病历书写(英文)
英语病历作文格式模板
英语病历作文格式模板英文回答：Medical History Template。
Patient Information。
Name:Date of Birth:Address:Phone Number:Email:Insurance Information:Chief Complaint。
A brief summary of the patient's primary reason for the visit.Example: "The patient presents with a 3-day history of fever and chills."History of Present Illness。
A detailed description of the patient's symptoms, including:Onset: When did the symptoms first appear?Duration: How long have the symptoms been present?Severity: How severe are the symptoms?Location: Where are the symptoms located?Associated symptoms: Any other symptoms that are present, such as nausea, vomiting, or headache.Past Medical History。
A list of any previous medical conditions, surgeries, or hospitalizations.Example: "The patient has a history of hypertension and hyperlipidemia."Family History。
英文病历书写模板 medical history questionnaire
Medical History QuestionnaireNAME: _________________________________________TODAY’S DATE: __________________ First Middle Initial LastDATE OF BIRTH: __________________This questionnaire was designed to provide important facts regarding the history of your pain or condition. The information you provide will assist in reaching diagnosis and determining the source of your problem. Please take your time and answer each question as completely and honestly as possible. Please sign every page.N Antibiotics Y N LatexY N Sedatives N AspirinY N Local anesthetics Y N Sleeping pills N Barbiturates Y N Metals Y N Sulfa drugsN Codeine Y N Penicillin Y N NIodineY NPlasticY NOther ______________________ ________________________ _________________________LIST ANY MEDICATIONS CURRENTLY BEING TAKEN:MedicationDosage/FrequencyReason_________________________ _____________________ _______________________________________________ _________________________ _____________________ _______________________________________________ _________________________ _____________________ _______________________________________________ _________________________ ____________________________________________________________________ MEDICAL HISTORY: (Please indicate dates on items marked current or past)Medical ConditionMedical ConditionAcid refluxInsomniaAdenoids RemovedIntestinal disorder AnemiaJaw joint surgery ArteriosclerosisKidney problems Arthritisliver disease AsthmaLow energyAutoimmune disorder Meniere's disease Bleeding easilyMenstrual cramps Blood pressure - HighMultiple sclerosis Blood pressure - Low Muscle achesBotoxMuscle shaking (tremors) Bruising easilyMuscle spasms or cramps CancerMuscular dystrophy ChemotherapyNasal allergiesChronic coughNeeding extra pillow to help Chronic fatiguebreathing at nightChronic painNervous system irritability Cold hands and feet Nervousness COPDNeuralgiaDepressionNumbness of fingers DiabetesOsteoarthritis Difficulty concentratingOsteoporosisPatient Signature ______________________________ Date _________________________ Page 1Medical condition Never Current Past Medical condition Never Current PastDifficulty sleeping Ovarian cysts Dizziness Parkinson's disease Emphysema Poor circulationEpilepsy Prior orthodontic treatment Excessive thirst Psychiatric care Fibromyalgia Radiation treatment Fluid retention Rheumatic fever Frequent cough Rheumatoid arthritis Frequent illnessesScarlet fever Frequent stressful situations ScoliosisGeneral anesthesia Shortness of breath Glaucoma Sinus problems Gout Skin disorder Hay Fever Sleep apnea Hearing impaired Slow healing sores Heart attackSpeech difficulties Heart disorder StrokeHeart murmur Swelling in ankles or feet Heart pacemaker Swollen, stiff or painful joints Heart valve replacement Tendency for ear infections Hemophilia Tendency for frequent colds Hepatitis Tendency for sore throats Hypertension Thyroid disorder HypoglycemiaTired muscles Immune system disorder Tonsils removed Injury to face Tuberculosis Injury to mouth Tumors Injury to neckUrinary disorders Injury to teethWisdom teeth extractionMedical conditionMedical condition Other ____________________ADDITIONAL MEDICAL HISTORY ITEMS:Recreational Drugs