实用产科英文病例模板(包含疫情问诊)
妇产科病例分析子宫内膜癌 - 英文版
rm the patient and family and sign informe surgical treatment
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hypertensive disease
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diabetes mellitus
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二、Diagnostic basis
20分
1.Have a history of postmenopausal vaginal bleeding
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2.Vaginal discharge is usually increased
Physical examination: T: 36.7℃, P80 times/min, R20 times/min, BP 150/100mmHg. Fat, superficial lymph nodes are not visible, cardiopulmonary auscultation is normal, abdomen is flat and soft, there is no pressure pain and rebound pain, liver andspleen are not visible under the rib, and both lower limbs are not swollen.
Terms: according to the above case summary, please send the preliminary diagnosis,
diagnostic basis (if there are two or more diagnosis, should be separately listed their
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三、The differential diagnosis
妇产科英文病历
Inpatient HistoryName: Xue Jingfang Sex: FemaleAge: 30year Ward: No.8Marital status: Married Birthplace: Kunshan Nationality: Han Provider: Patient, reliable. Record date: 2012-08-07G & O History: GW: 31weeks, G2P0, LMP: 2012-01-02; EDC: 2012-10-09Chief Complaint: G2P0, GW: 31weeks. This patient presents abdominal distention for 2 days.History of Present illness:The patient had regular menses previously. LMP: 2012-01-02; EDC: 2012-10-09. Uric HcG test was positive after 30 days of amenorrhea. Fetal movements were felt in 4 months’ gestation. The patient didn’t feel any discomfort during her ante-partum examination in our hospital . The patient has been diagnosed of SLE for 13years, with the symptoms of fever and facial maculae, the largest dose of prednisone was 8#/d during the treatment. She had sustained to use prednisone 2#/d, hydroxychloroquine sulfate 2#/d, aspirin 2#/d for 3years before and during the early stage of the gestation. In the 12weeks’ gestation, Chief Physician Lin Qide recommended to add a piece of Nadroparin a day because of the higher rate of S/D, after 5 weeks of treatment, aspirin was reduced to 1#/d, and the use of Nadroparin was stopped. The patient came to our hospital on Jul.25th with the diagnosis of “premature signs”, she felt improved after 4days treatment of ritodrine.The patient presents abdominal distention 2days ago ,without vaginal bleeding or water running . She went to Kunshan Frist RenMin Hospital but still felt abdominal aching after the treatment. B ultrasound showed bilateral hydronephrosis, and The patient didin’t feel better after the use of Cefmetazole. She was admitted on-2012-08-07.After admission, she appears clear, with a good appetite, good sleeping, and normal urination and defecation.Past history: the patient has been diagnosed of SLE for 13years. Denies history of hepatitis and tuberculosis. No history of allergies. Vaccinated regularly.No history of severe trauma and transfusion.Femoral head of using bone graft in 2007, Double knee arthroscopic decompression operation in 2009Review of systems:Respiratory system: No history of chronic cough or breathlessness. No hemoptysis or dyspnea.Cardiovascular system: No precordial pain. No palpation. No syncope. For details see present history.Gastroentestinal system: No history of chronic abdominal pain and diarrhea; No nausea or vomiting; No hematemesis and blood stool.Endocrinic system: No polydipsia or polyphasia or polyuria. No sudden change of character and intelligence.Hematologic system: No bruises or abnormal hemorrhage. No recurrent oral ulcer and gingival bleeding.Genitourinary system: No decreased libido; No vaginal dryness or vaginal bleeding; History of STD denied; No urinary frequency. No precipitant urination or dysuria. No hematuria or proteinuria.Neuropsychiatric system: No convulsion or anesthesia. No headaches. No abnormal orientation. No deterioration of memory or intelligence.Locomotor system: No arthralgia, no muscular atrophies or dystrophies.Personal History:Born and grown up in Kunshan. Patient denied history of tobacco or alcohol use. Marital and Childbearing history: Married. 0-0-1-0; She had a curettage because of inevitable abortion in 2010Family history: No family history of DM or stroke. No family history of nervous or mental diseases.Physical ExaminationT: 37.1℃P: 80/min R: 19/min BP: 120/70mmHgGeneral appearance: Patient is a 30 years old female who appears pleasant, in no apperant distress, given her age, well developed and well nourished. Oriented to person, place and time.Lymph nodes: Not enlarged.Skin: No jaundice or rashes. No cyanosis and bruises. No edema.Head: Skull and scalp normal. No tenderness. No loss of hair.Eyes: No edema in eyelids, no ptosis, no conjunctival congestion.Width of palpebral fissures is normal. No jaundice. Pupil’s size and shape is normal. Corneal is clear.No exophthalmos.Ears: Auditory acuity is excellent. No ear purulent discharge.Nose: Shape is normal. No obstruction. No deviation of nasal septum.Mouth: No lips herpes. No cyanosis. No gums pyorrhea and bleeding. No tongue deviation. Tonsils not enlarged.Neck: Her neck is soft. Trachea is midline. No thyroid abnormality was found. Neck vein was not distended.Chest: Contour is normal. No sternum tenderness. The breasts are bilaterally symmetrical. No tenderness and mass.Lung:Inspection: Respiration regular. Degree of expansion is symmetry.Plapation: Tactile fremitus symmetrical.Percussion: extensive resonance to percussion.Ausculation: Clear to ausculation with no rubs noted.Heart:Inspection: No abnormal pulsation or retraction.Plapation: The apex beat can be felt in the 5th intercostal space 1 cm inside of the left mid-clavicular line.Percussion: The border of cardiac is not enlarged.Ausculation: The heart sounds were of good quality and the rhythm was regular.Radial pulse is normal.Abdomen:Inspection: Universial abdominal bulge. Dilated veins observed.Palpation: Soft. Liver and spleen is not enlarged. Nontender. Murphy’s sign is negative. For details see obstetric examination.Percussion: No shifting dullness. The upper border of the liver is in the 5th intercostal space.Ausculation: Bowl sound clear. 4/min.Spine and extremities: Severe edema in both lower extremities. No clubbed finger.No disorder of the movement of axial and appendicular bones.Reflex: Symmetrical, equal without pathological responses. Babinski sign and Kernig sign and hoffmann sign are all negative.Obstetric examinationPatient appears pleasant, given her age, well developed and well nourished. No jaundice. No enlarged lymph nodes.Fetus: Abdominal girth:91cm; height of fundus: 26cm; fetal heart rate: 150/min;FM: active.Anorectal examination: fetal membrane: not ruptured.Flexion of knee: active.Laboratory and special examinationDec. 6th, Blood Rt: Hb: 121g/L; PLT 136×10e9Urin e Rt: uric protein(++); occlude blood: (+++)Dec. 7th, Fetal Ultrasound: BPD: 78mm; HC: 259mm; AC: 238mm; FL: 51mm; HL: 49mm. fetal presentation: head; Position of placenta: right wall of uterus.Thickness of placenta: 23mm. Degree of placental maturity:Ⅱ; fetalheartbeat and fetal movement seen; amniotic fluid: 64mm. There is nohematocoelia or ascites. The lower edge of placenta is 23mm from thecervix.Umbilical A: P2: 0.87; R2: 0.59; S/D: 2.46.Fetal heart rate: 145/minDec. 8th, 24h uric protein: 7.5gDec.10th, serum potassium: 3.9mmol/LScr: 86umol/LALT: 25U/L ; AST: 30U/LFeatures of the case:1.Female, 38years old, G2P0, GW: 30+5weeks.2.This patient presents hypertension for 3 months, and systemic edema for 2 weeks.3.PE: BP: 180/120mmHg. Obstetric exam: Fetus: Abdominal girth: 93cm; height offundus: 29cm; estimated fetal weight: 1600g; fetal position: LOA; point of fetal heart tone: ; fetal heart rate: 148/min; FM: active.Flexion of knee: active.boratory and special exam:Aug. 7th, Blood Rt: Hb: 122g/L; PLT 129×10e9;WBC 7.13X10^9/L;N% 77.5% HUrin e Rt: uric protein(-); LEU 500/ul HAug.8th, ALT: 11U/L ; AST: 18U/LDiagnosis and differential diagnosis:Diagnosis: G2P0, GW: 31weeks. premature signs, SLEDifferential diagnosis:1. Chronic hypertension due to renal disease. This includes chronic hypertension due to interstitial nephritis, chronic glomerulonephritis, SLE, diabetic glomerulosclerosis, and so on. In these occasions, the patient would also possibly present hypertension, proteinuria and edema, but her proteinuria was found recently and she didn’t have any symptoms associated with renal diseases previously. In addition, her serum creatinine is in the normal scale (Scr: 86umol/L), which contradicts the hypothesis that she has a renal disease. So the diagnosis of chronic hypertension due to renal disease is not considered at present.Further investigations and treatments:1.Close observation and monitoring, plus quick evaluation: daily monitoring ofprotein in urine; Regular liver and kidney function testing; Ultrasound of the abdomen; Fetus heartbeat monitor; Conduct PT, APTT, FDP, 3P test to evaluate the coagulant function.2.Rests: Lie in bed on left side.e prednisone , hydroxychloroquine sulfate , aspirin to control the developmentof SLEe ritodrine to prevent miscarriageClinic diagnosis:G2P0, GW: 31weeks. premature signs, SLESigniture:。
妇产科平行病历范文
妇产科平行病历范文英文回答：Obstetric Parallel Medical Record Template. Patient Information.Name:Age:Gravida:Para:Estimated date of delivery (EDD):Antenatal Care.Initial Visit:Medical history.Physical exam.Lab tests (e.g., blood count, urinalysis)。
Ultrasound.Follow-up Visits (weekly/biweekly):Weight gain.Blood pressure.Urine protein.Fundal height.Fetal heart rate.Ultrasound (as indicated)。
Labor and Delivery.Labor:Date and time of onset.Duration and intensity of contractions.Cervical dilation and effacement.Fetal position.Delivery:Mode of delivery (e.g., vaginal, cesarean)。
Time of delivery.Birth weight and length.Apgar scores.Postpartum Care.Immediate Postpartum Period:Vital signs.Fundal height.Lochia.Breastfeeding.6-8 Week Postpartum Visit:Physical exam.Lab tests (e.g., blood count, urine culture)。
Contraception discussion.Other.Prenatal Referrals:High-risk pregnancy.Genetic counseling.Nutrition counseling.Postpartum Referrals:Breastfeeding support.Postpartum depression screening. Childbirth education.中文回答：妇产科平行病历模板。
大病例中英文对照
