditary diseaserelated to the present illness)Father: 1.healthy 2.ill:________ 3.deceased cause: ___________________ Mother:1.healthy 2.ill:________ 3.deceased cause: ___________________ Others: ________________________________________________________ The anterior statement was agreed by the informant.Signature of informant: Datetime:Physical ExaminationVital signs:Temperature:______0C Blood pressure:_______/_______mmHg Pulse: _____ bpm (1.regular 2.irregular_____________________________) Respiration: ___bpm (1.regular 2.irregular____________________________) General conditions:Development: 1.Normal 2.Hypoplasia 3.HyperplasiaNutrition: 1.good 2.moderate 3.poor 4.cachexiaFacial expression: 1.normal 2.acute 3.chronic other_____________________ Habitus: 1.asthenic type 2.sthenic type 3.ortho-thenic typePosition: 1.active 2.positive pulsive 4.other_______________________ Consciousness: 1.clear 2.somnolence 3.confusion 4.stupor 5.slight coma6.mediate coma7.deep coma8.deliriumCooperation: 1Yes 2.No Gait: 1.normal 2.abnormal______Skin and mucosa:Color: 1.normal 2.pale 3.redness 4.cyanosis 5.jaundice 6.pigmentationSkin eruption:1.No 2.Yes( type: __________distribution:__________________) Subcutaneous bleeding: 1.no 2.yes (type:_______distribution:______________) Edema:1. no 2.yes ( location and degree________________________________) Hair: 1.normal 2.abnormal(details_____________________________________) Temperature and moisture: normal cold warm dry moist dehydration Liver palmar : 1.no 2.yes Spider angioma (location:________________) Others: __________________________________________________________ Lymph nodes: enlargement of superficial lymph node:1.no2.yesDescription: ________________________________________________ Head:Skull size:1.normal 2.abnormal (description:____________________________) Skull shape:1.normal 2.abnormal(description:___________________________) Hair distribution :1.normal 2.abnormal(description:______________________) Others:___________________________________________________________ Eye: exophthalmos:___________eyelid:____________conjunctiva:__________ sclera:________________Cornea:_______________________Pupil: 1.equally round and in size 2.unequal (R______mm L_______mm)Pupil reflex: 1.normal 2.delayed (R___s L___s ) 3.absent (R___L___)others:______________________________________________________ Ear: Auricle 1.normal 2.desformation (description:_______________________) Discharge of external auditory canal:1.no 2.yes (1.left 2.right quality:_____)Mastoid tenderness 1.no 2.yes (1.left 2.right quality:__________________)Disturbance of auditory acuity:1.no 2.yes(1.left 2.right description:_______) Nose: Flaring of alae nasi :1.no 2.yes Stuffy discharge 1.no 2.yes(quality______) Tenderness over paranasal sinuses:1.no 2.yes (location:_______________) Mouth: Lip______________Mucosa_____________Tongue________________ Teeth:1.normal 2. Agomphiasis 3. Eurodontia 4.others:____________________Gum :1.normal 2.abnormal (Description____________________________)Tonsil:___________________________Pharynx:_____________________Sound: 1.normal 2.hoarseness 3.others:_____________________________ Neck:Neck rigidity 1.no 2.yes (______________transvers fingers)Carotid artery: 1.normal pulsation 2.increased pulsation 3.marked distention Trachea location: 1.middle 2.deviation (1.leftward_______2.rightward______) Hepatojugular vein reflux: 1. negative 2.positiveThyroid: 1.normal 2.enlarged _______ 3.bruit (1.no 2.yes ________________) Chest:Chest wall: 1.normal 2.barrel chest 3.prominence or retraction:( left________right_________Precordial prominence__________) Percussion pain over sternum 1.No 2.YesBreast: 1.Normal 2.abnormal _______________________________________ Lung:Inspection: respiratory movement 1.normal 2.abnormal_____________ Palpation: vocal tactile fremitus:1.normal 2.abnormal _______________ pleural rubbing sensation:1.no 2.yes______________________Subcutaneous crepitus sensation:1.no 2.yes________________ Percussion:1. resonance 2. Hyperresonance &location_____________3 Flatness&location_________________________________4. dullness & location:_______________________________5.tympany &location:_______________________________lower border of lung: (detailed percussion in respiratory disease) midclavicular line : R:_____intercostae L:_____intercostaemidaxillary line: R:______intercostae L:_____intercostaescapular line: R:______intercostae L:_____intercostaemovement of lower borders:R:_______cmL:__________cm Auscultation: Breathing sound : 1.normal 2.abnormal _______________Rales:1.no 2.yes__________________________________ Heart: Inspection:Apical pulsation: 1.normal 2.unseen 3.increase 4.diffuseSubxiphoid pulsation: 1.no 2.yesLocation of apex beat: 1.normal 2.shift (______ intercosta,distance away from left MCL______cm) Palpation:Apical pulsation:1. normal 2.lifting apex impulse 3.negative pulsationThrill:1.no 2.yes(location:___________ phase:_________________)Percussion: relative dullness border: 1.normal 2.abnormalAuscultation: Heart rate:___bpm Rhythm:1.regular 2.irregular_______ Heart sound: 1.normal 2.abnormal________________________Extra sound: 1.no 2.S3 3.S4 4. opening snapP2_________ A2_________Pericardial friction sound:1.no 2.yesMurmur: 1.no 2.yes (location____________phase_____________quality______intensity________ transmission___________effects of position_________________________________effects of respiration______________________________ Peripheral vascular signs:1.None2.paradoxical pulse3.pulsus alternans4. Water hammer pulse5.capillary pulsation6.pulse deficit7.Pistol shot sound8.Duroziez signAbdomen:Inspection: Shape: 1.normal 2.protuberance 3.scaphoid 4.frog-bellyGastric pattern 1.no 2.yes Intestinal pattern 1.no 2.yesAbdominal vein varicosis 1.no 2.yes(direction:______________ )Operation scar1.no 2.yes ________________________________ Palpation: 1.soft 2. tensive (location:____________________________)Tenderness: 1.no 2.yes(location:_______________________)Rebound tenderness:1.no 2.yes(location:________________)Fluctuation: 1.present 2.abscentSuccussion splash: 1.negative 2.positiveLiver:_______________________________________________Gallbladder: __________________Murphy sign:____________Spleen:______________________________________________Kidneys:____________________________________________Abdominal mass:______________________________________Others:______________________________________________ Percussion: Liver dullness border: 1.normal 2.decreased 3.absentUpper hepatic border:Right Midclavicular Line ________IntercostaShift dullness:1.negative 2.positive Ascites:_____________degreePain on percussion in costovertebral area: 1.negative 2.positve ____ Auscultation: Bowel sounds : 1.normal 2.hyperperistalsis 3.hypoperistalsis4.absence Gurgling sound:1.no 2.yesVascular bruit 1.no 2.yes (location_____________________) Genital organ: 1.unexamined 2.normal 3.abnormalAnus and rectum: 1.unexamined 2.normal 3.abnormalSpine and extremities:Spine: 1.normal 2.deformity (1.kyphosis 2.lordosis 3.scoliosis)3.Tenderness(location______________________________)Extremities:1.normal 2.arthremia & arthrocele (location_________________)3.Ankylosis (location__________)4.Aropachy: 1.no 2.yes5.Muscular atrophy (location_______________________) Neurological system:1.normal 2.abnormal_______________________________ _____________________________________________________________________ Important examination results before hospitalized___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ Summary of the history:______________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ Initial diagnosis:_____________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________Recorder:Corrector:。