HIV/AIDSN Appendectomy Y N HeartYN ThyroidN Back Y N Hernia repair Y N TonsillectomyN EarY N Lung Y N Uvulectomy NGallbladderY NNasalY NPeriodontalPatient Signature _________________________________Date____________________Page 2FAMILY HISTORY Has any member of your family had (parent, sibling or grandparent):YNCancer YNSleep disorder YNFather snoresY N Heart disease Y N Obesity Y NMother snoresYNDiabetesY NThyroid troubleYNFather has sleep apnea Y N Stroke Y N High blood pressure Y N Mother has sleep apnea SOCIAL HISTORY:Tobacco Use:smokedAlcohol Use:Caffeine Intake:None Coffee/Tea/Soda #cups per day: _______Additional:Page 3。
英文病历书写疼痛
英文病历书写：疼痛(1)当上楼梯时，突然痛了起来，并且持续不止。
The pain came on suddenly while walking up the stairs and it was persistent.疼痛的发生感觉疼痛 feel (have; suffer from) a pain; pain is felt in ; feel painful头痛 have a headache; be troubled with a headache; feel a pain in one's head患剧烈头痛 have a nasty (bad) headache时常头痛 be subject (a martyr) to headaches有撞击似的两侧性头痛 have bilateral pounding headaches头痛逐渐地变为频发(较不严重) headaches gradually become more frequent (less severe)ex1:咀嚼时，有偶发的、暂时的、不可言状的疼痛或敏感。
There is occasional， transient， nondescript pain， or sensibility during mastication.ex2:该齿对于压迫作痛，且有钝麻如咬的疼痛。
The tooth became sore to pressure and there is a dull gnawing pain.发生时间ex1:Epigastric pain comes immediately after meal.ex2:Colic pain came on and off since yesterday.ex3:This pain has been relentlessly postprandial， regardless of the character of her meals.ex4:The joint pains were present mainly at night， with relief during the day.ex5:The mild frontal headaches were usually present upon awakening，but not severe enough to require analgesics.ex6:The pain usually commenced within 30 minutes after meals and lasted 1 to 3 hours.发生原因ex1:He described the pain as dull and aching， occurring approximately once a week， unrelated to food intake， and radiating to his back.(2)起初疼痛无变化，但数小时时变成发作性的'痛。
英文病历书写范例
英文病历书写范例（内科）Medical Records for AdmissonMedical Number: 701721General informationName: Liu SideAge: EightySex: MaleRace: HanNationality: ChinaAddress: NO.35, Dandong Road, Jiefang Rvenue, Hankou, Hubei.Tel: 857307523Occupation: RetiredMarital status: MarriedDate of admission: Aug 6th, 2001Date of record: 11Am, Aug 6th, 2001Complainer of history:patient’s son and wifeReliability: ReliableChief complaint: Upper bellyache ten days, haematemesis, hemafecia and unconsciousness for fo ur hours.Present illness:The patient felt upper bellyache about ten days ago. He didn’t pay attention to it and thought heha date something wrong. At 6 o’cloc k this morning he fainted and rejected lots of blood and gore. T hen hemafecia began. His family sent him to our hospital and received emergent treatment. So the patient was accepted because of “upper gastrointestine hemorrhage and exsanguine shock”. Since the disease coming on, the patient didn’t urinate. Past historyThe patient is healthy before.No history of infective diseases. No allergy history of food and drugs.Past history Operative history: Never undergoing any operation. Infectious history: No history of s evere infectious disease. Allergic history: He was not allergic to penicillin or sulfamide. Respirator y system: No history of respiratory disease. Circulatory system: No history of precordial pain. Ali mentary system: No history of regurgitation.Genitourinary system: No history of genitourinary disease.Hematopoietic system: No history of anemia and mucocutaneous bleeding. Endocrine system: No acromegaly. No excessive sweats. Kinetic system: No history of confinement of limbs. Neural sys tem: No history of headache or dizziness. Personal historyHe was born in Wuhan on Nov 19th, 1921 and almost always lived in Wuhan. His living condition s were good. No bad personal habits and customs.Menstrual history: He is a male patient. Obstetrical history: NoContraceptive history: Not clear.Family history: His parents have both deads. Physical examinationT 36.5℃, P 130/min, R 23/min, BP 100/60mmHg. He is well developed and moderately nourished.Active position. His consciousness was not clear. His