医学英语口语：英文病历

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医学英语阅读：英文病历

医学英语阅读：英文病历a sample of complete historypatient's name： mary swanchart number： 660518date of birth：10-5-1993sex： femaledate of admission： 10-12-2000date of discharge： 10-15-2000final discharge summarychief complaint：coughing, wheezing with difficult respirations.present illness：this is the first john hopkins hospital admission for this seven-year-old female with a history of asthma since the age of 3 who had never been hospitalized for asthma before and had been perfectly well until three days prior to admission when the patient development shortness of breath and was unresponsive to tedral or cough medicine.the wheezing progressed and the child was taken to john hopkins hospital emergency room where the child was given epinephrine and oxygen. she was sent home. the patient was brought back to the er three hours later was admitted.past history：the child was a product of an 8.5-month gestation. the mother had toxemia of pregnancy. immunizations： all. feeding：good. allergies： chocolate, dog hair, tomatoes.family history：the mother is 37, alive and well. the father is 45,alive and well. two sibs, one brother and one sister, alive and well. the family was not positive for asthma, diabetes, etc.review of systems：negative except for occasional conjunctivitis and asthma.physical examination on admission：the physical examination revealed a well-developed and well-nourished female, age 7, with a pulse of 96, respiratory rate of 42 and t emperature of 101.0℉. she was in a mist tent at the time of examination.funduscopic examination revealed normal fundi with flat discs. nose and throat were somewhat injected, particularlythe posterior pharynx. the carotids were palpable and equal. ears were clear. thyroid not palpable. the examination of the chest revealed bilateral inspiratory and expiratory wheezes. breath sounds were decreased in the left anterior lung field. the heart was normal. abdomen was soft and symmetrical, no palpable liver, kidney, or spleen. the bowel sounds were normal. pelvic： normal female child. rectal deferred. extremities negative.impression：bronchial asthma, and pharyngitis.laboratory data：the white count on admission was 13,600 with hgb of 13.0. differential revealed 64 segs and 35 lymphs with 3 eos. adequate platelets. sputum culture and sensitivity revealed alpha hemolytic streptococcus sensitive to penicillin. chestx-ray on admission showed hyperaeration and prominent bronchovascular markings. the child was started on procaine penicillin 600,000 unites im q.d in accordance with theculture and sensitivity of the sputum.hospital course：。

医学英语病历范文

医学英语病历范文Medical RecordPatient Information:Name: John SmithAge: 45Gender: MaleDate of admission: [Date]Date of birth: [Date]Weight: [Weight]Height: [Height]Chief complaint:Mr. Smith presents with a severe headache that has been ongoing for the past two days.History of present illness:The patient reports experiencing a sudden onset of throbbing headache, localized primarily on the left side of his head. The pain is aggravated by physical exertion and is accompanied by nausea and sensitivity to light and sound. The patient denies any recent head trauma or sinus congestion. Over-the-counter pain relievers have provided minimal relief.Medical history:Mr. Smith has a history of hypertension, for which he takes medication. He does not have any known allergies, and there is no family history of migraines or neurological disorders.Social history:The patient is a smoker, consuming approximately 10 cigarettes per day. He drinks alcohol in moderation, primarily on social occasions. He denies any illicit drug use. His occupation involves long hours of computer work.Physical examination:On examination, the patient appears to be in mild distress due to the headache. His vital signs are within normal limits. Neurological examination reveals no focal deficits, and his cranial nerves appear to be intact. There is no evidence of meningeal irritation. His neck is supple, and there is no nuchal rigidity. The remainder of the physical examination is unremarkable. Laboratory tests:Blood tests, including a complete blood count and comprehensive metabolic panel, were performed. All results were within normal limits.Imaging studies:A brain MRI was ordered to rule out any structural abnormalities. The scan revealed no evidence of intracranial hemorrhage, mass, or other abnormalities.Assessment and plan:Mr. Smith is presenting with a severe headache consistent with a migraine without aura. He will be prescribed a triptan medication for acute management of his headache. He will also be counseled on lifestyle modifications, including smoking cessation and stress reduction techniques. A follow-up appointment will be scheduled in two weeks to evaluate the effectiveness of the treatment plan.Additionally, the patient is advised to seek immediate medical attention if his symptoms worsen or if he develops any new neurological symptoms.Signature: [Physician's Name]Date: [Date]。