住院病历（一）(Medical Records for Admission)入院记录(General Information for Hospital Record)姓名(Name)：邮编(Post Code)：性别(Sex)：MALE 单位或现住址（Address)：年龄(Age)：56 years old 身份证号码(Identification No.)：婚姻(Marital Status)：Married 户口地址(Registered Residence Address)：民族(Race)：汉族联系电话(Contact Number):出生地(Place of Birth): FUDING入院日期(Date of Admission)：2013-08-05 13:04:22职业(Occupation):病史陈述者(Complainer of History):主诉(Chief Complaint)： headache and fever for 10 days.现病史(History of the Present Illness)：10 days ago, the patient had headache for no obvious reasons. There was persistent pain on the external parietal part of the head. The pain was not related to postural changes. The trigger was unclear but was accompanied by fever with body temperature fluctuations between 38.5°C to 38.8°C. Moreover, the patient was also experiencing dizziness, nausea, occasional vomiting of stomach contents. There is no blurred vision, tinnitus, earache, syncope, numbness, limbs twitch, or incontinence. He first went to the local Fuding hospital where they performed a lumbar puncture on him. The CSF WBC was 356X10^6/L, monocytes 85%; cerebrospinal fluid biochemistry: chlorine 119 mmol/L, glucose 1.74 mmol/L, protein 1.79 mmol/L. the MRI showed “bilateral centrum ovale multiple lacunar lesions, atherosclerotic changes in white matter, chronic sinusitis”. The patient was then diagnosed as “viral meningitis”and was prescribed “acyclovir”. He was also given “mannitol, glycerol & fructose injection” to decrease the intracranial pressure. Furthermore, PPI was given to decrease the stomach pain and rehydration treatment was done but, there was no significantimprovement in the symptoms. The patient then came to the emergency room of our hospital where he was diagnosed as having “intracranial infection”and was admitted to the hospital. Upon admission, the patient’s mind was clear, the spirit was good, he had a poor appetite, his sleep was good, he had soft yellow stool and there was no significant change in weight. 29 years ago, the patient had a renal history of tuberculosis.住院病历（二）(Medical Records for Admission)既往史(Past Medical history)：General health status: normalCo-morbid conditions:Hypertension: Absent Cardiac disease: AbsentDiabetes mellitus: Absent Kidney disease: AbsentHistory of infectious diseases:Tuberculosis: Absent Hepatitis: AbsentOthers: 29 years ago, he had a renal history of tuberculosis.History of preventive inoculation: Inoculation plan completed.Allergic History: History of blood transfusion: Negative1.Drug: Negative History of scars/wounds: Negative2.Food: Negative History of surgical operations: Negative3.Others: NegativeHistory of long-term drug use: NegativeHistory of drug abuse: Negative系统回顾(Review of Systems)：∙HEENT:No hearing loss, tinnitus, dizziness, tooth ache, gingival bleeding, throat ache, hoarseness.∙Respiratory :no chronic cough, sputum, expectorant, chest pain, asthma, dyspnea.∙Cardiovascular:No increase in blood pressure, palpitation, shortness of breath, cyanosis, precardial pain, orthopnea, dizziness, lower limb edema.∙GI: No hematemesis, swallowing difficulty, abdominal pain or distention, diarrhea, occult blood, constipation, jaundice, rash or itching.∙Genitourinary system: No urinary frequency, urgency, dysuria, hematuria, pyuria, nocturia or frothy urine.∙Hemapoietic: No ecchymose, purpura, lymphadenopathy, splenomegaly, epistaxis or gingival bleeding∙Endocrine:no polydipsia, polyphagia, polyuria,change in sexual function or personality or visual field defect.∙Musculoskeletal:No dysarthria, joint abnormality, spine abnormality, muscle atrophy or weakness in limbs.∙Neurology:no headache, loss of memory, aphasia, paralysis, tic.∙Mental state: no hallucination, delusional, disorientation, mood disorder个人史(Personal history)：Place of birth: Residence: Epidemic area: None Travel history: Negative Drinking history: Yes 500ml/day for 30years and stopped 2 years agoSmoking history: Yes 20cigarettes/day for 30 years and stopped for 2 months Toxin, dust, radioactive or industrial exposure: Negative婚姻、月经及生育史(Marital、Menstrual and Childbearing history):Marital status: Married Age of wedding: 25 years old spouse heath: normal children: 2 sons and 1 daughter ; all healthy家族史(Family History)：Father-deceased Condition: unknownmother- deceased Condition: unknownSiblings: HealthyHereditary disease(s): NegativeCongenital disease(s): Negative in grandparents, parents or siblings.住院病历（三）(Medical Records for Admission)体格检查(Physical Examination)一般情况(General Appearance)Consciousness: Refer to speciality Pulse rate: 78bpm Respiratory rate: 20 times/min Blood pressure: 128/70 mmHg Temperature: 38.8°CWeight: not measured kg Height: not measured cm Posture: Can answer correctly and collaborates.皮肤、黏膜(Skin、Mucosa)：Color: Refer to speciality Rash: Absent Hemorrhage: Absent Edema: refer to specialitySuperficial lymph nodes: No enlargement of superficial lymph nodes in the whole body头部及其器官(Head and HEENT)：Shape of head: Normal Conjunctiva: No hyperemia or edema Sclera: Refer to speciality Pupil: Symmetrically round Nasal cavity: Clear Sinus tenderness: Absent Teeth: Normal Oral mucosa: Normal Mastoid tenderness: Absent Hearing: No abnormality Tonsils: No enlargement Others: Negative颈部（Neck）:Flex: Soft position of trachea: Midline thyroid gland: No enlargement Jugular vein: No distensionOthers: None胸部(Chest)：Shape: Normal, symmetric intercostals space: Normal Breasts: Symmetric, no abnormality肺脏(Lungs)：Breathing: Symmetric percussion sound: Clear breath sounds: Clear Crackles: Absent Others: Absent心脏(Heart)：Heart rate:78bpm Heart sounds: Normal Murmurs: Absent Others: Absent血管(Blood Vessel)：Peripheral vessel sign: Negative腹部(Abdomen)：Refer to speciality外生殖器(Genitourinary system)：not examined直肠、肛门(Rectum、Anus)： Not examined四肢、脊柱(Extremities、Spine)：No abnormality神经系统(Neural System)：Muscle strength: Grade 5 Muscle tension: NormalKnee-jerk reflex: Normal Babinski’s sign; left:negative, right: negativeOthers: kernig (+)其他体征(Other Physical Signs)：Normal住院病历（四）(Medical Records for Admission)专科情况(Specific Appearance) ：General condition: Dulled consciousness, NO left supraclavicular lymph node enlargement,no icterus, no lower limb edema,no palmar erythema, no spider telangiectasia, no skin pigmentation, no flapping tremor,no capillary distension,no fetor hepaticus.Abdomen:1.Inspection: External appearance: Smooth Abdominal vein distension: Absent Breathing type: hyperventilated Breathing movement: NormalSurgical scar: Absent Discoloration: Absent2.Palpation: No painPain with pressure or rebound tenderness: Absent Swelling: Absent Liver:Palpable Gall bladder: Absent, no pain with pressure, negative Murphy sign Spleen: Not palpable Kidney: Not palpable Bladder: Full(distended)3.Percussion: Dullness of border of liver: On right, mid-clavicular line on the 5th ICS(Upper border) of a length of about 9 cm , no percussion pain on the region of the liver or gall bladder Dullness of border of spleen: Left mid-axillary line 9-11th ICS, about 9 cm No shifting dullness, no percussion pain of the costophrenic region.4.Auscultation: Borborygmus: Normal No metallic sound5. Others: None特殊检查(Special Examination)：MRI: Intracranial CT scan shows no change, renal atrophy with multiple stones mainly in bladder, left ureter. There is gall bladder bile duct stone. There is pneumonia with bilateral pleural effusion. Bilateral centrum ovale multiple lacunar white matter changes in atherosclerotic lesions of chronic sinusitisLabs Data:2013/07/28 Csfculture:protein+, wbc 356*10^6/L,Monocyte 85%,cl 119mmol/l,Glucose 1.74mmol/L, protein 1.79 g/lCSF culture2013/07/31 CSF: RBC18*10^6/L , WBC 220 *10^6/L , Monocyte: 90%,CSF biochemistry : CL 115mmol/L , Glucose 1.91 mmol/L, Protein 1.68g/L , ADA : 6U/L初步诊断(Primary Diagnosis):Intracranial infectionTuberculous meningitis。
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:。
英文病例范本
英文病例范本第一篇：英文病例范本Note for Jane Doe on 4/8/03Electronic Medical RecordsDr.Dermatology, MDDEA#:_____________________________________________________________Name: Jane DoeDate: 4/8/03Addr: 1231 8th Street, Suite 222West Des Moines , IA 50265_____________________________________________________________Tetracycline250 mg capsuleBIDX_____________________________________X_____________________________________ Substitution PermittedDispense as writtenRefills: 0Disp: 60Allow Generic: YesSample Referral LetterCharting Plus™Electronic Medical RecordsPatient Instructions for Jane Doe on 04/11/2002ACNE VULGARISWhat is it?Acne vulgaris, commonly referred to as just acne, is a chronic inflammation of the skin that occurs most often during adolescence but can occur off and on throughout life.The skin eruptions most often appear on the face, chest, back and upper arms and are more common in males than females.Signs andsymptoms:* Blackheads the size of a pinhead.* Whiteheads similar to blackheads.* Pustuleslarge, firm swollen lesions in severe acne.* Abscess-infected lesion that is swollen, tender, inflamed, filled with pus, also seen in severe acne.Causes:Oil glands in the skin become plugged for reasons unknown but during adolescence, sex-hormone changes play some role.When oil backs up in the plugged gland, a bacteria normally present on skin causes an infection.Acne is NOT caused by foods, uncleanliness or masturbation.Cleaning the skin can decrease its severity but sexual activity has no effect on it.A family history of acne can indicate if an individual will get acne and how severe it might be.Currently, acne can´t be prevented.Acne can be brought on or made worse by:* Hot or cold temperatures.* Emotional stress.* Oily skin.* Endocrine(hormone)disorder.* Drugs such as cortisones, male hormones, or oral contraceptives.* Some cosmetics.* Food sensitivities.Again, foods do not cause acne but some certain ones may make it worse.To discover any food sensitivities, eliminate suspicious foods from your diet and then start eating them again one at a time.If acne worsens 2-3 days after consumption, then avoid this food.Acne usually improves in summer so some foods may be tolerated in s ummer that can´t be eaten in winter.Treatment:* Most cases of acne respond well to treatment and will likely disappear once adolescence is over.Even with adequate treatment, acne will tend to flare up from time to time and sometimes permanent facial scars or pitting of the skin may occur.* If your skin is oily, gently clean face with a fresh, clean wash cloth using unscented soap for 3-5 minutes;an antibacterialsoap may work better.A pre viously used wet washcloth will harbor bacteria.Don´t aggressively s crub tender lesions as this may spread infection;be gentle.Rinse the soap off for a good 1-2 minutes.Dry face carefully with a clean towel and use an astringent such as rubbing alcohol that will remove the skin oil.Other tips that may help acne:* Shampoo hair at least twice a week.Keep hair off of face even while sleeping as hair can spread oil and bacteria.If you have dandruff, use a dandruff shampoo.Avoid cream hair rinses.* Wash sweat and skin oil off as soon as possible after sweating and exercising.* Use thinner, water-based cosmetics instead of the heavier oil-based ones.* Avoid skin moisturizers unless recommended by your doctor.* Do not squeeze, pick, rub or scratch your skin or the acne lesions.This may damage the skin causing scarring and delay healing of acne.Only a doctor should remove blackheads.* Keep from resting face on hands while reading, studying or watching TV.* Try to avoid pressing the phone receiver on you chin while talking on the phone.* Ultraviolet light may be a treatment recommended by your doctor but this is by no means a license to sunbathe!Don´t use the sun to treat acne.