全英文病例报告表模板
大病历模板(英文)
Union Hospital affiliated to Huazhong University of Science and Technology
Admission Record 0000337023 Department: Respiratory Medicine Area: J17 Respiratory Medicine Bed No. 109031 Case No. 1565825
Name: Hou Deguang Gender: Male Date of Birth: 15/9/ 1936 Age: 78 Nationality: China
ID No. Ethnicity: Han Occupation: other Marital status: Married
Address: Nanchong，Sichuan Tel No.
Source of History: Patient herself Reliability: Reliable
Admission Date & Time: 4/11/2014 14:36
Chief Complaint: Found pleural effusion for about 2 months.
Present Illness: The patient received the chest CT scan in the Wuhan Traditional Medicine Hospital two months ago and found right-side pleural effusion, right-side pulmonary atelectasis. After that,
英文病历书写范例
英文病历书写范例（内科）
Medical Records for Admisson
Medical Number: 701721
General information
Name: Liu Side
Age: Eighty
Sex: Male
Race: Han
Nationality: China
Address: NO.35, Dandong Road, Jiefang Rvenue, Hankou, Hubei.
Tel: 857307523
Occupation: Retired
Marital status: Married
Date of admission: Aug 6th, 2001
Date of record: 11Am, Aug 6th, 2001
Complainer of history:patient’s son and wife
Reliability: Reliable
Chief complaint: Upper bellyache ten days, haematemesis, hemafecia and unconsciousness for fo ur hours.
Present illness:
The patient felt upper bellyache about ten days ago. He didn’t pay attention to it and thought heha date something wrong. At 6 o’cloc k this morning he fainted and rejected lots of blood and gore. T hen hemafecia began. His family sent him to our hospital and received emergent treatment. So the patient was accepted because of “upper gastrointestine hemorrhage and exsanguine shock”. Since the disease coming on, the patient didn’t urinate. Past history
英文病历标准模版
Complete History
Name:Si Ruihua Department:Lumber electric power bureau Sex: female Present address: electric power bureau Age:80 years Date of admission:2003-5-17
Nationality: China xinjiang Date of record:2003-5-17
Marital status: be married Reliability:reliable
Occupation: family numbers History of allergy:deny
Chief complaints: Palpitation and breathlessnss for 1 hour
Present illness: The patient complained of palpitation with no precipitating factors an hour ago , at the same time she still feel breahlessness and precardial pain which didn’t radiated to other parts of body. This discomfort can’t be relieved by take a rest.As couldn’t suffer from that she had to came to hospital for help. In the course of the illness, he had no syncope, no cough, no headache, no diarrhea and vomiting. Her appetite, sleep, voiding and stool were normal.
英文完全病历模板-详细版
Admission Record
Name：* Nativity: * district, * city
Sex:male Race: Han
Age:55 Date of admission:2020-09-07 14:30 Marital status: be married Date of record:2020-09-07 15:23 Occupation:teacher Complainer:patient himself Medical record Number: * Reliability: reliable
Present address: NO*, building*, * village,* district, *city, *province
Chief complaint: cough and sputum for more than 6 years, worsening for 2 weeks
History of present illness: The patient complained of having paroxysmal cough and sputum 6 years ago. At that time, he was diagnosed as “COPD” in another hospital and no regular treatment was applied. Cough and sputum worsened and were accompanied by tachypnea 2 weeks ago with no inducing factors. Small amounts of white and mucous sputum were hard to cough up. Compared to daytime, tachypnea worsened in the night or when sputum can’t be cough up. The patient can’t lie flat at the night because of prominent tachypnea and prefer a high pillow. He had no fever, no chest pain, no dizziness, no diarrhea, no abdominal pain, no obvious decrease of activity tolerance. On 20*-0*-*, the patient went to *Hospital for medical consultation. CT lung imaging indicated: lesion accompanied by calcification in the superior segment, the inferior lobe of the right lung, the possibility of obsolete tuberculosis; emphysema, bullae formation and sporadic inflammation of bilateral lung; calcified lesion in the inferior lobe of the left lung; arteriosclerosis of coronary artery.
英语 病例 模板
CASE
Medical Number: 682786 General information
Name:Wang Runzhen Age: Forty three
Sex: Female
Race:Han Occupation: Teacher Nationality:China Marital status: Married Address: , Hangkong Road, Jiefang Rvenue, Hankou, Hubei. Tel: Date of admission:Jan 11st, 2001
Date of record: 11Am, Jan 11st, 2001 Complainer of history: the patient herself Reliability: Reliable
Chief complaint: Right breast mass found for more than half a month.