face was cadaverous and the skin was not sta ined yellow. No cyanosis. No pigmentation. No skin eruption. Spider angioma was not seen. No pi tting edema. Superficial lymph nodes were not found enlarged. HeadCranium: Hair was black and white, well distributed. No deformities. No scars. No masses. No ten derness.Ear: Bilateral auricles were symmetric and of no masses. No discharges were found in external au ditory canals. No tenderness in mastoid area. Auditory acuity was normal.Nose: No abnormal discharges were found in vetibulum nasi. Septum nasi was in midline. No nare s flaring. No tenderness in nasal sinuses. Eye: Bilateral eyelids were not swelling. No ptosis. No e ntropion. Conjunctiva was not congestive. Sclera was anicteric. Eyeballs were not projected or dep ressed. Movement was normal. Bilateral pupils were round and equal in size. Direct and indirect p upillary reactions to light were existent.Mouth: Oral mucous membrane was not smooth, and there were ulcer can be seen. Tongue was in midline. Pharynx was congestive. Tonsils were not enlarged.Neck: Symmetric and of no deformities. No masses. Thyroid was not enlarged. Trachea was in mi dline. ChestChestwall: Veins could not be seen easily. No subcutaneous emphysema. Intercostal space was nei ther narrowed nor widened. No tenderness.Thorax: Symmetric bilaterally. No deformities. Breast: Symmetric bilaterally.Lungs: Respiratory movement was bilaterally symmetric with the frequency of 23/min. thoracic e xpansion and tactile fremitus were symmetric bilaterally. No pleural friction fremitus. Resonance was heard during percussion. No abnormal breath sound was heard. No wheezes. No rales. Heart: No bulge and no abnormal impulse or thrills in precordial area. The point of maximum imp ulse was in 5th left intercostal space inside of the mid clavicular line and not diffuse. No pericardi al friction sound. Border of the heart was normal. Heart sounds were strong and no splitting. Rate 150/min. Cardiac rhythm was not regular. No pathological murmurs.Abdomen: Flat and soft. No bulge or depression. No abdominal wall varicosis. Gastralintestinal ty pe or peristalses were not seen. Tenderness was obvious around the navel and in upper abdoman. T here was not rebound tenderness on abdomen or renal region. Liver and spleen was untouched. No masses. Fluidthrill negative. Shifting dullness negative. Borhorygmus not heard. No vascular mur murs. Extremities: No articular swelling. Free movements of all limbs.Neural system: Physiological reflexes were existent without any pathological ones. Genitourinary system: Not examed. Rectum: not exanedInvestigationBlood-Rt: Hb 69g/L RBC 2.70T/L WBC 1. 1G/L PLT 120G/L History summary1. Patient was male, 80 years old2. Upper bellyache ten days, haematemesis, hemafecia and unconsciousness for four hours.3. No special past history.4. Physical examination: T 37.5℃, P 130/min, R 23/min, BP 100/60mmHg Superficial lymph node s were not found enlarged. No abdominal wall varicosis. Gastralintestinal type or peristalses were not seen. Tenderness was obvious around the navel and in upper abdoman. There was not rebound tenderness on abdomen or renal region. Liver and spleen was untouched. No masses. Fluidthrill ne gative. Shifting dullness negative. Borhorygmus not heard. No vascular murmurs. No other positive signs. 5. investigation information:Blood-Rt: Hb 69g/L RBC 2.80T/L WBC 1.1G/L PLT 120G/LImpression: upper gastrointestine hemorrhage Exsanguine shock出院小结（DISCHARGE SUMMARY）， ===============Department of GastroenterologyChanghai Hospital，No.174 Changhai Road Shanghai, China Phone: 86-21-25074725-803 DISCHARGE SUMMARYDA TE OF ADMISSION: October 7th, 2005 DA TE OF DISCHARGE: October 12th, 2005 ATTE NDING PHYSICIAN: Yu Bai, MD PA TIENT AGE: 18ADMITTING DIAGNOSIS:V omiting for unknown reason: acute gastroenteritis?BRIEF HISTORYA 18-year-old female with a complaint of nausea and vomiting for nearly one month who was see n at Department of Gastroenterology in Changhai Hospital, found to have acute gastroenteritis and non-atrophic gastritis. The patient