* Dermabrasion may be another option to treat acne scars.This is a type of cosmetic surgery to help remove unsightly scars.Medications that may be prescribed to help acne include:* Oral or topical antibiotics.* Cortisone injections into acne lesions.* Oral contraceptives.* Tretinoin, which may increase sun sensitivity and excessive dryness, is not recommended during pregnancy.*Accutane(isotretinoin)is a powerful drug to treat acne but causes birth defects.A woman taking this drug must be on two types of birth control and have negative pregnancy tests.Thisdrug also increases sun sensitivity.Other more serious side effects can occur and your doctor will discuss those with you if Accutane is to be prescribed.TETRACYCLINEYour doctor has prescribed Tetracycline for your condition.Tetracycline is a very safe antibiotic.It is not related to penicillin and an allergy to it is unusual.There are several potential side effects:1.Tetracycline can cause nausea or heartburn.2.Tetracycline can cause vaginitis.3.Tetracycline can cause excessive sun burn.CAUTIONS:1.Do not take Tetracycline with milk or milk products(ice cream, cheese, yogurt, etc.).This will cancel out the Tetracycline.Separate the Tetracycline from these products by one and one-half hours before and after each capsule.Do have a small amount of non milk-containing food in your stomach first to prevent nausea.2.Do not take Tetracycline if you are pregnant.3.Do not take Tetracycline if you are taking birth control pills unless specifically instructed to do so.4.If at the beach or skiing in the sun, use an effective sunblock(SPF-15 or greater)to prevent burning.If problems or questions arise, call the office for assistance.Side effects can occur and your doctor will discuss those with you if Accutane is to be prescribed._______________________________A.Dermatologist, MD第二篇：英文病例汇报实用句型英文病例汇报实用句型1.一般情况（完全套话）Mr./Ms.**(family name), a **(age)year-old **(profession), was admitted on **(admission date).2.病史He complains that...He complains of one-month history of palpitation and short of breathness after exertion.He complainedabout epigastric pain which has lasted for 3 months.He noticed a hardened lump on the left neck 3 months ago.Pancytopenia was found a month ago.He presented with dyspnea since 10 days ago.His chief complaint was...既往诊疗~~~~~~~~He was confirmed as / definitely diagnosed as...(确诊为)To make a definite diagnosis, bone marrow aspiration was performed.He was suspected as...(疑似)The discomfort tended to worsening, which urged him to seek for medical care.He has been given 3 cycles of DA regimen for chemotherapy and complete remission was achieved only after the first cycle.He was given the thyroidectomy of the left lobe in local hospital.He was treated with antibiotics(details unknown), which didn't take effect as expected.The general condition is good at present.He was pain free now and hemodynamically stable.3.查体Nothing noteworthy was found in the physical examination.There was nothing remarkable in the physical examination except for… The physical examination was otherwise normal except that…（上点小菜~~~血液科常见体征）皮肤粘膜generalized pallor，scattered petechiae，oral mucosal hematoma 淋巴结enlarged lymph nodes头部yellow eyes(yellow-stained sclera)胸部tenderness in sternum，coarse breath sound, cardiac murmur, arrhythmia腹部enlargement of liver，splenomegaly4．辅助检查The laboratory findings suggested/indicated/demonstrated/showed that… Bone marrow film was performed, which confirmed the diagnosis of ALL.The results of blood routine showed that WBC count was 4,000 /cm3,while NEU count 2,500/cm3, hemoglobin 100 g/L, PLT count 100,000 /cm3.(/cm3 is pronounced as per cubic millimeter) Chest CT scan supported the diagnosis of NHL.第三篇：英文病例对照住院病历的英汉对照分享宋丽秀 21:06分享随着中外交流的加强，专业英语对医院也是越来越重要！花了点时间整理了下“住院病历的英汉对照”的格式，发上来和大家分享，希望对能用到的人有所帮助！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 InformantHistory 职业入院日期病史叙述者病史 Chief complaint 主诉History of presentillness 现病史Pasthistory 既往史：Previous health status: well ordinary badInfectious diseases平素健康状况：良好一般较差传染病史Immunizations Allergies: N Yclinical 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 mmHg General 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 cm Dusculation: 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 P2 S3 无有S4 无有A2 P2 Extra 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 gallbladd er: 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(+)(-)others Kernig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-ray X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 记录日期第四篇：英文病例汇报常用体格检查术语英文病例汇报常用体格检查术语•1、肋骨和软组织[ribs and soft tissure]•胸骨上切迹[suprasternal notch]•浮肋[free ribs]•胸壁[chest wall]•扁平（桶状、佝偻、漏头、鸡）胸[flat(barrel,rachitic, funnel, pigeon)chest] •皮下气肿[subcutaneous emphysema]•捻发音[Crepitus]•佝偻病串珠[rachitic rosary]•软骨病[chondrosteoma]•脂肪瘤[lipoma]•软骨发育不全[achondroplasia(chondrodysplasia)]•软组织损伤[soft tissue injury]•肋骨畸形[abnormality of the ribs(rib deformity, costal anomaly)] •肋骨串珠（错位）[beading(displacement)of rib] •肋软骨畸形[costochondral deformity]•肋软骨增生[costal cartilage hyperplasia]•肋下切口[subcostal incision]•肋间隙宽（窄）[wide(narrow)intercostal space]2、乳房[breast]•对称性[symmetry]•乳头内陷（内缩）[crater(retracted)nipple]•乳头皱裂[cracked nipple]•乳头偏斜（抬高）[nipple skewness(elevation)]•乳头溢液[nipple discharge]•乳头脓肿（溃疡、血肿）[abscess(ulcer, hematoma)of nipple] •乳头过小[hypomastia]•乳斑[milk spots]•乳房潮红[breast flush]•乳房出血[mastorrhagia]•乳房过早发育[premature thelarche]•乳房肿胀（脓肿）[mammary swelling(abscess)]•乳房湿疹[eczema mammae]•乳房下垂[mastoptosis(pendulous breast)]•乳房萎缩[mastatrophy]•巨乳[macromastia]•乳晕[mammary areola]•乳房硬化[zaranthan]医.学.全.在线.网.站.提供•异常泌乳[abnormal lactation]•男子女性化乳房[gynecomastism]•乳房皮肤红肿[erythroswelling of mammary skin]•乳房桔皮征[mammary orange-peel sign]•乳记局限性凹陷[mammary localized pitting]•乳房瘘管[breast fistula]•正常女性乳房[normal female breasts]•无压痛性肿块[nontender mass]3、肺[lung]•呼吸缓慢（急促）[bradypnea(tachypnea)]•呼吸浅慢（深快）[hypopnea(hyperpnea)]•呼吸不规则[irregular respiration]•点头呼吸[nodding breathing]•端坐呼吸[orthopnea]•三凹征[retraction sign of three fossae]•叹息样呼吸[sighing respiration]•浅快[shallow and rapid]•呼（吸）气性呼吸困难[expiratory(inspiratory)dyspnea]•呼吸道烧伤（塌陷）[burn(collapse)of respiratory tract(airway)]•呼吸道阻塞[respiratory tract obstruction]•呼吸均匀（呼吸加深或加快）[eupnea(exaggerated or acclerated respiratory)]•呼吸停止[apnea]•呼吸费力[respiration is labored]•语音（触觉）震颤[vocal(tactile)fremitus]•语颤相等（减弱、增强）[vocal fremitus is equal(diminished, accentuated)]•间接（直接）叩诊[mediate(immediate)percussion]• 浊（实、鼓、清、过清、金属）音[dullness(flatness, tympany, vesicular resonance, hyperresonance, bell)]•移动范围[range of movement]医学.全.在线.网.站.提供• 呼吸音消失（减弱，增强）[absence(diminution, exaggeration)of breath sound] •呼吸音粗（清）[sound of breath(SOB)is rough(clear)]•支气管（支气管肺泡，肺泡）音[bronchophony(bronchovesicular sound, vesicular sound)] •管状呼吸音[tubular breath sound]•捻发音[crepitantrales]•爆裂音[crackles]•干（湿）罗音[dry(moist)rales]•细（中等、粗）罗音[fine(medium, coarse)rales]•呼（吸）气未罗音[end-inspiratory(expiratory)rales]•胸膜摩擦音[pleural friction rub]•呼（吸）气延长[prolonged inspiratory(expiratory)]•高（低）调鼾音[sibilant(sonorous)rhonchi(sonorous rales)] •哨笛音[sibilant rales]•哮鸣音[wheezing]•小（中、大）水泡音[small(middle, big)bubbles]•支气管语音[bronchophony]•耳语音[whispered]•羊鸣音[egophony]•高（低）音调[high(low)-pitched]•两肺部（右背部）[over both lung fields(right back)]•两（左）肺底[over the both(left)lower lung]•整个肺野[the whole lung field]•左（右）上（下）肺[the left(right)upper(lower)lung]•肺尖（底）[apex(base)of lung]4、心脏[Heart]•用手掌（指尖）触诊心尖搏动[palpate apical area with palm(fingertips)]•心前区隆起（凹陷）[precordial bulge(retraction)]•搏动弥漫（局限）[diffuse(local)pulsation]•负性搏动[inward inpulse]•心尖搏动[apex beat(apical impulse)]•剑突下搏动[xiphoideusalpulsaton]•抬举性心尖搏动[heaving apex impulse]•心尖搏动最强点[point of maximal impulse(PMI)]•锁骨中线[mid-calvicular line(MCL)]•肋间[intercostal space(ICS)]•收缩（舒张）期震颤[systolic(diastolic)thrill]•心浊音界[the border of cardiac dullnes]•心绝对（相对）浊音界扩大（缩小）[enlarged(diminished)absolute(relative)cardiac dullness] •叩诊心脏大小正常[heart size is normal on(to)percussion]•心脏向左（右）扩大[cardiac dilation(enlargement)to the left(right)]•第1（2、3、4）心音[S1(S2,S3,S4)]•第1心音增强（减弱，听不清）[first heart sound is exaggerate(decreased, muffled)] •生（病）理性杂音（分裂）[physiologic(pathological)murmur(splitting)]•生理性（固定、反常、逆）分裂[physiologic(fixed, paradoxical, reversed)splitting] •肺动脉瓣第2心音>(=，(=，•大炮音[connon sound]•心音消失[heart sound is absent(disapeared)]•心音增强（减弱）[accentuated(diminished)cardiac sound]•心音响亮（遥远）[cardiac sound is loud(distant)]•收缩期（舒张期，连续性）杂音[systolic(diastolic, continuous)murmur]•收缩（舒张）前（中、晚）期杂音[pre-(mid-, post)systolic(diastolic)murmur] •全收缩期的[holosystolic(pansystolic)]•全舒张期的[holodiastolic(pandiastolic)]•低（高）音调[low(high)pitched]•递减（递增，递减-递增）性杂音[decrescendo(crescendo, decrescendo-crescendo)murmur] •呈喷射型[be ejection in type] •Ⅳ级喷射型收缩期杂音[grade Ⅳ(I-Ⅳ/6)systolic ejection murmur]•吹风样杂音[murmur of puffing character]•低音调隆隆样[low-pitched rumbling quality]•柔和（粗糙）的[soft(harsh or rough)]•吹风样（喷射性、隆隆样、沙沙声样、搔抓声样、机器声样、汽笛声样、倒水声样）杂音[blowing(ejection, rumbling, rustting, scratching, machinary, whistling, pouring)murmur]•功能性（器质性）杂音[functional(organic)murmur]•血管（静脉）杂音[vascular(venous)murmur]•枪击音[pistol shot sound]医学全.在线网.站.提供•静脉营营音[venous hum]•奔马律[gallop rhythm]•胎心律[embryocardia]•心律齐（不齐）[regular(irregular)rhythm]•心律不齐[arrhythmia]•二（三）联律[bigeminy(trigeminy)]•早搏[premature(extrasystol)]•喀嗽音[click]•钟摆律[pendular rhythm]•二尖瓣开瓣音[mitral opening snap]•心包摩擦音[pericardial friction sound]•听诊[on auscultation]•二尖瓣（主瓣，肺瓣，三尖瓣）听诊区[mitral(aortic, pulmonary, tricuspid)valve area] •心包叩击音[pericardial knock]•肿瘤扑落音[tumor plop]5、腹部[abdomen]•腹（妊娠）纹[abdominal striae(striaegravidarum)]•腹膨隆[abdominal distention(prominence)]•腹平坦（凹陷）[abdominal flatness(retraction)]•蛙状（球状、舟状）腹[frog(bulbous, scaphoid)belly(abdomen)]•腹围增大[increased abdominal girth]•肠型[intestinal pattern]•梯形腹[ladder-shaped abdomen]•胃（小肠）蠕动波[gastric(intestinal)peristaltic wave]•静脉曲张[varicosity(dilated tortuous vein)]•疤痕[scar]•腹壁紧张（松驰）[guarding(abdominal muscular relaxation)] •腹壁切口（创伤）[incision(wound)of abdominal wall]•腹部分区[abdominal region]•左（右）上（下）腹[left(right)upper(lower)quadrant]•脐膨出[projection of the umbilicus]•腹式呼吸[abdominal(diaphragmatic)breathing]•腹壁松弛[lax abdominal wall]•肝肿大[hepatomegaly(enlargement of the liver)]•脾肿大[splenomegaly(enlargement of the spleen)]•右肋下5厘米[5 cm below the right costal margin]•肿块（肝）质硬[firm mass(liver)]•莫菲氏征[murphy`s sigh]•肌卫现象[muscle guarding(tension)]•反跳痛[rebound tenderness]•压痛点[tenderness point]•剑突下压痛[tenderness beneath the xiphoid process]•麦氏点压痛[McBurney`s point tenderness]•腹肌强直（板状腹，板样强直）[rigor of abdominal muscle(wooden belly, board-like rigidity)]•柔韧感[dough kneeding sensation]医学.全在线•波动感[fluctuation]•腹股沟疝[inguinofemoral hernia]•腹壁反射[abdominal reflex]•腹水征[sign of ascites]•膀胱肿大[bladder expansion]•膀胱区（脊肋角）压痛[tenderness of bladder region(costovertebral angle)]•肾（肝）区叩击病[percussion tenderness on kidney(liver)region]•移动性浊音[shifting dullness]•鼓音[tympany(tampanitic resonance)]•肝（脾）浊音区[hepatic(splenic)dullness area]•肠鸣音正常（亢进、减弱、消失）[normal(hyperactive, diminished, absent)bowel sound] •气过水声[gurgling] •振水声[succusion(splashing)sound]第五篇：病例病例范文 2010-06-02 17:40 |(分类:默认分类)1）一般项目：籍贯（须写明省、市或县别）、入院日期：急症或重症应注明时刻。
英文病例模版
discharges were found invetibulum nasi. Septum nasi was in midline. No
nares flaring. No tenderness in nasal sinuses.