soap英文病历

soap英文病历Patient Name: James SmithAge: 45Gender: MaleNationality: AmericanChief Complaint:The patient presents with a persistent rash on his arms and legs, accompanied by itching. He states that the rash appeared suddenly and has been present for the past two weeks. The patient is seeking medical attention to determine the cause and appropriate treatment for his condition.Medical History:The patient has a history of allergies, specifically to dust mites and pollen. He has not experienced any previous skin conditions or rashes. The patient is not currently taking any medications and has no known drug allergies.Present Illness:The patient reports that the rash initially started as small, red bumps on his arms and legs. Over time, the bumps have increased in size and have become itchy. He denies any associated symptoms, such as fever, fatigue, or joint pain. The patient has used over-the-counter hydrocortisone cream for itch relief, but it has provided only temporary relief.Physical Examination:On examination, the patient has multiple erythematous patches with raised edges on his arms and legs. The affected areas appear dry and slightly scaly. There are no signs of oozing or crusting. The rash is symmetrical and does not extend to the trunk or face. There is no lymphadenopathy or other abnormal findings on examination.Differential Diagnosis:1. Contact dermatitis: Contact with an irritant or allergen may cause a localized rash with itching and erythema.2. Atopic dermatitis: Chronic inflammatory skin condition characterized by itching, redness, and dryness of the skin.3. Psoriasis: Autoimmune disorder causing thick, scaly patches on the skin.4. Scabies: Infestation of the skin by microscopic mites causing intense itching and a characteristic rash.Investigations:1. Skin scraping and microscopic examination: To rule out scabies infestation.2. Allergy testing: To determine if the rash is related to an allergic reaction.Treatment Plan:1. Topical steroid cream: Prescribe a stronger topical steroid cream to reduce inflammation and relieve itching. Instruct the patient to apply a thin layer to the affected areas twice daily for two weeks.2. Moisturizers: Recommend using non-fragrance, hypoallergenic moisturizers to keep the skin hydrated and prevent dryness.3. Avoid triggers: Advise the patient to avoid known allergens or irritants that may exacerbate the rash.4. Follow-up: Schedule a follow-up appointment in two weeks to evaluate the effectiveness of the treatment and make any necessary adjustments.Patient Education:1. Review proper application of the topical steroid cream and discuss potential side effects, such as skin thinning and discoloration.2. Emphasize the importance of avoiding scratching to prevent infection and further skin damage.3. Discuss the potential triggers for allergic reactions and provide recommendations for allergen avoidance, such as using fragrance-free products and washing clothes with mild detergents.Prognosis:With appropriate treatment and adherence to the prescribed regimen, the prognosis for this patient is good. The symptoms should improve within two weeks with resolution of the rash and relief from itching. However, it is important to monitor the patient for any signs of exacerbation or recurrence.。