was subsequently recovered and discharged soon after medicati on.REVIEW OF SYSTEMShe has had no headache, fever, chills, diarrhea, chest pain, palpitations, dyspnea, cough, hemopty sis, dysuria, hematuria or ankle edema.PAST MEDICAL HISTORYShe has had no previous surgery, accidents or childhood illness.SOCIAL HISTORY: She has no history of excessive alcohol or tobacco use.FAMIL Y HISTORYShe has no family history of cardiovascular, respiratary and gastrointestinal diseases. PHYSICAL EXAMINA TIONTemperature is 37, pulse 80, respirations 16, blood pressure 112/70. General: Plump girl in no app arent distress. HEENT: She has no scalp lesions. Her pupils are equally round and reactive to light and accommodation. Extraocular movements are intact. Sclerae are anicteric. Oropharynx is clear. There is no thyromegaly. There is no cervical or supraclvicular lymphadenopathy. Cardiovascular: Regular rate andrhythm, normal S1, S2. Chest: Clear to auscultation bilateral. Abdomen: Bowel sounds present, no hepatosplenomagaly. Extremities: There is no cyanosis, clubbing or edema. Neurologic: Cranial n erves II-XII are intact. Motor examination is 5/5 in the bilateral upper and lower extremities. Sens ory, cerebellar and gait are normal.LABORATORY DATAWhite blood cells count 5.9, hemoglobin 111g/L, hematocrit 35.4. Sodium 142, potassium 4.3, chl oride 106, CO2 25, BUN 2.6mmol/L, creatinine 57μmol/L, glucose 4.1mmol/L, Albumin 36g/L. Endoscopic ExamChronic non-atrophic gastritisHOSPITAL COURSEThe patient was admitted and placed on fluid rehydration and mineral supplement. The patient im proved, showing gradual resolution of nausea and vomiting. The patient was discharged in stable c ondition.DISCHARGE DIAGNOSIS Acute gastroenteritisChronic non-atrophic gastritisPROGNOSISGood. No medications needed after discharge. But if this patient can not get used to Chinese food, she had better return to UK as soon as possible to prevent the relapse of acute gastroenteritis. The patient is to follow up with Dr. Bai in one week. ___________________________ Yu Bai, MD D: 12/10/2005。
门诊病历书写规范模板
门诊病历书写规范模板门诊病历是诊断和治疗疾病的重要文件，对于医生来说，书写规范的门诊病历能够排除歧义，保证病历信息准确完整，提高医疗质量。
下面是一份门诊病历书写规范模板（英文翻译）。
1. Personal InformationName:Gender:Age:Occupation:Address:Contact Number:2. Chief ComplaintPlease describe your main reason for seeking medical attention.患者主诉：3. Present IllnessPlease provide a detailed description of your current illness, including when it started, the progression of symptoms, and any factors that may have worsened or improved the condition.患者现病史：4. Medical HistoryPlease provide information about any previous medical conditions, surgeries, or hospitalizations.患者既往史：5. AllergiesPlease list any known allergies, including medication allergies.患者过敏史：6. MedicationsPlease list any medications that you are currently taking, including dosage and frequency.患者用药史：7. Family HistoryPlease provide information about any significant medical conditions that run in your family.家族史：8. Social HistoryPlease provide information about your lifestyle and any habits that may affect your health, such as smoking, alcohol use, or drug use. 社会史：9. Review of SystemsPlease provide information about any additional symptoms or concerns you may have, including details about your cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, and nervous systems, as well as your skin, eyes, ears, and throat.患者系统回顾：10. Physical ExaminationPlease provide a summary of your physical examination findings, including vital signs, general appearance, and any specific abnormalities identified during the examination.体格检查：11. DiagnosisPlease provide a provisional or confirmed diagnosis based on your medical history, physical examination, and any diagnostic tests performed.临床诊断：12. InvestigationsPlease list any diagnostic tests that have been performed or ordered, including laboratory tests, imaging studies, or other investigations. 检查规格：13. TreatmentPlease provide details about any treatments that have been prescribed or administered, including medication, dosage, frequency, and any other relevant information.