Superficial lymph nodes：Superficial lymph nodes were not found enlarged.
Head:Cranium:Hair was black and white, well distributed.No deformities. No scars.No pain when we press on. No masses.No tenderness.
Kinetic system:No history of joint pain, numbness,red and swollen,
metallaxis,myalgia or myophagism.
Neural system:No history of long-term headache,dizziness and vertigo,
atage 46.
Marital history：She’s marriedat 28,her husband is heslth,and the relationship
between them were concord.
Childbearing history：G4P2,induced abortion twice,natural labourtwice,and they are heathy.
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 andfrequency.]Allergies:[Note any known allergies to medications, foods, or environmental factors.]Family Medical History:[Provide information on any significant medicalconditions in the patient's family.]Social History:[Include relevant lifestyle factors such as smoking status, alcohol consumption, exercise habits, and occupation.]Review of Systems:[Briefly summarize the patient's current state inrelation to various body systems, e.g., "No chest pain, no shortness of breath."]Physical Examination:[Record findings from the physical examination, including vital signs, general appearance, and specific observations related to the chief complaint.]Assessment:[Summarize the likely diagnosis or condition based on the information gathered.]Plan:[Outline the proposed treatment plan, including medications, referrals, follow-up appointments, and any necessary tests or procedures.]。
院外分娩个案说明范文
院外分娩个案说明范文英文回答：Prenatal Care and Labor Management of an Out-of-Hospital Birth.Case Study.A 35-year-old gravida 2 para 1 woman presents to the clinic at 38 weeks of gestation. She is seeking prenatal care for the first time in this pregnancy. She has ahistory of an uncomplicated vaginal delivery 5 years ago. She is currently residing in a rural area and has chosen to have an out-of-hospital birth attended by a certifiednurse-midwife (CNM).The patient's medical history is unremarkable. She is a non-smoker, does not use alcohol, and has no history of illicit drug use. She has no known allergies. She is currently taking prenatal vitamins and iron supplements.On examination, the patient is in good health. Her blood pressure is 110/70 mmHg, her heart rate is 80 beats per minute, and her respiratory rate is 16 breaths per minute. Her abdomen is gravid and her fundal height is consistent with 38 weeks of gestation. Fetal heart tones are strong and regular.The patient's prenatal laboratory tests are unremarkable. Her hemoglobin is 12.5 g/dL, her hematocrit is 38%, and her platelet count is 200,000/μL. Her urinalysis is negative for protein and glucose.The patient's birth plan includes the following:She would like to labor at home in a supportive environment.She would like to use natural pain relief methods, such as a birthing pool, massage, and aromatherapy.She would like to have a vaginal birth without anyinterventions, if possible.The CNM discusses the patient's birth plan with her in detail. She explains the risks and benefits of out-of-hospital birth, and answers the patient's questions. The CNM also provides the patient with resources on natural pain relief methods.The patient and the CNM agree that the patient is a good candidate for an out-of-hospital birth. The CNM will provide intermittent prenatal care to the patient, and will be on call for the delivery.Labor Management.The patient goes into labor at 40 weeks and 2 days of gestation. She labors at home for several hours, using the birthing pool and massage for pain relief. The CNM arrives at the patient's home when the patient is in active labor.The patient's labor progresses well. She gives birth to a healthy baby boy weighing 8 pounds, 6 ounces. Thedelivery is uncomplicated, and both the mother and baby are doing well.Postpartum Care.The CNM provides postpartum care to the patient and her baby at home. She checks the patient's vital signs, examines the baby, and provides breastfeeding support. The patient and her baby are discharged home 24 hours after the delivery.Conclusion.This case study demonstrates that out-of-hospital birth can be a safe and satisfying option for women who are low-risk and have a supportive care provider.中文回答：产前护理和院外分娩案例说明。
产科英文病历
Admission of Record of ObstetricsName: Shi Yang Date of Admission: 0 AM, Feb.24th, 2003 Medical Number:755924 Age: 27 years old Occupation: Office clerk Nationality: ChinaGeneration: 0 time Pregnancy: 1 timeDate of the first antenatal examination: Oct.28th, 2002Total examination time: 7 times. There were not abnormal findings in these examinations.Chief complaints: the first pregnancy and no generation history, have generated for more than 39 weeks and is generating, premature rupture of membranes.Uterine contraction: noExcretion of vagina: quality: amniotic fluid quantity: middlingOthers: time of rupture of membranes: 11:20 pm, Feb.23rdFormer pregnancy and generation condition: noPresent pregnancy and generation condition:Last menstrual period: May.22nd, 2002 To last: 5~6 daysExpected time of confinement: Mar.1st, 2003First fetal movement: in more than 4 months after pregnancyHemorrhage: occurred in earlier period of pregnancy Leucorrhea: normalUrine: normal Appetite: good Hyperemesis: no Stool: normalHeadache: no Edema: yes Sleeping: goodGeneral healthy condition: goodPersonal history of illness: no hereditary disease, no allergic history, no infectious disease.Family healthy condition: no hereditary disease, no infectious disease.Physical examination:T 36.7℃, P 90 times p.m., Bp 130/86 mmHgGeneral development: well Nutrition state: middlingSkin: normal Deformity: noLymph nodes: not enlargedHead: no deformityEyes: normal Ears: normal Nose: normal Teeth: normalTongue: normal Pharynx: normalNeck: soft Thyroid: not enlargedChest: normal Breasts: plumpy Nipples: normalHeart: HR 90 bpm with regular rhythm, no murmursLungs: breath sound is clear without ralesAbdominal: bulgedAbdomen circumference: 112 cm Spinal column: bend physiologicallyAnus: normal Perineum: married type Limbs: normalTendon reflex: exist Edema: ++Obstetrics examination:Fundus of uterus: 39 cm Fetal position: ROAFetal heart rate: 140 bpm Fetal presentation: floatingExternal pelvimetry:Interspinal diameter: 24 cm intercrestal diameter: 28 cmOccipitofrotal diameter: 20 cm Intertuberal diameter: not detailedPosteriorsagital diameter of outlet: not detailed Pubic arch: not detailed Anal examination:Dialation of the cervix: not to be seenFetal presentation: -2 cmImpression: 1.the first pregnancy and no generation history2.generate for more than 39 weeks and is generating,3.premature rupture of membranesRecord time: 0:30 AM ,Feb.24th, 2003。
妊娠肺炎病例书写模板范文
妊娠肺炎病例书写模板范文英文回答：Pneumonia in Pregnancy Case Study.Case Presentation:A 25-year-old G1P0 female, at 34 weeks gestation, presents to the emergency department with a 3-day history of progressive dyspnea, non-productive cough, and subjective fevers. She denies associated chest pain, sputum production, nausea, vomiting, or diarrhea.Medical History:The patient is a non-smoker with no significant medical history. She is currently receiving prenatal care and has had regular appointments throughout her pregnancy.Physical Exam:Vital Signs:Temperature: 38.5°C (101.3°F)。
Heart Rate: 110 bpm.Respiratory Rate: 24 bpm.Blood Pressure: 120/70 mmHg.Oxygen Saturation: 88% on room air.Respiratory: Auscultation reveals bilateral crackles at the lung bases.Cardiovascular: Examination is normal.Gastrointestinal: Examination is normal.Laboratory Findings:Complete Blood Count:White Blood Cell Count: 12,000 cells/μL.Neutrophils: 75%。
妇产科英文模板
CASEMedical Number: 756943General informationName:Yue Jun-rong Age: Forty- two years oldSex: Female Race:HanOccupation: Unemployment Nationality:ChinaMarital status: Married Address : Xiaochang county of Xiaogan city in Hubei. Tel: 4835963Date of admission: Feb.27th, 2003 Date of record: 3pm, Feb.27th, 20 03Complainer of history: the patient herself Reliability: ReliableChief complaint: The patient was found “myoma of uterus” over two yearsago and menometrorrhagia for 5 months.Present illness: In 1999, the patient was found “myoma of uterus” in a physic al examination. But she had nothing uncomfortable and her catamenia was normal. She used some Chinese traditional medicine. About 5 months ago, she found the cycle of her catamenia was shorten from 30 days to 20 days and the period laste d from 2 days to 4 days. She felt no pain and the quantity was normal. She was accepted in our hospital and her diagnosis was “subserous myoma of uterus”.Since onset, her appetite was good, and both her spiritedness and physical ener gy are normal. Defecation and urination are normal, too.Past historyOperative history: Never undergoing any operation.Infectious history: No history of severe infectious disease.Allergic history: She was not allergic to penicillin or sulfamide.Respiratory system: No history of respiratory disease.Circulatory system: No history of precordial pain.Alimentary system: No history of regurgitation.Genitourinary system: No history of genitourinary disease.Hematopoietic system: No history of anemia and mucocutaneous bleeding. Endocrine system: No acromegaly. No excessive sweats.Kinetic system: No history of confinement of limbs.Neural system: No history of headache or dizziness.Personal historyShe was born in Hubei on July 16th, 1956 and almost always lived in Wuhan. She graduated from senior high school. Her living conditions were good. No bad per sonal habits and customs.Menstrual history: The first time when she was 14. Lasting 2 days every times and its cycle is about 30 days.Obstetrical history: Pregnacy 3 times, once nature production, induced abortio n twice.Contraceptive history: Not clear.Family history: His parents are both alive.Physical examinationT 36.8℃, P 80/min, R 20/min, BP 120/80mmHg. She is well developed and moderat ely nourished. Active position. The skin was not stained yellow. No cyanosis. N o pigmentation. No skin eruption. Spider angioma was not seen. No pitting edema. Superficial lymph nodes were not enlarged.HeadCranium: Hair was black and well distributed. No deformities. No scars. No m asses. 