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.。

医学英语-英文病例-范文

医学英语-英文病例-范文Case HistoryName: Meretrix Gender: FemaleAge: 40 Occupation: NurseBirth Place: Washington DC Marital Status: MarriedAddress: #112, Main Avenue, Washington DCReliability: Reliable Supplier: Patient herselfDate of Admission: 10am, Aug. 6th, 2006Date of Record: Aug. 6th, 2006C.C.:Palpitation and breathlessness after exertion for 7 years; edema of lower extremities for 4 daysH.P.I.:The patient got palpitation and breathlessness after overexertion and going upstairs alleviating after having a rest 7 years ago. Then she saw her doctor, and the roentgenography showed an enlargement of the heart; but it was so negligible that she was not treated. She came to Washington 5 years ago because of frequent bad colds due to bad weather conditions with strong cough which didn’t ameliorate with the disappearance of the palpitation and breathlessness but with orthopnea at night. She was once hospitalized with an injection of penicillin and glucose and had a rest of 2 weeks, thus propelling the symptoms. She complains of a flatulence without edema of lower extremities in the recent 2 years. One month ago, she was admitted to our hospital with sore throat, cough, hemoptysis, palpitation, breathlessness, and orthopnea due to a bad cold resulting from exhaustion. Antitussive and penicillin have been employed but it was in vain. Edema of lowerextremities came into being in the recent 3 days or so; urine is little with a dark color; feces are not amorphous with once a day; dyspepsia and nausea are overt. Digitalis has not been used and good in mental status with infrequent insomnia.P.H.:The patient has been and is weak with frequent sore throat since her childhood. Shegot malaria 11 years ago with a medication of quinine and thus symptoms disappeared a week after with a recurrence and a similar treatment resulting in good outcome; no migrant rash was found. No histories of allergy to drug or food, of trauma or surgery, of blood transfusion. And we are not informed of a history of inoculation.Pers. H.:The patient was a Shanghaier and came to Washington DC 5 years ago. No visiting history to other places. She was an undergraduate. The patient is a housewife with a gasto of reading. She is quiet and not addicted to smoke or wine. SheF.H.:She married at the age of 24 and her husband is 39 now. Parents, a girl aged 10, and a boy aged 6 are all living and well.Mens. H.:614——4028P.E.:T. 38.0℃. P. 70. R. 30. B.P. 100/70mmHg.The patient stayed in bed in semi-reclining position. She looked actually ill, but remained conscious, and was well oriented to time, place, and person.Skin and Lymph Node: N.A.D. (No abnormality detected.)Head: There was flaring of the nares, but otherwise normal.Neck: Negative.Chest: Excursion decreased on the right side of the chest. Trachea in the midline. Heart: Disseminated rales in the fundi of the two lungs, especially the right lung. Lungs: Slightly increased fremitus, dull percussion note, diminished breath sound, and fine moist inspiratory rales were present on the right bases. The rest of the chest showed nothing special.Abdomen: Soft. Liver felt 1.5 cm below L.C.M. (lower costal margin) on the mid-clavicular line. Spleen not felt. Murphy’s sign weakly positive, withno palpable gall-bladder. No tenderness or mass elsewhere.Spine, Extremities, Rectum and External Genitalia: Nothing remarkable. Neurological Reflexes: Physiological reflexes normal. No pathological reflexes elicited. O.P.D. Lab. Findings (Out-Patient Department Laboratory Findings):Blood:W.B.C. 14,000/cmmD.B.C. P.M.N.82%, Lymph. 16%, M.1%R.B.C. 3,900,000/cmmHgb. 11 gmFeces:Dark yellow, slightly cloudy, acidic.Density 1.019Protein (+)Glucose (-)W.B.C. 5/HPMajor Diagnostic Evidence:1.History of streptococcal infection and a weak body.2.Symptoms and signs of heart failure and pulmonary edema.3.W.B.C. of 14,000 with 82% polys.Impression:1. Rheumatic valvular disease.Mitral stenosis complicated with mitral regurgitationAtrial fibrillationGrade III heart failure2. Acute onset of a chronic tonsillitis.Date: Aug. 6th, 2006Attending Physician____________。

常用医学英语口语对话

常用医学英语口语对话文章摘要：本文介绍了一些常用的医学英语口语对话，包括医生和病人之间的问诊、诊断、治疗、检查、转诊等场景。

本文旨在帮助医学英语学习者掌握一些基本的医学英语表达，提高与外国病人沟通的能力。

本文采用了表格的形式，列出了中文和英文的对话内容，方便读者对比和记忆。

一、问诊中文英文你怎么了？What's the matter with you?你哪里不舒服？Where do you feel uncomfortable?你有什么症状？What symptoms do you have?你多久有这种感觉了？How long have you had this feeling?你的病情有没有变化？Has your condition changed?你以前有过类似的情况吗？Have you had anything like this before?你有什么过敏吗？Are you allergic to anything?你有什么家族史吗？Do you have any family history?你有什么不良习惯吗？Do you have any bad habits?你最近有没有去过其他地方？Have you been to any other places recently?二、诊断中文英文我要给你量一下血压。