Present illness: Half a month ago, the patient suddenly felt pain in her right chest when she put up her hand. After touching it, she found a mass in her right breast, but no tendness, and the patient didn’t pay attention it. Then the pain became more and more serious, so the patient went to tumour hospital and received a pathology centesis. Her
英文病历标准模版
英文病历标准模版Patient Profile
Name: Si Ruihua
Department: ___ Power ___
Sex: Female
Present Address: Electric Power Bureau Age: 80 years
Date of n: May 17.2003
nality: Chinese Xinjiang
Date of Record: May 17.2003
Marital Status: Married
Reliability: Reliable
n: Family ___
History of Allergy: None reported
Chief 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
DM-英文病例模板
Type 2 diabetes
In Oct, 1997, He was diagnosed as type 2 diabetes in Beijing. Healthy eating, exercise can help to control the blood glucose level. From 1998, he began to take DIAMICRON for one year. He had body check in Guangzhou, china. The lab results were: FBG 6.7 mg, PBG 15.4 mg. The peak of Glucose tolerance shifted backwards. The plasma insulin and insulin-C peptide level ware normal. Blood potassium, cholesterol and uric acid were normal.
英语病历模板范文
英语病历模板范文
Patient Identification:
Date of Birth: [DOB]
Sex: [Male/Female]
Patient ID: [Unique Identifier]
Chief Complaint:
[Patient's primary concern or reason for the visit, e.g., "Severe headache for the past 3 days"]
History of Present Illness:
[Detailed account of the onset, duration, severity, and any associated symptoms of the current illness. Include any treatments already attempted.]
Past Medical History:
[List any previous medical conditions, surgeries, or hospitalizations.]
Medications:
[List all current medications, including dosages and
frequency.]
Allergies:
[Note any known allergies to medications, foods, or environmental factors.]
Family Medical History:
英文病例模版
not clear,No history of hepatitis, tuberculosis or other infective diseases.
insomnia.Never coma.No deterioration of the memory,visual disorder,disturbance of consciousness.No history of paralysis,hyperspasmia and abnormal sensation.
Consciousness is clear and wellcooperation.The answers werepertinent to the questions.No unusual facies. Expression is freely and the tread is normal.
No allergy history of food and drugs. Never undergoing any operation
or transfusion.
System reviewRespiratory system: No history of asthma，Hemoptysis，Dyspnea,no chronic Cough,expectoration and chest pain.
英文版病例汇报
Present history
Recurrence
• 2015-06-01 Left liver lesion biopsy: Poorly differentiated carcinoma, consistent with metastatic carcinoma.
Harbin Medical University cancer hospital
Present history
The pathologic diagnosis • Rectal: moderately differentiated adenocarcinoma and mucinous adenocarcinoma with disc protrude type • Invading wall of intestine • A negative upper margin of resection • Number of positive lymph nodes 0/22
RAS Gene Test
2015-6-11 KRAS/NRAS WT
Harbin Medical University cancer hospital
临床诊断： 直肠癌术后pT4N0M0 ⅡB期 肝转移
Present history
英文病例汇报模板
CT
1、阑尾术后改变并回盲部、阑尾周围脓肿， 建议治疗后复查； 2、阑尾周围多发淋巴结影； 3、肝右叶后上段不典型小血管瘤多考虑，随 访； 4、阴道穹窿部少量积液，请结合临床考虑。
Diagnosis
1. appendicitis after appendectomy
2. Abdominal Abscess
Rebound tenderness（+）;
Blood routine
21-Apr 29-Apr 4-May 8-May 10-May WBC
14.37 12.3 10.34 14.619.42 X10~9 /L 3.5--9.5
NEUT% 82.4 RBC
83.3 85.5 88.7 84.1 %
Two months after appendicectomy；
Recurrent abdominal pain associated
with fever for one month
Present history 1
right ventral abdominal pain，2 months ago appendicectomy in Hongkong abdominal pain associated with fever for one month
Tumor marker
AFP
英文病历样本
英文病历样本
General information
Name
Age
Sex RaceNationalityAddress OccupationMarital status
Date of admission
Date of record
Complainer of historyReliability: Reliable
Chief complaint
The patient has a cough producing thick rusty sputum and a high fever that is accompanied by shaking chills. He has a right chest pain when breathing.