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 acui ty was normal.Nose: No abnormal discharges were found in vetibulum nasi. Septum nasi was i n midline. No nares flaring. No tenderness in nasal sinuses.Eye: Bilateral eyelids were not swelling. No ptosis. No entropion. Conjuncti va was not congestive. Sclera was anicteric. Eyeballs were not projected or dep ressed. Movement was normal. Bilateral pupils were round and equal in size. Dir ect and indirect pupillary reactions to light were existent.Mouth: Oral mucous membrane was smooth, and of no ulcer or erosion. Tongue w as in midline. Pharynx was not congestive. Tonsils were not enlarged.Neck: Symmetric and of no deformities. No masses. Thyroid was not enlarged. Tra chea was in midline.ChestChestwall: Veins could not be seen easily. No subcutaneous emphysema. Interco stal space was neither narrowed nor widened. No tenderness.Thorax: Symmetric bilaterally. No deformities.Breast: Symmetric bilaterally. Neither nipples nor skin were retracted. Elast icity was fine.Lungs: Respiratory movement was bilaterally symmetric with the frequency of 2 0/min. Thoracic expansion and tactile fremitus were symmetric bilaterally. No p leural friction fremitus. Resonance was heard during percussion. No abnormal br eath sound was heard. No wheezes. No rales.Heart: No bulge and no abnormal impulse or thrills in precordial area. The po int of maximum impulse was in 5th left intercostal space inside of the mid clav icular line and not diffuse. No pericardial friction sound. Border of the heart was normal. Heart sounds were strong and no splitting. Rate 80/min. Cardiac rh ythm was regular. No pathological murmurs.Abdomen: Flat and soft. No bulge or depression. No abdominal wall varicosis. Ga stralintestinal type or peristalses were not seen. There was not tenderness and rebound tenderness on abdomen or renal region. Liver was not reached. Spleen w as not enlarged. No masses. Fluidthrill negative. Shifting dullness negative. B orhorygmus 5/min. No vascular murmurs.Extremities: No articular swelling. Free movements of all limbs.Neural system: Physiological reflexes were existent without any pathological o nes.Genitourinary system: Not examed.Rectum: not exanedInvestigationBlood-Rt: Hb 127g/l RBC 3.93T/l WBC 3.9G/lUrine-Rt: SG 1.070 pH 6.0B-ultrasound: 1. subserous myoma of uterus2. position of loop is normalHepatic function: NormalPT & APTT: NormalProfessional ExaminationPudendum: Married typeVagina: unobstructed, secretion is excessive, white and ropy.Os of cervix: No bleeding, slight anabrosis.Body of uterus: Big like a fist of man, hard and its surface is smooth.Others: NormalHistory summary1. Patient was female, 45 years old2. The patient was found “myoma of uterus” over two year ago and me nometrorrh agia for 5 months..3. No special past history.4. Physical examination showed no abnormity in lung, heart and abdoman. Profess ional examination can been seen above.5. investigation information: see aboveImp ression: subserous myoma of uterusSignature: He Lin (95-10033)来源：杨帆|分享(7)|浏览(49)（注：文档可能无法思考全面，请浏览后下载，供参考。
妇产科英文模板
CASEMedical Number: 756943General informationName:Yue Jun-rong Age: Forty- two years oldSex: Female Race:HanOccupation: Unemployment Nationality:ChinaMarital status: Married Address : Xiaochang county of Xiaogan city in Hubei. Tel: 4835963Date of admission: , 2003 Date of record: 3pm, , 2003Complainer of history: the patient herself Reliability: ReliableChief complaint: The patient was found “myoma of uterus” over two yearsago and menometrorrhagia for 5 months.Present illness: In 1999, the patient was found “myoma of uterus” in a physic al examination. But she had nothing uncomfortable and her catamenia was normal. She used some Chinese traditional medicine. About 5 months ago, she found the cycle of her catamenia was shorten from 30 days to 20 days and the period laste d from 2 days to 4 days. She felt no pain and the quantity was normal. She was accepted in our hospital and her diagnosis was “subserous myoma of uterus”.Since onset, her appetite was good, and both her spiritedness and physical ener gy are normal. Defecation and urination are normal, too.Past historyOperative history: Never undergoing any operation.Infectious history: No history of severe infectious disease.Allergic history: She was not allergic to penicillin or sulfamide.Respiratory system: No history of respiratory disease.Circulatory system: No history of precordial pain.Alimentary system: No history of regurgitation.Genitourinary system: No history of genitourinary disease.Hematopoietic system: No history of anemia and mucocutaneous bleeding.Endocrine system: No acromegaly. No excessive sweats.Kinetic system: No history of confinement of limbs.Neural system: No history of headache or dizziness.Personal historyShe was born in Hubei on July 16th, 1956 and almost always lived in Wuhan. She graduated from senior high school. Her living conditions were good. No bad per sonal habits and customs.Menstrual history: The first time when she was 14. Lasting 2 days every times and its cycle is about 30 days.Obstetrical history: Pregnacy 3 times, once nature production, induced abortio n twice.Contraceptive history: Not clear.Family history: His parents are both alive.Physical examinationT ℃, P 80/min, R 20/min, BP 120/80mmHg. She is well developed and moderately nourished. Active position. The skin was not stained yellow. No cyanosis. No pi gmentation. No skin eruption. Spider angioma was not seen. No pitting edema. Su perficial lymph nodes were not enlarged.HeadCranium: Hair was black and well distributed. No deformities. No scars. No m asses. 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 acui ty was normal.Nose: No abnormal discharges were found in vetibulum nasi. Septum nasi was i n midline. No nares flaring. No tenderness in nasal sinuses.Eye: Bilateral eyelids were not swelling. No ptosis. No entropion. Conjuncti va was not congestive. Sclera was anicteric. Eyeballs were not projected or dep ressed. Movement was normal. Bilateral pupils were round and equal in size. Dir ect and indirect pupillary reactions to light were existent.Mouth: Oral mucous membrane was smooth, and of no ulcer or erosion. Tongue w as in midline. Pharynx was not congestive. Tonsils were not enlarged.Neck: Symmetric and of no deformities. No masses. Thyroid was not enlarged. Tra chea was in midline.ChestChestwall: Veins could not be seen easily. No subcutaneous emphysema. Interco stal space was neither narrowed nor widened. No tenderness.Thorax: Symmetric bilaterally. No deformities.Breast: Symmetric bilaterally. Neither nipples nor skin were retracted. Elast icity was fine.Lungs: Respiratory movement was bilaterally symmetric with the frequency of 2 0/min. Thoracic expansion and tactile fremitus were symmetric bilaterally. No p leural friction fremitus. Resonance was heard during percussion. No abnormal br eath sound was heard. No wheezes. No rales.Heart: No bulge and no abnormal impulse or thrills in precordial area. The po int of maximum impulse was in 5th left intercostal space inside of the mid clav icular line and not diffuse. No pericardial friction sound. Border of the heart was normal. Heart sounds were strong and no splitting. Rate 80/min. Cardiac rh ythm was regular. No pathological murmurs.Abdomen: Flat and soft. No bulge or depression. No abdominal wall varicosis. Ga stralintestinal type or peristalses were not seen. There was not tenderness and rebound tenderness on abdomen or renal region. Liver was not reached. Spleen w as not enlarged. No masses. Fluidthrill negative. Shifting dullness negative. B orhorygmus 5/min. No vascular murmurs.Extremities: No articular swelling. Free movements of all limbs.Neural system: Physiological reflexes were existent without any pathological o nes.Genitourinary system: Not examed.Rectum: not exanedInvestigationBlood-Rt: Hb 127g/l RBC l WBC lUrine-Rt: SG pHB-ultrasound: 1. subserous myoma of uterus2. position of loop is normalHepatic function: NormalPT & APTT: NormalProfessional ExaminationPudendum: Married typeVagina: unobstructed, secretion is excessive, white and ropy.Os of cervix: No bleeding, slight anabrosis.Body of uterus: Big like a fist of man, hard and its surface is smooth.Others: NormalHistory summary1. Patient was female, 45 years old2. The patient was found “myoma of uterus” over two year ago and menometrorrh agia for 5 months..3. No special past history.4. Physical examination showed no abnormity in lung, heart and abdoman. Profess ional examination can been seen above.5. investigation information: see aboveImp ression: subserous myoma of uterusSignature: He Lin (95-10033)来源：杨帆|分享(7)|浏览(49)。
表格式住院病例中英版POMR
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 diagnoseand 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 odynuria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 bleeding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 and communicable 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cm Dusculation: 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V ocal 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。
妇科英文病历模板
妇科英文病历模板篇一:妇产科英文模板CASEMedical Number: 756943General informationName: Yue Jun-rongAge: Forty- two years old Sex: FemaleRace: Han Occupation: UnemploymentNationality: ChinaMarital status: Married Address : Xiaochang county of Xiaogan cityin Hubei. Tel: 4835963Date of admission: Feb.27th, 2003Date of record: 3pm, Feb.27th, 2003 Complainer of history: the patient herselfReliability: ReliableChief complaint: The patient was found “myoma ofuterus” over two years ago and menometrorrhagia for 5 months.Present illness: In 1999, the patient was found “myoma ofuterus” in a physical examination. But she had nothing1uncomfortable and her catamenia was normal. She used some Chinese traditional medicine. About 5 months ago, she found the cycle of her catamenia was shorten from 30 days to 20 days and the period lasted from 2 days to 4 days. She felt no pain and the quantity was normal. She was accepted in our hospital and her diagnosis was “subserous myoma of uterus”.Since onset, her appetite was good, and both her spiritedness and physical energy are normal. Defecation and urination are normal, too.Past historyOperative history: Never undergoing any operation.Infectious history: No history of severe infectious disease.Allergic history: She was not allergic to penicillin or sulfamide.Respiratory system: No history of respiratory disease.Circulatory system: No history of precordial pain.Alimentary system: No history of regurgitation.Genitourinary system: No history of genitourinary disease. Hematopoietic system: No history of anemia andmucocutaneous bleeding. Endocrine system: Noacromegaly. No excessive sweats.2Kinetic system: No history of confinement of limbs.Neural system: No history of headache or dizziness.Personal historyShe was born in Hubei on July 16th, 1956 and almost always lived in Wuhan. She graduated from senior high school. Her living conditions were good. No bad personal habits and customs.Menstrual history: The first time when she was 14. Lasting 2 days every times and its cycle is about 30 days.Obstetrical history: Pregnacy 3 times, once nature production, induced abortion twice.Contraceptive history: Not clear.Family history: His parents are both alive.Physical examinationT 36.8?, P 80/min, R 20/min, BP 120/80mmHg. She is well developed and moderately nourished. Active position. The skin was not stained yellow. No cyanosis. No pigmentation. No skin eruption. Spider angioma was not seen. No pitting edema. Superficial lymph nodes were not enlarged.HeadCranium: Hair was black and well distributed. No deformities. No scars. No masses. No tenderness.3Ear: Bilateral auricles were symmetric and of no masses. No discharges were found in external auditory canals. No tenderness in mastoid area. Auditory acuity was normal.Nose: No abnormal discharges were found in vetibulum nasi. Septum nasi was in midline. No nares flaring. No tenderness in nasal sinuses.Eye: Bilateral eyelids were not swelling. No ptosis. No entropion. Conjunctiva was not congestive. Sclera was anicteric. Eyeballs were not projected or depressed. Movement was normal. Bilateral pupils were round and equal in size. Direct and indirect pupillary reactions to light were existent.Mouth: Oral mucous membrane was smooth, and of no ulcer or erosion. Tongue was in midline. Pharynx was not congestive. Tonsils were not enlarged.Neck: Symmetric and of no deformities. No masses. Thyroid was not enlarged. Trachea was in midline.ChestChestwall: Veins could not be seen easily. No subcutaneous emphysema. Intercostal space was neither narrowed nor widened. No tenderness.Thorax: Symmetric bilaterally. No deformities.4Breast: Symmetric bilaterally. Neither nipples nor skin were retracted. Elasticity was fine.Lungs: Respiratory movement was bilaterally symmetric