I'm going to take your blood pressure.我要给你听一下心跳。

I'm going to listen to your heart.我要给你看一下喉咙。

I'm going to look at your throat.我要给你量一下体温。

I'm going to take your temperature.我要给你做一下体格检查。

I'm going to give you a physical examination.我要给你开一张化验单。

医学英语病历写作范文

医学英语病历写作范文Chief Complaint: Left leg pain with recent fall.History of Present Illness: The patient is a 65-year-old male who presents to the emergency department with a chief complaint of left leg pain. He states that he fell down a flight of stairs approximately 3 hours prior to presentation. He reports that he is in moderate to severe pain, which is localized to his left lower extremity. He denies any associated numbness or tingling. He has no prior history of leg pain or injury.Past Medical History: The patient has a history of hypertension, which is well-controlled with medication. He has no other significant medical history.Social History: The patient is married and has two children. He is a retired construction worker. He smokes one pack of cigarettes per day and drinks alcohol socially.Family History: The patient's father has a history of coronary artery disease. His mother has a history of Alzheimer's disease.Physical Examination:Vital signs: Blood pressure 140/80 mmHg, heart rate 80 bpm, respiratory rate 18 breaths per minute, temperature 98.6°F (37°C).General: The patient is in moderate distress due to pain. He is alert and oriented to person, place, and time.HEENT: Normocephalic and atraumatic. Pupils are equal and reactive to light. Extraocular movements are intact. No conjunctival injection or discharge. Tympanic membranes are intact and mobile.Neck: Supple with full range of motion. No masses or tenderness.Chest: Auscultation reveals clear breath soundsbilaterally. No wheezes, rales, or rhonchi.Cardiovascular: Regular rate and rhythm. No murmurs, rubs, or gallops.Abdomen: Soft and non-tender. No masses or organomegaly.Extremities: Left lower extremity: Examination reveals swelling and tenderness of the left knee. There is a palpable step-off deformity of the lateral aspect of theleft knee. Active and passive range of motion is limiteddue to pain. Distal pulses are palpable and capillaryrefill is brisk. Sensation is intact. Right lower extremity: Examination reveals no abnormalities.Neurological Examination:Mental status: Alert and oriented to person, place,and time. No deficits in attention, memory, or language.Cranial nerves: No deficits.Motor: Strength is 5/5 in both upper and lower extremities. No atrophy or fasciculations.Sensory: Sensation is intact to light touch, pinprick, and temperature in all four extremities.Diagnostic Studies:X-ray of the left knee: The X-ray shows a displaced lateral tibial plateau fracture.Assessment:Left knee pain.Displaced lateral tibial plateau fracture.Plan:The patient will be admitted to the hospital for further evaluation and treatment.He will be placed in a knee immobilizer and will be started on pain medication.Orthopedic surgery will be consulted for further management.。

医学英语病历写作范文

医学英语病历写作范文Chief Complaint: Patient presents with chest pain and shortness of breath for 3 days.History of Present Illness: The patient, a 55-year-old male, reports experiencing sudden onset of chest pain 3 days ago. The pain is described as sharp and crushing, radiating to the left arm. He also reports associated shortness of breath and diaphoresis. The symptoms are aggravated with physical activity and alleviated with rest. There is no history of similar episodes in the past.Past Medical History: The patient has a history of hypertension and hyperlipidemia. He is on regular medications including amlodipine and atorvastatin.Family History: The patient's father had a history of myocardial infarction at the age of 60. His mother has hypertension and diabetes.Social History: The patient is a non-smoker and denies alcohol or recreational drug use. He is currently employed as a manager and reports moderate stress at work.Review of Systems: The patient denies any recent weight changes, fever, or chills. There is no history of cough, sputum production, or hemoptysis. He denies any gastrointestinal symptoms such as nausea, vomiting, or abdominal pain.Physical Examination:- Vital signs: Blood pressure 140/90 mmHg, heart rate 90 bpm, respiratory rate 20 breaths per minute, oxygen saturation 96% on room air.- General: The patient appears uncomfortable and diaphoretic.- Cardiovascular: Regular rhythm, no murmurs, rubs, or gallops. Capillary refill time is less than 2 seconds.- Respiratory: Clear breath sounds bilaterally, no wheezing or crackles.Assessment and Plan:1. Rule out acute coronary syndrome: The patient's presentation is concerning for acute coronary syndrome given the symptoms of chest pain, shortness of breath, anddiaphoresis. ECG and cardiac enzymes will be obtained to evaluate for myocardial ischemia.2. Blood pressure management: The patient's blood pressure is elevated, and optimization of antihypertensive medications will be addressed.3. Lipid management: Given the patient's history of hyperlipidemia, lipid panel will be obtained to assess for dyslipidemia and adjust medications as needed.4. Stress management: The patient's moderate stress at work will be addressed through counseling and potential referral to a stress management program.中文病历：主诉：患者因胸痛和呼吸急促已3天。