治疗方案：14. Follow-up PlanPlease provide information about any follow-up appointments, tests, or referrals that have been recommended or scheduled.随访计划：15. Advice and InstructionsPlease provide any advice or instructions that have been given to the patient, including information about medication side effects or precautions.医嘱：16. PrognosisPlease provide an assessment of the patient's prognosis, including any potential complications or long-term consequences of the current illness.预后评估：17. SignaturePlease sign and date the medical record to indicate that you have reviewed and confirmed its contents.医生签名日期：以上是一份门诊病历书写规范模板，对每个部分都进行了详细说明，希望能为医生书写规范的门诊病历提供参考。
口腔科英文病历书写范文
口腔科英文病历书写范文Patient Information.Name: [Patient Name]Age: [Patient Age]Chief Complaint.[Patient's chief complaint, e.g., "Pain in the lower left quadrant of the mouth"]History of Present Illness.Onset: [Date or time of onset]Duration: [How long the symptoms have been present]Severity: [Patient's description of the pain or discomfort]Associated symptoms: [Other symptoms associated with the chief complaint, e.g., swelling, bleeding, discharge]Aggravating factors: [Activities or situations that worsen the symptoms]Alleviating factors: [Activities or situations that relieve the symptoms]Previous treatment: [Any previous treatments the patient has received for the symptoms]Medical History.Past medical history: [Any significant past medical conditions, surgeries, or hospitalizations]Current medications: [All medications the patient is currently taking, including prescription and over-the-counter drugs]Allergies: [Any known allergies to medications orother substances]Social history: [Relevant social history, such as tobacco use, alcohol use, or occupational exposures]Dental History.Last dental visit: [Date of the patient's last dental appointment]Dental problems: [Any previous or current dental problems, including cavities, gum disease, or dental trauma]Dental habits: [Patient's daily oral hygiene routine, including brushing, flossing, and using mouthwash]Extraoral Examination.Head and neck: [Evaluation of the head and neck, including symmetry, lymph nodes, and range of motion]Face: [Evaluation of the face, including skin texture, color, and symmetry]Intraoral Examination.Soft tissues: [Examination of the soft tissues of the mouth, including the lips, cheeks, tongue, and palate]Hard tissues: [Examination of the hard tissues of the mouth, including the teeth and supporting structures]Periodontal examination: [Evaluation of theperiodontal tissues, including the gums, periodontal pockets, and bone levels]Occlusion: [Examination of the patient's bite]Radiographic Examination.[List of any radiographic examinations performed, e.g., X-rays, panoramic views, or CT scans]Findings: [Description of the radiographic findings]Diagnosis.[Diagnosis based on the history, examination, and radiographic findings]Treatment Plan.[Description of the recommended treatment plan, including any medications, procedures, or lifestyle modifications]Patient education: [Instructions for the patient onhow to care for their oral health and manage their symptoms]Progress Notes.[Follow-up progress notes documenting the patient's response to treatment, any changes in their symptoms, and any adjustments to the treatment plan]Additional Information.[Any other relevant information, such as the patient's dental insurance information or contact information for their primary care physician]。
英文病历书写
过饱的人 a heavy （great; hard） eater
食量 capacity for eating
ex1:他的食欲良好，但他平常的吃食习惯，由于口里伤处而中断。
His appetite was good, but the sore place in his mouth interrupted his usual eating habit.
没有发烧 be afebrile; have no fever
ex1:在发烧期间，他的平均体温是摄氏39度。
He ran a febrile course with an average temperature of 39°C.
ex2:他在患病期间尿量减少，并且发烧。
发烧
发烧 become feverish; have a temperature
发高烧 have a high fever
平常有微热，有几次升到38.4度 have low grade （slight） fever to 38.4°C on a few occasions
（2）他诉说非常口渴，但一点食欲也没有。
He complains of his thirst hard to release, while he has absolutely no appetite.
口渴
口渴 be （feel） thirsty form
ex2:他的胃口变得很大，食物热量增加2倍，但体重却减轻了10公斤。