with the frequency of 20/min. Thoracic expansion and tactile fremitus were symmetric bilaterally. No pleural friction fremitus. Resonance was heard during percussion. No abnormal breath sound was heard. No wheezes. No rales.Heart: No bulge and no abnormal impulse or thrills in precordial area. The point of maximum impulse was in 5th left intercostal space inside of the mid clavicular line and not diffuse. No pericardialfriction sound. Border of the heart was normal. Heart sounds were strong and no splitting. Rate 80/min. Cardiac rhythm was regular. Nopathological murmurs.Abdomen: Flat and soft. No bulge or depression. No abdominal wall varicosis. Gastralintestinal type or peristalses were not seen. There was not tenderness and rebound tenderness on abdomen or renal region. Liver was not reached. Spleen was not enlarged. No masses. Fluidthrill negative. Shifting dullness negative. Borhorygmus 5/min. No vascular murmurs.Extremities: No articular swelling. Free movements of all5limbs.Neural system: Physiological reflexes were existent without any pathological ones. Genitourinary system: Not examed.Rectum: not exanedInvestigationBlood-Rt: Hb 127g/l RBC 3.93T/l WBC 3.9G/lUrine-Rt: SG 1.070 pH 6.0B-ultrasound: 1. subserous myoma of uterus2. position of loop is normalHepatic function: NormalPT & APTT: NormalProfessional ExaminationPudendum: Married typeVagina: unobstructed, secretion is excessive, white and ropy.Os of cervix: No bleeding, slight anabrosis.Body of uterus: Big like a fist of man, hard and its surface is smooth.Others: NormalHistory summary1. Patient was female, 45 years old2. The patient was found “myoma of uterus” over two6year ago and menometrorrhagia for 5 months..3. No special past history.4. Physical examination showed no abnormity in lung, heart and abdoman. Professional examination can been seen above.5. investigation information: see aboveImpression: subserous myoma of uterusSignature: He Lin (95-10033)来源:杨帆| 分享(7) | 浏览(49)篇二:妇产科英文病历Inpatient HistoryName: Yali ZhouSex: FemaleAge: 38year Ward: No.8 Bed: No.816 Marital status: Married Birthplace: ShanghaiNationality: Han Provider: Patient, reliable. Record date: 2005-12-13G & O History: GW: 30+5weeks, G2P0, LMP: 2005-5-10; EDC: 2006-2-17Chief Complaint: G2P0, GW: 30+5weeks. This patient presents hypertension for 3 months, and systemic edema for 2 weeks.7History of Present illness:The patient had regular menses previously. LMP: 2005-5-10; EDC:2006-2-17. Uric HcG test was positive after 40 days of amenorrhea. Fetal movements were felt in 4 months’ gestation. In 12+2weeks’ gestation, the patient’s blood pressure was found 160/90 mmHg when shecompleted her first ante-partum examination in Hospital of Women and Children’s Health in Huangpu District. Therewas no symptoms at that time, and she didn’t take anytreatment. Half a month ago, she presented edema on both the lower extremities, which expanded to the whole body gradually. She came to our hospital on Dec, 5th and took her sencond ante-partum examination. The bp was200/160mmHg, and uric protein(++) on dipstick test. She has occasional headaches, but no epigastric pain, no visual disturbances, no oliguria, no nausea or vomiting, no thoracic pain. She was admitted on 2005-12-6.After admission, she appears clear, with a good appetite, good sleeping, and normal urination and defecation.Past history: Patient denies history of hepatitis and tuberculosis. No history of allergies. Vaccinated regularly. Past medical history is uemarkable. Surgical history denied.8No history of severe trauma and transfusion.Review of systems:Respiratory system: No history of chronic cough or breathlessness. No hemoptysis or dyspnea.Cardiovascular system: No precordial pain. No palpation. No syncope. For details see present history.Gastroentestinal system: No history of chronic abdominal pain and diarrhea; No nausea or vomiting; No hematemesis and blood stool.Endocrinic system: No polydipsia or polyphasia or polyuria. No sudden change of character and intelligence.Hematologic system: No bruises or abnormal hemorrhage. No recurrent oral ulcer and gingival bleeding.Genitourinary system: No decreased libido; No vaginal dryness or vaginal bleeding; History of STD denied; No urinary frequency. No precipitant urination or dysuria. No hematuria or proteinuria.Neuropsychiatric system: No convulsion or anesthesia. No headaches. No abnormal orientation. No deterioration of memory or intelligence.Locomotor system: No arthralgia, no muscular atrophies or dystrophies.9Personal History:Born and grown up in Shanghai. Patient denied history of tobacco or alcohol use.Marital and Childbearing history: Married. 0-0-1-0; She had an abortion in 3 months’ gestation in Dec., 2004. Birthcontrol has been instructed.Family history: The patient’s Mother and a sister sufferedfrom hypertension. No family history of DM or stroke. No family history of nervous or mental diseases.Physical ExaminationT: 37? P: 89/minR: 20/minBP: 180/120mmHgGeneral appearance: Patient is a 38 years old female who appears pleasant, in no apperant distress, given her age, well developed andwell nourished. Oriented to person, place and time.Lymph nodes: Not enlarged.Skin: No jaundice or rashes. No cyanosis and bruises. No edema.Head: Skull and scalp normal. No tenderness. No loss of hair.Eyes: No edema in eyelids, no ptosis, no conjunctivalcongestion.Width of palpebral fissures is normal. No10jaundice. Pupil’s size and shape is normal. Corneal is clear. No exophthalmos.Ears: Auditory acuity is excellent. No ear purulent discharge.Nose: Shape is normal. No obstruction. No deviation of nasal septum.Mouth: No lips herpes. No cyanosis. No gums pyorrhea and bleeding. No tongue deviation. Tonsils not enlarged.Neck: Her neck is soft. Trachea is midline. No thyroid abnormality was found. Neck vein was not distended.Chest: Contour is normal. No sternum tenderness. The breasts are bilaterally symmetrical. No tenderness and mass.Lung:Inspection: Respiration regular. Degree of expansion is symmetry.Plapation: Tactile fremitus symmetrical.Percussion: extensive resonance to percussion.Ausculation: Clear to ausculation with no rubs noted.Heart:Inspection: No abnormal pulsation or retraction.Plapation: The apex beat can be felt in the 5th intercostal space 1 cm inside of the left mid-clavicular line.11Percussion: The border of cardiac is not enlarged.Ausculation: The heart sounds were of good quality and the rhythm was regular.Radial pulse is normal.Abdomen:Inspection: Universial abdominal bulge. Dilated veins observed.Palpation: Soft. Liver and spleen is not enlarged. Nontender. Murphy’s sign is negative. For details seeobstetric examination.Percussion: No shifting dullness. The upper border of the liver is in the 5th intercostal space.Ausculation: Bowl sound clear. 4/min.Spine and extremities: Severe edema in both lower extremities. No clubbed finger. No disorder of the movement of axial and appendicular bones.Reflex: Symmetrical, equal without pathological responses. Babinski sign and Kernig sign and hoffmann sign are all negative.Obstetric examinationPatient appears pleasant, given her age, well developed and12well nourished. No jaundice. No enlarged lymph nodes.Fetus: Abdominal girth: 93cm; height of fundus: 29cm; estimated fetal weight: 1600g; fetal position: LOA; point of fetal heart tone: ; fetal heart rate: 148/min; FM: active.Pelvis: 24-17-19-9 cm.Anorectal examination: fetal presentation: N/A; sincipital presentation: N/A; fetal membrane: not ruptured. Amniotic fluid: N/A;Flexion of knee: active.Laboratory and special examinationthDec. 6, Blood Rt: Hb: 121g/L; PLT 136×10e9Urine Rt: uric protein(++); occlude blood: (+++)Dec. 7th, Fetal Ultrasound: BPD: 78mm; HC: 259mm; AC: 238mm; FL:51mm; HL:49mm. fetal presentation: head; Position of placenta: right wall of uterus.Thickness of placenta: 23mm. Degree of placental maturity: ?; fetal heartbeat and fetal movement seen; amniotic fluid: 64mm. There is no hematocoelia or ascites. The lower edge of placenta is1323mm from thecervix.Umbilical A: P2: 0.87; R2: 0.59; S/D: 2.46.Fetal heart rate: 145/minDec. 8th, 24h uric protein: 7.5gDec.10th, serum potassium: 3.9mmol/LScr: 86umol/LALT: 25U/L ; AST: 30U/LFeatures of the case:1. Female, 38years old, G2P0, GW: 30+5weeks.2. This patient presents hypertension for 3 months, andsystemic edema for 2 weeks.3. PE: BP: 180/120mmHg. Obstetric exam: Fetus: Abdominal girth: 93cm; height offundus: 29cm; estimated fetal weight: 1600g; fetal position:LOA; point of fetal hearttone: ; fetal heart rate: 148/min; FM: active.Pelvis: 24-17-19-9 cm.Flexion of knee: active.4. Laboratory and special exam:Dec. 6th, Blood Rt: Hb: 121g/L; PLT 136×10e9Urine Rt: uric protein(++); occlude blood: (+++)14Dec. 7th, Fetal Ultrasound: BPD: 78mm; HC: 259mm; AC: 238mm; FL:51mm;Degree of placental maturity: ?; fetal heartbeat and fetalmovementseen; amniotic fluid: 64mm.Umbilical A: P2: 0.87; R2: 0.59; S/D: 2.46.Fetal heart rate: 145/minDec. 8th, 24h uric protein: 7.5gDec.10th, serum potassium: 3.9mmol/LScr: 86umol/LALT: 25U/L ; AST: 30U/LDiagnosis and differential diagnosis:Diagnosis: 1. Severe pre-eclampsia. This patient is a 38-year-old woman, who presents with hypertension and edema. Pre-eclampsia is hypertension associated with proteinuria and edema, occurring primarily in nulliparas after the 20th gestational week and most frequently near term. Other clinical findings of the patient include uric protein (++),etc. These lead to the diagnosis of pre-eclampsia, which feature the clinic status of the latter. The patient has (1) blood pressure 180/120mmHg(160/110mmHg);15(2)proteinuria(++) on dipstick testing and 7.5g (5g)in a 24-hour period. Conclusively, she can be classified as severe pre-eclampsia.Pre-eclampsia is a multisystemic syndrome, primary investigations reveal that she has occasional headaches, but no epigastric pain, no visual disturbances, no oliguria, no nausea or vomiting, no thoracic pain, indicating that there are no many complications at present. Further evaluations are indispensable, which requires more careful investigations.2. Chronic essential hy pertension. The patient’shypertension began from the 12w of gestation, which indicate thatshe has chronic hypertension. Besides, she has a family history of hypertension. After all, she doesn’tpresent severe complaints when her blood pressure were as high as 200/160mmHg. All these lead to the diagnosis of chronic hypertension. To confirm the diagnosis, the blood pressure after delivery should be evaluated.Differential diagnosis: 1. chronic essential hypertension associated with pregnancy. Essential hypertension associated with pregnancy can also cause a very high blood pressure. However, given the age,proteinuria and edema are possibly not complications of hypertension, indicating that she has16superimposed pre-eclampsia. Besides, the symptoms of proteinuria and edema are temporally associated with gestation.2. Chronic hypertension due to renal disease. This includes chronic hypertension due to interstitial nephritis, chronic glomerulonephritis, SLE, diabetic glomerulosclerosis, and so on. In these occasions, the patient would also possibly present hypertension, proteinuria and edema, but her proteinuria was found recently and she didn’t have any symptoms associated with renal diseases previously. In addition, her serum creatinine is in the normal scale (Scr: 86umol/L), which contradicts the hypothesis that she has a renal disease. So the diagnosis of chronic hypertension due to renal disease is not considered at present.Further investigations