医学英语病历书写范文

医学英语病历书写范文Here's a sample of a medical English patient chart entry, written in an informal yet professional manner, adhering to the given requirements:The patient presented with complaints of persistent headache and occasional dizziness. He mentioned that the pain was localized to the left side of his forehead and tended to worsen with stress.On physical examination, I noticed a slight elevation in blood pressure, but other vital signs were within normal limits. The patient's neurological reflexes were intact.The patient mentioned a history of high blood pressure and was on regular medication for the same. However, he admitted to missing a few doses recently.We discussed possible causes of his headache, including stress, lack of sleep, and diet. I recommended lifestylemodifications and a follow-up visit if symptoms persisted.The patient expressed concern about the possibility of a more serious underlying condition. I assured him that while we need to be vigilant, his current symptoms are more likely to be related to lifestyle factors.I prescribed a mild pain reliever and advised him to monitor his blood pressure regularly. The patient seemed relieved after the consultation and thanked me for my time.Overall, the patient's condition seems manageable with lifestyle changes and regular monitoring. I'll recommend further testing if symptoms worsen or persist.。

医学英语口语：英文病历

医学英语口语：英文病历a sample of complete historypatient's name ：mary swanchart number ：660518date of birth ：10-5-1993sex ：femaledate of admission ：10-12-2000date of discharge ：10-15-2000final discharge summarychief complaint ：coughing, wheezing with difficult respirations.present illness ：this is the first john hopkins hospital admission for this seven-year-old female with a history of asthma since the age of 3 who had never been hospitalized for asthma before and had been perfectly well until three days prior to admission when the patient development shortness of breath and was unresponsive to tedral or cough medicine.the wheezing progressed and the child was taken to john hopkins hospital emergency room where the child was given epinephrine and oxygen. she was sent home. the patient was brought back to the er three hours later was admitted. history ：pastthe child was a product of an 8.5-month gestation. the mother had toxemia of pregnancy. immunizations ：all. feeding good. allergies ：chocolate, dog hair, tomatoes.family history ：the mother is 37, alive and well. the father is 45, alive and well. two sibs, one brother and one sister, alive and well. the family was not positive for asthma, diabetes, etc.review of systems ：negative except for occasional conjunctivitis and asthma.physical examination on admission ：the physical examination revealed a well-developed and well-nourished female, age 7, with a pulse of 96, respiratory rate of 42 and temperature of 101.0 T . she was in a mist tent at the time of examination.funduscopic examination revealed normal fundi with flat discs. nose and throat were somewhat injected, particularly the posterior pharynx. the carotids were palpable and equal. ears were clear. thyroid not palpable. the examination of the chest revealed bilateral inspiratory and expiratory wheezes. breath sounds were decreased in the left anterior lung field. the heart was normal. abdomen was soft and symmetrical, no palpable liver, kidney, or spleen. the bowel sounds were normal. pelvic ：normal female child. rectal deferred. extremities negative.impression ：bronchial asthma, and pharyngitis.laboratory data ：the white count on admission was 13,600 with hgb of 13.0. differential revealed 64 segs and 35 lymphs with 3 eos. adequate platelets. sputum culture and sensitivity revealed alpha hemolytic streptococcus sensitive to penicillin. chest x-ray on admission showed hyperaeration and prominent bronchovascular markings. the child was started on procaine penicillin 600,000 unites im q.d in accordance with the culture and sensitivity of the sputum.hospital course ：the child was given penicillin im as stated above. ten drops of isuprel were added to the respirator every 2 hours. the patient improved steadily. she took her diet well. she was discharged on 10-15-2000 in good condition.operation procedure ：nonecondition on discharge ：improveddiagnosis ：asthma. pharyngitis. possible right upper lobs pneumonia.new words and expressionswheeze vi & n. 喘息（声）asthma n. 哮喘、气喘病epinephrine n 肾上腺素gestation n 妊娠toxemia n 毒血症。

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.。

医患英语对话第1期-询问病史

医患英语对话第1期-询问病史医患英语对话第1期:询问病史I’d like to ask you about your past medical history.我想询问一下你的病史。