His appetite became ravenous and his caloric intake doubled, yet he lost 10 kg.
英文病历书写——睡眠
儿科病历书写英文词汇(一)
儿科病历书写英文词汇（一）一、条目类入院记录：Admission note病史陈述者：Medical history presenter主述：Chief complaint现病史：History of present illness既往史：Past history个人史：Personal history家族史：Family history过敏史：Allergy history二、症状及病史类发热：fever咳嗽：cough流涕：runny nose热峰：peak temperature寒战：chill抽搐：seizure/convulsion头痛：headache头晕：dizziness晕厥：syncope嗜睡：drowsiness恶心：nausea呕吐/呕吐物：vomit喷射性呕吐：jetting vomit腹痛：abdominal pain腹泻：diarrhea水样便：watery stool粘液：mucus脓血：pus and blood里急后重：tenesmus泡沫尿：foamy urine胸闷：chest tightness胸痛：chest pain喘息：wheezing皮疹：rash脱皮：molt关节疼痛：joint pain口唇紫绀：blue lips甲状腺肿大：goiter肌肉酸痛：muscle soreness间断：intermittent加重：worsen progressively体温降至正常：temperature drop to normal缓解：relieve消退：subside剖腹产：cesarean足月顺产：naturally delivered at full term预防接种按计划进行：Vaccines are carried out as planned 精神运动发育：intellectural/mental and motor development 窒息：asphyxia缺氧：hypoxia抢救：rescue三、查体类神志清楚：clear mind精神好/差：good/poor spirit营养好：good nutrition status呼吸平稳：breath steadily黄染：yellowing贫血貌：pale appearance面色黄：sallow face皮疹：rash出血：bleeding瘀斑：ecchymosis/petechiae血肿：hematoma触及：palpable质软/韧： texture is soft/tough触痛：tenderness畸形：deformity眼睑水肿：eyelid edema结膜：conjunctiva充血：hyperemia巩膜：sclera对光反射灵敏：normal light reflection眼球充血：bloodshot eyes耳廓：auricle外耳道：external auditory canal分泌物：discharge/secretion口唇皲裂：dry and cracked lips草莓舌：strawberry tongue鼻腔：nasal cavity鼻中隔：nasal septum鼻翼扇动：fanning nose偏曲：deviation脓性分泌物：purulent secretion颈软：soft neck肿块：lump气管居中：centered trachea三凹征：triple/three concave sign胸廓对称：symmetrical thorax cavity 胸骨：sternum痰鸣音：phlegm干/湿啰音：dry/wet rales隆起：bulge心前区：precordial area心律规整：regular heart rhythm心脏杂音：murmur瓣膜听诊区：auscultation area肠鸣音：bowel sound反跳痛：rebound pain肌力：muscle strength肌张力：muscle tone脑膜刺激征：meningeal irritation sign 肘窝：elbow fossa皮毛窦：dermal sinus四、化验检查类：常规：routine血沉：erythrocyte sedimentation rate 降钙素原：procalcitonin多个核细胞：multinucleate cell涂片：smear革兰氏染色阳性：gram positive墨汁染色：ink stain抗酸杆菌涂片：acid fast test肺炎链球菌：streptococcus pneumoniae肺炎支原体：mycoplasma pneumoniae巨细胞病毒：cytomegalovirusEB病毒：Epstein-Barr virus单纯疱疹病毒：hepes simplex virus寡克隆区带：oligoclonal band微量白蛋白：trace protein窦性心律不齐：sinus arrhythmia室性早搏：ventricular premature beat超声：ultrasound心脏超声：echocardiography三尖瓣返流：tricuspid regurgitation心包积液：pericardial effusion冠状动脉瘤：coronary artery aneurysm腹腔积液：abdominal effusion脾大：splenomegaly肠系膜淋巴结肿大：mesenteric lymphadenopathy白细胞增多：leukocytosis蛋白尿：proteinuria低蛋白血症：hypoalbuminemia高脂血症：hyperlipidemia高凝状态：thrombophilia/hypercoagulabity巨核细胞：megakaryocyte肌电图：electromyography脑电图：electroencephalography骨髓穿刺：bone marrow biopsy直立倾斜试验：head-up tilt test支气管镜：bronchoscopy支气管肺泡灌洗术：bronchoalveolar lavage支气管舒张试验：bronchodilation test/airway reversibility test 胃镜：gastroscopy肠镜：colonoscopy胃肠镜：gastrointestinal endoscopy五、药物类阿奇霉素：azithromycin头孢曲松：ceftriaxone头孢地尼：cefdinir头孢吡肟：cefepime头孢类：cephalosporin阿莫西林：amoxicillin红霉素：erythromycin利奈唑胺：linezolid万古霉素：vancomycin美罗培南：meropenem阿昔洛韦：acyclovir甲泼尼龙：methylprednisolone低塞米松：dexamethasone甲钴胺：methylcobalamin退热药：antipyretics布洛芬：ibuprofen甘露醇：mannitol氨溴索：ambroxol解痉药：antispasmodic止痛药：analgesic利妥昔单抗：rituximab六、诊断类：化脓性脑膜炎：purulent meningitis真菌性脑膜炎：fungal meningitis结核性脑膜炎：tuberculous meningitis败血症：sepsis肺炎：pneumonia血小板减少：thrombocytopenia特发性血小板减少性紫癜：idiopathic thrombocytopenia purport 胃肠炎：gastroenteritis肠套叠：intussusception肾病综合征：nephrotic syndrome淋巴结炎：lymphadenitis川崎病：Kawasaki disease脑脊液鼻漏：CSF rhinorrhea电解质紊乱：electrolyte disturbance血管迷走性晕厥：vasovagal syncope体位性心动过速：postural orthostatic tachycardia体位性低血压：orthostatic hypotension。
英文病历书写规范
Lab Orders
Electrolytes
– NA, K, CO2, Cl, BUN, Creatinine, Glucose – K or potassium is the most critical to assess whether a potential for dysrhythmia exists – Glucose will assess diabetic status – BUN and Creat will assess renal and liver function
Hospital Chartwork Components
Operative note Dictated Operative Report Post-op progress notes Post-op orders Discharge Note Discharge Orders Dictated Discharge Summary
– Bedrest, activity ad lib, bathroom privileges with assistance, etc.
N = Nurautions, suction at bedside, etc.