and treatments:1. Close observation and monitoring, plus quick evaluation: daily weighing; q4-6h monitoring of blood pressure; daily monitoring ofprotein in urine; Regular liver and kidney function testing; Ultrasound of the abdomen; Fetus heartbeat monitor; Conduct ophthalmoscopy examination to evaluat e the severity of the patient’s condition; Conduct PT,APTT, FDP, 3P test to evaluate the coagulant function.172. Rests: Lie in bed on left side.3. Magnesium sulfate administration with close observation offlexion of knee, respiratory rate and urine.4. Control hypertension with Labetalol or Nitroglycerin. The goal of bp control is diastolic pressure《110mmHg andMAP《140mmHg.5. Administer furosemide to control edema.6. Cautious evaluation of the maternal and fetal complications and take action correspondingly. Severe maternal complications include edema of the brain, pulmonary edema; DIC; HELLP syndrome; renal failure. Indicative symptoms include headache, epigastric pain, visual disturbances, oliguria, nausea and vomiting, thoracic pain, etc.7. Use corticosteroids to accelerate fetal lung maturity.8. Delivery. In an effort to reduce perinatal morbidity and mortality, delivery should be delayed. If the patient develops into the following conditions: 1.Blood pressure consistently higher than 100mmHg diastolic in a 24h period or confirmed higher than 110mmHg; 2. Rising serum creatinine; 3. Persistent severe headache; 4. epigastric pain; 4. abnormal liver function tests; 5: Thrombocytopnia; 6: HELLP18syndrome; 7: Eclampsia; 8: Pulmonary edema; 9: Abnormal antepartum fetal heart rate testing; 10: SGA fetus with failure to grow on serial ultrasound examinations.Clinic diagnosis: 1. Severe pre-eclampsia2. Chronic essential hypertension Signiture: /Jacky Luo 篇三:妇科英文病历CASEMedical Number: 756943General informationName: Yue Jun-rongAge: Forty- two years oldSex: FemaleRace: HanOccupation: UnemploymentNationality: ChinaMarital status: MarriedAddress: Xiaochang county of Xiaogan city in Hubei. Tel: 4835963 Date of admission: Feb.27th, 2003 Date of record: 3pm, Feb.27th, 2003 Complainer of history: the patient herself Reliability: Reliable Chief complaint: The patient was found “myoma ofuterus” over two years ago and menometrorrhagia for 519months.Present illness: In 1999, the patient was found “myoma ofuterus” in a physical examination. But she had nothing uncomfortable and her catamenia was normal. She used some Chinese traditional medicine. About 5 months ago, she found the cycle of her catamenia was shorten from 30 days to 20 days and the period lasted from2 days to 4 days. She felt no pain and the quantity was normal. She was accepted in our hospital and her diagnosis was “subserous myoma of uterus”.Since onset, her appetite was good, and both her spiritedness and physical energy are normal. Defecation and urination are normal, too.Past historyOperative history: Never undergoing any operation.Infectious history: No history of severe infectious disease.Allergic history: She was not allergic to penicillin or sulfamide. Respiratory system: No history of respiratory disease.Circulatory system: No history of precordial pain.Alimentary system: No history of regurgitation. Genitourinary system: No history of genitourinary disease.20Hematopoietic system: No history of anemia and mucocutaneous bleeding.Endocrine system: No acromegaly. No excessive sweats.Kinetic system: No history of confinement of limbs.Neural system: No history of headache or dizziness.Personal historyShe was born in Hubei on July 16th, 1956 and almost always lived in Wuhan. She graduated from senior high school. Her living conditions were good. No bad personal habits and customs.Menstrual history: The first time when she was 14. Lasting 2 days every times and its cycle is about 30 days.Obstetrical history: Pregnacy 3 times, once nature production, induced abortion twice.Contraceptive history: Not clear.Family history: His parents are both alive.Physical examinationT 36.8?, P 80/min, R 20/min, BP 120/80mmHg. She is well developed and moderately nourished. Active position. The skin was not stained yellow. No cyanosis. No pigmentation. No skin eruption. Spider angioma was not seen. No pitting edema. Superficial lymph nodes were not21enlarged. HeadCranium: Hair was black and well distributed. No deformities. No scars. No masses. No tenderness.Ear: Bilateral auricles were symmetric and of no masses. No discharges were found in external auditory canals. No tenderness in mastoid area. Auditory acuity was normal.Nose: No abnormal discharges were found in vetibulum nasi. Septum nasi was in midline. No nares flaring. No tenderness in nasal sinuses.Eye: Bilateral eyelids were not swelling. No ptosis. No entropion.Conjunctiva was not congestive. Sclera was anicteric. Eyeballs were not projected or depressed. Movement was normal. Bilateral pupils wereround and equal in size. Direct and indirect pupillary reactions tolight were existent.Mouth: Oral mucous membrane was smooth, and of no ulcer or erosion. Tongue was in midline. Pharynx was not congestive. Tonsils were not enlarged.Neck: Symmetric and of no deformities. No masses. Thyroid was not enlarged. Trachea was in midline.ChestChestwall: Veins could not be seen easily. No subcutaneous22emphysema. Intercostal space was neither narrowed nor widened. No tenderness.Thorax: Symmetric bilaterally. No deformities.Breast: Symmetric bilaterally. Neither nipples nor skin were retracted. Elasticity was fine.Lungs: Respiratory movement was bilaterally symmetric with the frequency of 20/min. Thoracic expansion and tactile fremitus were symmetric bilaterally. No pleural friction fremitus. Resonance was heard during percussion. No abnormal breath sound was heard. No wheezes. No rales.Heart: No bulge and no abnormal impulse or thrills in precordial area. The point of maximum impulse was in 5th left intercostal space inside of the mid clavicular line and not diffuse. No pericardialfriction sound. Border of the heart was normal. Heart sounds were strongand no splitting. Rate 80/min. Cardiac rhythm was regular. Nopathological murmurs.Abdomen: Flat and soft. No bulge or depression. No abdominal wall varicosis. Gastralintestinal type or peristalses were not seen. Therewas not tenderness and rebound tenderness on abdomen or renal region. Liver was not reached. Spleen was not enlarged. No masses. Fluidthrill23negative. Shifting dullness negative. Borhorygmus 5/min. No vascular murmurs. Extremities: No articular swelling. Free movements of all limbs.Neural system: Physiological reflexes were existent without anypathological ones.Genitourinary system: Not examed.Rectum: not exanedInvestigationBlood-Rt: Hb 127g/l RBC 3.93T/l WBC 3.9G/lUrine-Rt: SG 1.070 pH 6.0B-ultrasound: 1. subserous myoma of uterus2. position of loop is normalHepatic function: NormalPT & APTT: NormalProfessional ExaminationPudendum: Married typeVagina: unobstructed, secretion is excessive, white and ropy.Os of cervix: No bleeding, slight anabrosis.Body of uterus: Big like a fist of man, hard and its surface is smooth. Others: Normal24History summary1. Patient was female, 45 years old2. The patient was found “myoma of uterus” over twoyear ago and menometrorrhagia for 5 months..3. No special past history.4. Physical examination showed no abnormity in lung, heart and abdoman. Professional examination can been seen above.5. investigation information: see aboveImpression: subserous myoma of uterusSignature: He Lin (95-10033)25。
产科MOSD诊治讲课病例
治疗效果显著
经过mosd诊治，患者病情得到有效控制，症状明显改善，生活质 量提高。
长期随访
为了评估治疗效果的持久性，对患者进行了长期随访，结果显示病 情稳定，无复发迹象。
对照实验
将mosd诊治组与常规治疗组进行对照实验，结果显示mosd诊治 组在疗效、安全性等方面均优于常规治疗组。
病例特点与难点
病例特点
。
参考文献2
02
提供了一份关于产科mosd的流行病学数据，分析了其发病原因
和影响因素。
参考文献3
03
综述了当前产科mosd的治疗方法，比较了各种方法的优缺点。
THANKS
感谢观看
鉴别诊断
排除其他类似疾病，确保 诊断的准确性。
治疗方案制定
根据患者具体情况，制定 个性化的治疗方案。
03
治疗过程
BIG DATA EMPOWERS TO CREATE A NEW
ERA
治疗方案
药物治疗
支持治疗
根据患者的具体情况，选择适当的药 物进行治疗，如抗生素、抗炎药等。
提供必要的营养、水和电解质支持， 维持患者的生命体征。
手术治疗
对于严重的产科mosd病例，可能需 要进行手术治疗，如清创术、引流术 等。
治疗过程及效果
初始治疗
根据患者的病情和诊断，制定初 始治疗方案，并进行初步治疗。
病情监测
在治疗过程中，密切监测患者的 病情变化，及时调整治疗方案。
疗效评估
根据患者的治疗效果，进行评估 和调整，确保治疗效果最佳。
并发症处理
改进建议
建议开展更多关于mosd诊治的临床研究，以积累更多的经验 和资料。加强医生培训和技术交流，提高mosd诊治的技术水 平和应用范围。同时，应关注患者的心理健康，加强心理支 持和护理。
妇科英文病历
妇科英文病历第一篇：妇科英文病历CASEMedical Number: 756943 General information Name: Yue Jun-rong Age: Forty-two years old Sex: Female Race: Han Occupation: Unemployment Nationality: China Marital status: Married Address: Xiaochang countyofXiaogan city in Hubei.Tel: 4835963Date of admission: Feb.27th, 2003 Date of record: 3pm, Feb.27th, 2003 Complainer of history: the patient herself Reliability: Reliable Chief complaint: The patient was found “myoma of uterus” over two years ago and menometrorrhagia for 5 months.Present illness: In 1999, the patient was found “myoma of uterus” in a physical examination.But she had nothing uncomfortable and her catamenia was normal.She used some Chinese traditional medicine.About 5 months ago, she found the cycle of her catamenia was shorten from 30 days to 20 days and the period lasted from 2 days to 4 days.She felt no pain and the quantity was normal.She was accepted in our hospital and her diagnosis was “subserous myoma of uterus”.Since onset, her appetite was good, and both her spiritedness and physical energy are normal.Defecation and urination are normal, too.Past history Operative history: Never undergoing any operation.Infectious history: No history of severe infectious disease.Allergic history: She was not allergic to penicillin or sulfamide.Respiratory system: No history of respiratory disease.Circulatory system: No history of precordial pain.Alimentary system: No history ofregurgitation.Genitourinary system: No history of genitourinary disease.Hematopoietic system: No history of anemia and mucocutaneous bleeding.Endocrine system: No acromegaly.No excessive sweats.Kinetic system: No history of confinement of limbs.Neural system: No history of headache or dizziness.Personal history She was born in Hubei on July 16th, 1956 and almost always lived in Wuhan.She graduated from senior high school.Her living conditions were good.No bad personal habits and customs.Menstrual history: The first time when she was sting 2 days every times and its cycle is about 30 days.Obstetrical history: Pregnacy 3 times, once nature production, induced abortion twice.Contraceptive history: Not clear.Family history: His parents are both alive.Physical examinationT 36.8℃, P 80/min, R 20/min, BP 120/80mmHg.She is well developed and moderately nourished.Active position.The skin was not stained yellow.No cyanosis.No pigmentation.No skin eruption.Spider angioma was not seen.No pitting edema.Superficial lymph nodes were not enlarged.Head Cranium: Hair was black and well distributed.No deformities.No scars.No masses.No tenderness.Ear: Bilateral auricles were symmetric and of no masses.No discharges were found in external auditory canals.No tenderness in mastoid area.Auditory acuity was normal.Nose: No abnormal discharges were found in vetibulum nasi.Septum nasi was in midline.No nares flaring.No tenderness in nasal sinuses.Eye: Bilateral eyelids were not swelling.No ptosis.No entropion.Conjunctiva was not congestive.Sclera was anicteric.Eyeballs were not projected or depressed.Movement was normal.Bilateral pupils were round and equal in size.Direct and indirect pupillary reactions to lightwere existent.Mouth: Oral mucous membrane was smooth, and of no ulcer or erosion.T ongue was in midline.Pharynx was not congestive.Tonsils were not enlarged.Neck: Symmetric and of no deformities.No masses.Thyroid was not enlarged.Trachea was