Can you tell me whether you have had any childhood diseases,你能告诉我你小时候得过什么病吗，for example chickenpox, measles, mumps or rubella?比如水痘，麻疹，流行性腮腺炎或者风疹,When I was small, I had measles, chickenpox and whooping cough, butI don’t think I ever had rubella.小时候得过麻疹，水痘和百日咳，但是不记得得过风疹。

Have you ever been hospitalized for anything, or have you ever had anoperation?因为生什么病住过院吗,或者说做过手术吗,Well, I had my tonsils taken out when I was a child.嗯，小时候做过扁桃体切除。

Have you had any major health problems since then?从那以后有过什么大的健康问题吗,Yes, I have diabetes.是的，我有糖尿病。

When were you first diagnosed with diabetes?第一次诊断出糖尿病是什么时候,What were your symptoms?有什么症状,I was diagnosed when I turned 14. I was always thirsty, tired and depressed.我14岁的时候被诊断出糖尿病，总是感到口渴，疲劳，情绪低落。

常用医学英语口语对话

常用医学英语口语对话1. Patient Registration (患者登记)- English: "What seems to be the problem today?"- 中文: "今天您感觉哪里不舒服？"2. Taking Medical History (询问病史)- English: "Have you been experiencing any pain?"- 中文: "您有没有感到疼痛？"3. Physical Examination (体格检查)- English: "Please take a deep breath and exhale slowly."- 中文: "请深呼吸，然后慢慢呼气。

"4. Prescribing Medication (开药)- English: "I'm going to prescribe you some medication for your infection."- 中文: "我将为您开一些治疗感染的药物。

"5. Explaining Procedures (解释程序)- English: "You will need to fast for at least 8 hours before the test."- 中文: "在做这个检查之前，您需要空腹至少8小时。

"6. Giving Instructions (给予指导)- English: "Take two tablets with water after meals, three times a day."- 中文: "饭后用水服用两片药，一天三次。

医学英语口语：收集病人的症状和病史

医学英语口语：收集病人的症状和病史Taking the patient's symptoms and history1. Have you been short of breath?你有过喘息吗？2. The pain is getting worse and worse.疼痛越来越严重3. In that part of her belly is the pain?她腹部的什么位置痛？4. Is she rimming a temperature?她发烧吗？5. Has she a cough?她咳嗽吗？6. Do you bring up any phlegm?你有痰吗？7. Does your phlegm have any blood?你痰里有血吗？8. When did you first notice blood in your phlegm?你什么时候开始发现你的痰里有血的？9. Does it hurt to pass urine?小便时痛吗？10. Is there any radiation of the pain to the back?这里的痛扩散到背部吗？11. Have you taken any medicine for the pain?你服过什么药来止痛吗？12. About how many time a day has she vomited?她一天大约呕吐几次？13. Has she been moving her bowels regularly?她的大便正常吗？14. When did the diarrhea start?腹泻是什么时候开始的？15. Do you eyelids swell?你的眼睑肿吗？16. Is this first time you have ever experienced this?这是你第一次碰到这种情况吗？17. Did you have any diseases?你以前生过什么病吗？18. Have you ever had trouble with you stomach?你的胃有过毛病吗？19. Have you been with anyone who has a cold?你与感冒的人接触过吗？20. Does any in your family suffer from hypertension?你家里有人患高血压吗？21. Have you been to a doctor recently?你最近看过医生吗？22. Have you had any operations in the past?你过去做过手术吗？23. Are you allergic to anything?你对什么过敏吗？24. When was your last period?你最近一次例假是在什么时候？25. Have you been drinking at all?你是不是一直嗜酒26. Do you smoke?你抽烟吗？27. Have you lost any weight recently?你近来体重减轻了吗？28. Have you had your heart tested this year?你今年检查过心脏吗？29. Have you ever had diabetes?你患过糖尿病吗30. Did you have the history of dyspnea?你有过呼吸困难的病史吗？。

医学英语现病史

医学英语：现病史医学英语：现病史[History of present illness (HPI/PI)▲尿痛[micturition pain]▲少尿〔无尿、多尿〕[oliguria (anuria, polyuria)]▲大便失禁[fecal incontinence]▲小便失禁[incontinence of urine]▲精神不振[lassitude]▲精神紧张〔抑郁〕[mental stress (depression)]▲精神混乱[confusion]▲精神失常[amentia (mental state is bad)]▲精神状态正常[orthophrenia (mental state is good)]▲体力旺盛〔缺乏，正常〕[hypersthenia (hyposthenia, euthesia)] ,现病史书写的重点包括：一、主诉中病症的详细描述；二、疾病的开展过程；三、诊疗经过；四、目前的一般情况。