Admission Orders
D = Diet (regular, diabetic, soft, etc.) I = Intake and output (urine, IV fluid, etc.) S = Symptomatic drugs
– Analgesics
S = Specific drugs
– Patient's usual medications
Hospital Charts
Paperwork and Protocols From admission through surgery in the O.R. or clinic to discharge
英语作文病历模板
英语作文病历模板英文回答：Medical History Template。
Patient Information。
Name:Date of Birth:Gender:Address:Phone Number:Email Address:Reason for Visit。
What brings you to the clinic today?Medical History。
Past Medical History。
Do you have any past medical conditions?Have you ever been hospitalized or had surgery?Do you currently take any medications?Do you have any allergies?Family Medical History。
Do any of your close family members have any medical conditions?Have any of your close family members passed away at a young age due to illness?Social History。
What is your occupation?Are you currently married or in a relationship? Do you have any children?Do you smoke, drink alcohol, or use drugs?Physical Examination。
General Appearance:Height:Weight:BMI:Vital Signs:Blood pressure: Pulse:Respiratory rate: Temperature:Cardiovascular:Heart rate:Heart sounds:Blood pressure: Respiratory:Respiratory rate: Lung sounds:Abdomen:Girth:Soft and non-tender: Liver span:Musculoskeletal:Range of motion:Strength:Reflexes:Skin:Color:Texture:Turgor:Assessment。
英文病历报告作文模板
英文病历报告作文模板英文：Medical Record Report。
Name: John Smith。
Age: 35。
Gender: Male。
Date of Admission: 05/01/2021。
Date of Discharge: 05/07/2021。
Chief Complaint:The patient complained of a persistent cough and shortness of breath.History of Present Illness:The patient had a persistent cough and shortness of breath for two weeks. He tried to treat himself with over-the-counter medication but his symptoms did not improve. He decided to seek medical attention when his cough became more severe and he started to experience chest pain.Past Medical History:The patient has a history of asthma and seasonal allergies. He has been hospitalized in the past for asthma exacerbations.Physical Examination:On physical examination, the patient had wheezing and crackles in his lungs. His oxygen saturation was 92% on room air.Diagnostic Tests:A chest X-ray showed bilateral infiltrates consistent with pneumonia. A COVID-19 test was negative.Treatment:The patient was started on antibiotics for pneumonia and given nebulizer treatments for his asthma exacerbation. He was also given supplemental oxygen to maintain his oxygen saturation above 94%.Outcome:The patient's symptoms improved with treatment and he was discharged home after a week in the hospital.中文：病历报告。
英文病历书写
发觉（ 有点） 食欲不振 noted （ minimal） anorexia
食欲不定（ 无食欲障碍） one's appetite is variable （ undisturbed）
食欲反复无常 have a capricious appetite
食欲不佳 have a poor （feeble; weak; delicate） appetite
食欲增进 one's appetite improved
食欲有节制 （食欲旺盛，贪食不饱） have a moderate （good, enormous） appetite
无食欲障碍 one's appetite is undisturbed
食不过饱的人 a moderate （ spare; light） eater
不想吃 be disinclined to eat
取食不规则 eat irregularly
停吃 cease eating
促进食欲 improve （stimulate; sharpen; whet） the appetite
ex1:他无胃口，只吃了一点点东西。
体重以惊人的速度减少 lose weight with alarming speed
体重始终一样 weight remained stationary （steady）
体重不变 weight is stable （ unchanged）
体重维持不变 weight is well maintained
体重减轻
住院时体重 admission weight
最高（最低）体重 maximal （ minimal） weight
抑郁症英文病历书写模板
抑郁症英文病历书写模板
[医院名称]
[日期]
患者信息：
姓名：[患者姓名]
性别：[男/女]
年龄：[患者年龄]
联系电话：[患者联系电话]
主诉：
[患者的主要抱怨和症状描述]
现病史：
[患者目前的病情描述，包括起病时间、症状进展等]
既往史：
[患者的既往病史，包括过去的医学史、精神疾病史、手术史等]
家族史：
[患者家族中是否有精神疾病、抑郁症等相关疾病的家族史]
个人史：
[患者个人生活习惯、学习或工作情况、日常生活负担等]
体格检查：
- 一般情况：[患者的一般状态，如疲劳、食欲变化等]
- 精神状态：[患者的精神状态，如情绪低落、焦虑等]
- 神经系统检查：[对患者神经系统功能进行的检查结果]
辅助检查：
[患者曾进行的辅助检查，如血液化验、神经影像学检查等的结果]
诊断：
[医生对患者的初步诊断，如抑郁症、轻度抑郁发作等]
治疗计划：
- 药物治疗：[针对患者的症状和病情制定的药物治疗方案，包括药物名称、剂量和用法]
- 心理治疗：[计划进行的心理治疗方法，如认知行为疗法、支持性治疗等]
- 生活指导：[针对患者日常生活习惯、行为方式等方面的指导建议]
随访计划：
[医生制定的患者随访计划，包括下次随访时间和内容]
备注：
[医生对患者病情的特殊说明和其他需要备注的信息]
医生签名：
[医生姓名]
[医生职称/科室]
以上即为抑郁症的英文病历书写模板，供参考使用。
请根据实际病情和诊疗需求进行调整。
英文病历书写
na and so on.