History of present illness
The patient has had a cold after swimming in the cold water recently. He had a cough with thick rusty sputum. He had shaking chills and felt a chest pain on the right side. He saw a doctor. A week after, he thought he was over it and didn’t pay attention to it, went swimming again. Now the condition is more serious. He has a high fever with 39℃that is accompanied by shaking chills. He has a bad cough with
英文病例模版
Since the disease coming on, the patient’s spirit and appetite is normal,the stool andurinatewere natural.
Superficial lymph nodes：Superficial lymph nodes were not found enlarged.
Head:Cranium:Hair was black and white, well distributed.No deformities. No scars.No pain when we press on.No masses.No tenderness.
Ear:Bilateral auricles were symmetric and of no masses. No discharges were found in external auditory canals. No tenderness in mastoid area.
Auditory acuity was normal.
Hematopoietic system:No history offatigue for a long time,dizziness,dim eyesight, never have gingiva, nose or subcutaneous hemorrhage,or bone ache history.
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?
病理诊断报告单英文模板
病理诊断报告单英文模板
Sichuan Provincial People’s Hospital
Diagnostic Report on Pathologic Tissues (or Humor)
Date when the sample was received:
Report No: Surgical xxxx-xx Name of patient : xxx
Pathologic Findings & Diagnosis Diagnostic conclusion (for the 1st time): chronic cystitis Double-checked the pathologic section of xxxx-xx and found that the wall of the small vessel on the bladder membrana propria thickens, indicating that vasculitis has changed. Inflammatory infiltration of the interstitial tissue is obvious; there are many oxyphil cells. Based on the above changes, I assume that the symptom is resulted from the reaction of illness on connective tissue.
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CASE REPORT FORM TEMPLATE
Version: 6.0 (8 November 2012)
PROTOCOL: [INSERT PROTOCOL NUMBER]
[INSERT PROTOCOL TITLE]
Participant Study Number:
Study group:
BASELINE DATA
General Instructions for Completion of the Case Report Forms (CRF)
Completion of CRFs
• A CRF must be completed for each study participant who is successfully enrolled (received at least one dose of study drug)
•For reasons of confidentiality, the name and initials of the study participant should not appear on the CRF. General
•Please print all entries in BLOCK CAPITAL LETTERS using a black ballpoint pen.
•All text and explanatory comments should be brief.
•Answer every question explicitly; do not use ditto marks.
•Do not leave any question unanswered. If the answer t o a question is unknown, write “NK” (Not Known). If a requested test has not been done, write “ND” (Not Done). If a question is not applicable, write “NA” (Not Applicable).
•Where a choice is requested, cross (X) the appropriate response.
Dates and Times
•All date entries must appear in the format DD-MMM-YYYY e.g. 05-May-2009. The month abbreviations are as follows:
January = Jan May = May September = Sep
February = Feb June = Jun October = Oct
March = Mar July = Jul November = Nov
April = Apr August = Aug December = Dec
In the absence of a precise date for an event or therapy that precedes the participant’s inclusion into the study,
a partial date may be recorded by recording “NK” in the fields that are unknown e.g. where the day and month are not clear, the following may be entered into the CRF: N K N K 2 0 0 9
DD MMM YYYY
•All time entries must appear in 24-hour format e.g. 13:00. Entries representing midnight should be recorded as 00:00 with the date of the new day that is starting at that time.
Correction of Errors
•Do not overwrite erroneous entries, or use correction fluid or erasers.
•Draw a straight line through the entire erroneous entry without obliterating it.
•Clearly enter the correct value next to the original (erroneous) entry.
•Date and initial the correction.
Protocol Number: Page 1 of 15
PARTICIPANT INFORMATION
Participant Number
Study Group ______________________________________________ Study Site (Health Centre Name) ______________________________________________
Inclusion/exclusion criteria
*Patient must meet all criteria to eligible for the study
Met all 1.Not met* 2.
Date of Informed Consent
D D M M M Y Y Y Y
Date of Birth D D M M M Y Y Y Y
Or estimated age
_______
Gender 1
Male
2
Female
Pregnant 1.Yes2. No9. Unknown If pregnant, Estimated Gestational Age ___________weeks
Date of Enrolment
D D M M M Y Y Y Y
Had malaria in the last 28 days 1. Yes2. No9. Unknown Had antimalarial in the last 28 days 1. Yes2. No9. Unknown