in midline.ChestChestwall: Veins could not be seen easily.No subcutaneous emphysema.Intercostal space was neither narrowed nor widened.No tenderness.Thorax: Symmetric bilaterally.No deformities.Breast: Symmetric bilaterally.Neither nipples nor skin were retracted.Elasticity was fine.Lungs: Respiratory movement was bilaterally symmetric with the frequency of 20/min.Thoracic expansion and tactile fremitus were symmetric bilaterally.No pleural friction fremitus.Resonance was heard during percussion.No abnormal breath sound was heard.No wheezes.No rales.Heart: No bulge and no abnormal impulse or thrills in precordial area.The point of maximum impulse was in 5th left intercostal space inside of the mid clavicular line and not diffuse.No pericardial friction sound.Border of the heart was normal.Heart sounds were strong and no splitting.Rate 80/min.Cardiac rhythm was regular.No pathological murmurs.Abdomen: Flat and soft.No bulge or depression.No abdominal wall varicosis.Gastralintestinal type or peristalses were not seen.There was not tenderness and rebound tenderness on abdomen or renal region.Liver was not reached.Spleen was not enlarged.No masses.Fluidthrill negative.Shifting dullness negative.Borhorygmus 5/min.No vascular murmurs.Extremities: No articular swelling.Free movements of all limbs.Neural system: Physiological reflexes were existent without any pathological ones.Genitourinary system: Not examed.Rectum: not exaned Investigation Blood-Rt: Hb 127g/l RBC 3.93T/l WBC 3.9G/lUrine-Rt: SG 1.070 pH 6.0 B-ultrasound: 1.subserous myoma of uterus2.position of loop is normal Hepatic function: Normal PT & APTT: NormalProfessional Examination Pudendum: Married typeVagina: unobstructed, secretion is excessive, white and ropy.Os of cervix: No bleeding, slight anabrosis.Body of uterus: Big like a fist of man, hard and its surface is smooth.Others: NormalHistory summary1.Patient was female, 45 years old2.The patient was found “myoma of uterus” over two year ago and menometrorrhagia for 5 months..3.No special past history.4.Physical examination showed no abnormity in lung, heart and abdoman.Professional examination can been seen above.5.investigation information: see aboveImpression: subserous myoma of uterusSignature: He Lin(95-10033)第二篇：妇科方面护理病历妇科护理病历一、病人基本情况科别：妇科姓名：刘志玲性别：女年龄：45岁婚姻：已婚职业：干部文化程度：大专民族：汉入院日期：2013-11-10 收集资料日期：2013-12-1 医疗诊断：异位妊娠既往身体状况：1.个人史：生于原籍，久居成都市彭州，无放射性物质及毒物接触史，无烟酒等不良嗜好。
英文病例汇报模板
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Chief compliant
Two months after appendicectomy； Recurrent abdominal pain associated
with fever for one month
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Present history 1
right ventral abdominal pain，2 months
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Diagnosis
1. appendicitis after appendectomy 2. Abdominal Abscess
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Discusion：
further treatment?
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ago
appendicectomy in Hongkong
abdominal pain associated with fever for one
month
maximum body temperature up to 38.9℃
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Family History
There are no similar diseases in his family
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Physical Examination
right low abdominal pains tenderness（+）、 Rebound tenderness（+）;
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Blood routine
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CASEMedical Number: ********** General informationName:** Age: 25 years oldSex: Female Race: HanOccupation: others Nationality: ChinaMarital status: Married Address:ChangZhou JiangSuTel: *********Date of admission: Dec.27th, 2020 Date of record:11am, Dec.27th, 2020Complainer of history: the patient herself Reliability: ReliableChief complaint:The patient was found cessation of menstruation for 36+2w and vaginal bleeding for over one week.Present illness: The patient had regular menses previously. The first time when she was 14. Lasting4days every times and its cycle is about 30-45 days.LMP: 2020-4-17. Uric HCG test was positive after 50 days of amenorrhea. On 2020-6-10,her type-B ultrasonic revealed Intrauterine early pregnancy,correspond to gestational week of 6weeks+.According to the early ultrasonic result,we calculate EDC is 2021-2-2.The patient did not have obvious nausea and vomiting of pregnancy (NVP)in early stage of pregnancy .Fetal movements were felt in 4 months’gestation. She did ante-partum examination for totally seven times,but did not do down's screening and TORCH screening.OGTT showed that the level of her fasting blood glucose is 5.17mmol/L,while the level of postprandial blood sugar is normal.In the course of gestation, the patient did not get in touch with any radioactive rays,toxicant or pets. On 2020-12-20,the patient went to local hospital for treatment as a result of a little vaginal bleeding. After admission,she was given magnesium sulfate for fetus protection and dexamethasone for promotion of fetal lung maturity.when her bleeding station is under control, she left hospital. On 2020-12-26,as a result of “large amount of vaginal bleeding,more than menstr ual blood volume”, she went to Central Hospital of Wujin with emergency visit. After admission, she was given Ritodrine for fetus protection. And then she was sent to our hospital for further treatment. Until today, the patient is found cessation of menstruation for 36+2w,and further accounting gestational age is 35 weeks according to the ultrasonic. There is still some dark red vaginal bleeding. While the patient did not feel abdonimal pain, and there was no vaginal discharge. So she was accepted to our hospital and her diagnosis was “36+2weeks of gestation, Dangerous placenta previa”. After admission, she appears clear, with a good appetite, good sleeping, and normal urination and defecation. Her strength is a little diminished, and the weight has physiological changes.Past historyHealth status:good.Operative history: She received cesarean operation in 2011.Infectious history: No history of severe infectious disease.Allergic history: She was not allergic to penicillin or sulfamide.Respiratory system: No history of respiratory disease.Circulatory system: No history of precordial pain.Alimentary system: No history of regurgitation.Genitourinary system: No history of genitourinary disease.Hematopoietic system: No history of anemia and mucocutaneous bleeding.Endocrine system: No acromegaly. No excessive sweats. Kinetic system: No history of confine ment of limbs.Neural system: No history of headache or dizziness.Personal historyShe was born in Changzhou and almost always lived in Changzhou. There was no any endemic disease in Changzhou. Her living conditions were good. No bad personal habits and customs. Menstrual history: The first time when she was 14. Lasting 4days every times and its cycle i s about 30-45 days. LMP: 2020-4-17.Obstetrical history: marital age:22 years old.Pregnacy 4 times, once cesareandelivery.induced abortion 2 times.Family history: Her parents are both alive.COVID-19 epidemic area：NO.Physical examinationT: 36.0℃P: 76/min R: 20/min BP: 112/67mmHgGeneral appearance: Patient is a 25 years old female who appears pleasant, in no apperant distress, given her age, well developed and well nourished. Oriented to person, place and time. Lymph nodes: Not enlarged.Skin: No jaundice or rashes. No cyanosis and bruises. No edema.Head: Skull and scalp normal. No tenderness. No loss of hair.Eyes: No edema in eyelids, no ptosis, no conjunctival congestion.Width of palpebral fissures is normal. No jaundice. Pupil’s size and shape is normal. Corneal is clear. No exophthalmos. Ears: Auditory acuity is excellent. No ear purulent discharge.Nose: Shape is normal. No obstruction. No deviation of nasal septum.Mouth: No lips herpes. No cyanosis. No gums pyorrhea and bleeding. No tongue deviation. Tonsils not enlarged.Neck: Her neck is soft. Trachea is midline. No thyroid abnormality was found. Neck vein was not distended.Chest: Contour is normal. No sternum tenderness. The breasts are bilaterally symmetrical. No tenderness and mass.Lung:Inspection: Respiration regular. Degree of expansion is symmetry.Plapation: Tactile fremitus symmetrical.Percussion: extensive resonance to percussion.Ausculation: Clear to ausculation with no rubs noted.Heart:Inspection: No abnormal pulsation or retraction.Plapation: The apex beat can be felt in the 5th intercostal space 1 cm inside of the leftmid-clavicular line.Percussion: The border of cardiac is not enlarged.Ausculation: The heart sounds were of good quality and the rhythm was regular.The left mid-clavicular line is 8.5 cm away from front midsternal line.Radial pulse is normal.Abdomen:Inspection: Universial abdominal bulge. Dilated veins unobserved.Palpation: Soft. Liver and spleen is not enlarged. Nontender. Murphy’s sign is negative. For details see obstetric examination.Percussion: No shifting dullness. The upper border of the liver is in the 5th intercostal space.Ausculation: Bowl sound clear. 4/min.Spine and extremities: Severe edema in both lower extremities. No clubbed finger. No disorder of the movement of axial and appendicular bones.Reflex: Symmetrical, equal without pathological responses. Babinski sign and Kernig sign and hoffmann sign are all negative.Obstetric examinationFetus: Abdominal girth: 116cm; height of fundus: 35cm; fetal heart rate: 148/min,regular. Uterine contraction is untouched. Internal Examination is not done. Pelvis: 23-27-19-9 cm. Outpatient data: one copy of medical record of outpatient.Features of the case:1. Patient was female, 25 years old ,married.2. The patient was found “cessation of menstruation for 36+2w and vaginal bleeding for over one week.”3. No special past history.4. Physical examination showed no abnormity in lung, heart and abdoman. Professional examinati on can been seen above.5. investigation information: see aboveImpression: 1. 36+2weeks of gestation.2. G4P13. LOA4. Dangerous placenta previa5. GDM6. Scarred uterusSignature:***.2020-01-21,11amDiscussionPlacenta praevia is an obstetric complication in which the placenta is inserted partially or wholly in the lower uterine segment. It is a leading cause of antepartum haemorrhage . So it should be taken seriously . Firstly, the situation should be stabilized. Secondly , relevant inspection should be carried to further prove our diagnosis and evaluate whether to terminate pregnancy. After admission, the patient was advised a complete rest in bed and was given Ritodrine to suppression uterus contraction. As for the examination results, we can see that NST is responsible, and FHR is 145bpm. Blood routine is normal, there is no anemia and infection. Besides, the level of blood glucose is normal. The diagnosis is proved to be central type of placenta previa, according to the ultrasonic. Besides ,it is likely that there exists partial placental implantation. Since the patient received cesarean section in the past, the situation is more dangerous. So we should terminate pregnancy as soon as possible. On the third day after admission, the patient received cesarean section and Lower uterine segment narrow suture operation. Because the placenta was not delivered completely and partial placental implantation existed, the patient needed to reexamined the ultrasonic some time later. Exact cause of placenta praevia is unknown. So we can not prevent it well. But if we take regular ante-partum examination, we can find it early and take serious attitude to it, it is better for both the mother and the babies.。