1、诱因·无诱因下[With no inducing factors]·无明显诱因下[Under no obvious predisposing causes]·感冒一周后[After getting (catching) common cold for 1 week] 2、病症出现的表达·有……病症▲suffer from▲have an attack of▲have(fell)▲begin to fell▲a feeling (sensation) of……▲complain (of)▲……sensation (feeling) in (of) ……▲[发热]have a temperature (become feverish)·在……情况下发生▲活动时呼吸困难[dyspnea on exertion]▲躺下后即出现咳嗽[Cough occurs soon after lying]·与……有〔无〕关▲与……有关[be associated with]▲与……有关[have (make) relation to]▲与……无关[have (make)no relation to]·在……情况下加重〔减轻〕▲餐后加重[become worse after taking meals]▲站立后缓解[be relieved by standing up]▲随呼吸和咳嗽而加重[become more severe with breathing and cough]·伴有……▲be accompanied by3、起病方式·急性腹痛[acute abdominal pain]·慢性低热[chronic lower fever]·爆发性发病[the onset was fulminating]·骤起胸痛[an explosive onset of chest pain]·突然起病伴高热[the onset was sudden with high fever]·突发突止[attacks began and ended abruptly]·因……而突然起病[the attack is precipitated by……]·很快发生晕厥[syncope occured rapidly]·逐渐出现咳嗽咳痰[gradual onset of cough and sputum]·偶而[occasionally (sporadically, accidentally)]·反复胸闷心悸[recurrent (bouts of) chest discomfort and palpitation]·一过性发作[transitory attack]·连续胸痛[chest pain continually]·时重时轻[waned and waxed]·时好时坏[hang in the balance]·不停地咳嗽[have a fit of cough]·发作性呼吸困难[paroxysmal short of breath]·频繁咳嗽[cough frequently (very often)]·持续性〔间歇性〕[persistent (intermittent)]·频发胸痛[frequent episodes of chest pain]·持续不变[be steady]4、病情变化描述·[病症好转] ▲fell better than before▲take a favorable turn▲take a turn for the better▲improve▲make favorable progress ▲turn for the better▲change for the better▲be better·[病症减轻] ▲alleviate ▲reduce▲palliate▲diminish▲ease(lighten)▲mitigate·[病症消失] ▲disappear ▲subside▲regress▲clear up▲vanish▲dissolve▲die (fade) away▲relieve·[病症加重] ▲be (make,become,get) worse ▲worsen▲become more severe▲take a turn for the worse▲be aggravated▲increase in severity▲take a bad turn▲make (become) more serious▲make (become) heavier·[无变化] ▲remain the same as……▲continue without change▲be identical▲be alike▲be similar▲resemble·[时好时坏] ▲wane and wax▲hang in the balance·[体温/血压升降]▲升至[rise (go up) to ]▲已升至[have risen (gone up) to ]▲从……升至……[go up from ……to……]▲升至[be elevated to]▲迅速下降[fall (decline, abate) abruptly]▲骤降〔升〕[sudden drop (elevation)]▲渐降〔升〕[fall (elevate) gradually]▲缓慢下降[slow crisis (lysis) of ]▲一天天下降[be (become) lower day by day]▲开始降低[begin to remit]▲降至正常[drop (was reduced) to normal]▲已降至[have gone down (dropped) to]▲回复到正常[return (revert) to normal]▲由……降〔升〕至……[fall (elevate) from……to……]▲维持在……水平[maintain at a level of……]▲稳定在……[stabilize at……]▲热退了[fever disappeared]▲不超过[do not go up over (exceed)……]▲在……和……之间波动[fluctuate (vary) between……and……]▲在……至……范围内[range from……to……]▲平均38.5℃[an average temperature of 38.5℃]▲有39.2℃的体温[have fever (a temperature) of 39.2℃] 5、病症的时间表示·持续▲lasted for 2 days▲have gone on for 1 month▲have continued for 10 hours ▲lasted on the average 3-5 hours▲lasted a variable time from 5 minutes to several hours。

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。