Urogenital system: no history of swollen eyelids or lumbago. No frequent micturition, urgency of micturition or urodynia. No dysuria ,hematuria or retention and incontinence of urine .no history of acute or chronic neph ritis.
Hemopoeltic system: No pallid countenance ,weakness,dizziness , daze ,ti nnitus. No history of bleeding and repeated infections. No history of enl argement of liver and spleen. Metabolic and Endocrine system: no abnormal cold or hot feeling, hidosis ,headache weakness,impaired vision,polyphagia ,polyuria ect.normal di stributed hair.no change of temper and intelligence. Nervous system: No headache ,projectile vomiting . no syncope ,spasm ,i mpaired vision, abnormal sensation or motion. No change of personalit y .no mania ,depression or hallucination. Motor system: lumbago and limitation of movement for 2 years. weakness and numbness at lower limbs, the left more severe. No spasm, atrophy or palalysis. No joint red swollen, hot ,pain or limitation of motion. No tr auma or fracture.
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A. Outline of case record
1. Biographical data Biographical information of patient should include his full name, age (date of birth), sex, race, occupation, nationality, marital status and permanent home address. Also, the date of admission, the time at which you took the history, the source of history and estimate of reliability should be involved. 2. chief complaint The chief complaint consists of main symptom(s) and duration. It should constitute in a few simple words the main reasons why the patient consulted doctor and should be state as nearly as possible in the patient’s own wards. In general, the chief complaint should include age, sex, complaint, and duration of the complaint. It should no included diagnostic terms or disease entities. For example:” This 70-year old man has had short breath for a week.”
7. Marital history It includes data concerning the health of mate, sexual adjustment, the number of children and their Physical status, and the general social adjustment within the family. 8. Menstrual history ( for female patients) Age of onset, interval between periods, duration, amount and character of flow, concomitant symptoms, date of last menstruation, age of menopause. 9. Childbearing (reproductive) history Age and date of pregnancy(ies) and childbirth(s). Date of artificial or natural abortions, stillbirths, operative delivery, puerperal fever. Method of family planning, the possible factors of infertility (also for male patients).
How to make a good history record
When creating a record, you do more than simply make a list of what the patient has told you and what you have found on examination. You must review your data, organize them, evaluate the importance and relevance of each item, and construct a clear, concise, yet comprehensive report.
3. History of present illness (HPI) The history of present ill ness should be a well-organized, sequentially developed elaboration of his chief complaint(s) on its various characteristics: ①date of onset, ②character of complaint, ③mode of onset, course and duration, ④ location, ⑤relationship to other symptoms, bodily function and activities, ⑥exacerbation and remissions, and ⑦effect of treatment. 4. Past history (PH) It should include a review of all past ill nesses, surgical procedures, and injuries, and allergy history (medicine, food), which are particularly related to the present illness.
How to make a good history record
1. Order is imperative 2. Keep items of history in the history 3. Describe specifically any pertinent negative information 4. Data not recorded are data lost 5. Use short words instead of long and probably fancier ones when they mean the same thing 6. Be objective 7. You should write the record as soon as possible
Importance of history record
1. Diagnosis and treatment purpose An accurate, clear, well organized record reflects and facilitates sound clinical thinking. It leads to good communication among the many professionals who participate in caring for the patient 2. Teaching and research purpose 3. Medicolegal purposes
10. Family history (FH) The health status of the patient’s family (mother, father, siblings and children) and if died, the age and cause of death should be recorded, such as diabetes, hypertension, cancer, obesity, allergic disorders, coronary artery disease and mental illness. 11. Physical examination (PE) The recording of Physical examination should follow a logical sequence as follows: vital signs, general status, skin, nodes, head, neck, chest, lungs, heart and blood vessels, abdomen, genitalia, rectum, spine and extremities, nervous reflexes. 12. Laboratory tests and instrumental examination The findings of them onkly serve to confirm what you have found on history and Physical examination. The routine laboratory studies include blood, urine and stool tests, electrolytes, X-rays and ECG.
5. Review of system (ROS) The purpose of sys tem review is twofold: a thorough evaluation and a double check prevent omission of significant data relative to the present illness. The review is a comprehensive account of all complaints referable to each body system progressing in a logical manner from the head toward the feet, including respiratory system, cardiovascular system, digestive system, Urinary system, hemopoietic system, endocrine system, nervous system and skeletal system. 6. Personal history (social and occupational history) It includes personal habits (smoking, alcohol drinking), business life, sex life, occupation (exposure to certain irritating agents), condition of work.