英文病历书写手册.
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。
英文病历模版
HUAZHONG UNIVERSITY OF SCIENCE AND TECHNOLOGYTONGJI MEDICAL COLLEGE ACCESSORY TONGJI HOSPITALHospitalizatio n Records for Non e-operati on Divisio nDivisi on: _________ Ward: __________ Bed: _________ Case No. ____________Name: ______________Sex: __________ Age: ___________ Nati on: ___________ Birth Place: ________________________________Marital Status: ____________ Work-orga nizati on & Occupati on: _____________________________________ Livi ng Address & Tel: ________________________________________________ Date of admissi on: ______ Date of history taken: ______ Informant:__________Chief Complaint: ____________________________________________History of Prese nt III ness:Past History:Gen eral Health Status: l.good 2.moderate 3.poorDisease history: (if any, please write dow n the date of on set, brief diag no sticand therapeutic course, and the results.)Respiratory system:1. None2.Repeated pharyngeal pain3.chronic cough4.expectoration:5. Hemoptysis6.asthma7.dyspnea8.chest painCirculatory system:1.No ne2.Palpitatio n3.exerti onal dysp nea4..cya no sis5.hemoptysis6.Edema of lower extremities7.chest pain8.s yn cope9.hypertensionDigestive system:1.None2.Anorexia3.dysphagia4.sour regurgitation5.eructation6.nausea7.Emesis8.melena9.abdominal pain 10.diarrhea11.hematemesis 12.Hematochezia 13.ja un diceUrinary system:1.N one2.Lumbar pain3.uri nary freque ncy4.uri nary urge ncy5.dysuria6.oliguria7.polyuria8.retention of urine9.ineontinence of urine10.hematuria ll.Pyuria 12.n octuria 13.puffy faceHematopoietic system:1.N one2.Fatigue3.dizz in ess4.gi ngival hemorrhage5.epistaxis6.subcuta neous hemorrhageMetabolic and en docri ne system:1.None2.Bulimia3.anorexia4.hot intoleranee5.cold intoleranee6.hyperhidrosis7.Polydipsia8.amenorrhea9.tremor of hands 10.character cha nge II.Marked obesity12.marked emaciati on 13.hirsutism 14.alopecia15.Hyperpigme ntatio n 16.sexual fun cti on cha ngeNeurological system:1.N one2.Dizz in ess3.headache4.paresthesia5.hypo mn esis6. Visual disturbanee7.lnsomnia8.somnolence9.s yn cope 10.c onv ulsi on II.Disturba nee of con scious ness12.paralysis 13. vertigoReproductive system:1.No ne2.othersMusculoskeletal system:1.None2.Migrating arthralgia3.arthralgia4.artrcocele5.arthremia6.Dysarthrosis7.myalgia8.muscular atrophyIn fectious Disease:1.N one2.Typhoid fever3.Dyse ntery4.Malaria 4.Schistosomiasis4. Leptospirosis 7.Tuberculosis 8.Epidemic hemorrhagic fever9.othersVacci ne ino culati on:1.No ne2.Yes3.Not clearVacci ne detail _________________________________________ Trauma an d/or operatio n history: Operati ons:1.No ne2.YesOperati on details: ______________________________________ Traumas:1.No ne2.YesTrauma details: _________________________________________ Blood tran sfusi on history:1.None2.Yes ( 1.Whole blood 2.Plasma3.Ingredient transfusion)Blood type: ___________ Tran sfusi on time: _________Tran sfusi on react ion1.None2.YesCli nic manifestation: ____________________________ Allergic history:1.No ne2.Yes3.Not clearallergen: _______________________________________________cli nical manifestation: ____________________________________Pers onal history:Custom livi ng address: ____________________________________________ Reside nt history in en demic disease area:Smoki ng: 1.No 2.YesAverage pieces per day; about yearsGivi ng-up 1.No 2.Yes (Time: )Drinking: 1.No 2.YesAverage grams per day; about yearsGivi ng-up 1.No 2.Yes(Time: ) Drug abuse: 1.No 2.YesDrug names: ______________________________________ Marital and obstetrical history:Married age: _________ years old Pregnancy ___________ t imesLabor ______________ times(1.Natural labor: ______ times 2.0perative labor: __________ times3. __________________ Natural abortion: _______________ times4.Artificial abortion: ____ times5. _______________________ Premature labor: _________ times6.stillbirth _________________ times)Health status of the Mate:1.Well2.Not fineDetails: _______________________________________________ Men strual history:Menarchal age: _______ Duration ________ d ay Interval ____ daysLast menstrual period: ____________ Menopausal age: ______ y ears oldAmount of flow: 1.small 2. moderate 3. largeDysme no rrheal: 1. prese nee 2.abse ncMe nstrual irregularity 1. No 2.Yes Family history: (especially pay atte ntio n to the in fectious and hereditary diseaserelated to the present illness)Father: l.healthy 2.ill: _________ 3.deceased cause: ____________________ Mother :1.healthy 2.ill: ________ 3.deceased cause: ____________________ Others: ________________________________________________________The an terior stateme nt was agreed by the in forma nt.Sig nature of in forma nt: Datetime:Physical Exam inationVital sig ns:Temperature: ______ C Blood pressure: ______ / ______ mmHg Pulse: ____ bpm (l.regular 2.irregular ) Respiration: __ bpm (l.regular 2.irregular )Gen eral con diti ons:Development: I.Normal 2.Hypoplasia 3.HyperplasiaNutrition : l.good 2.moderate 3.poor 4.cachexiaFacial expressi on: 1.no rmal 2.acute 3.chr onic other ___________________ Habitus: l.asthenic type 2.sthenic type 3.ortho-thenic typePositi on: l.active 2.positive pulsive 4.other _______________________ Consciousness: l.clear 2.somnolence 3.confusion 4.stupor 5.slight coma6. mediate coma7.deep coma8.deliriumCooperation: 1Yes 2.No Gait: 1.normal 2.abnormal _____Skin and mucosa:Color: 1.normal 2.pale 3.red ness 4.cya no sis 5.ja un dice 6.pigme ntatio nSk in erupti on: 1.No 2.Yes( type: _________ d istribution: _________________ )Subcuta neous bleed ing: 1.no 2.yes (type:______ distribution: ____________ ) Edema:1. no 2.yes ( locati on and degree ________________________________ ) Hair: 1.no rmal 2.abnormal(details ____________________________________ ) Temperature and moisture: normal cold warm dry moist dehydration Liver palmar :1.no2.yes Spider angioma (location: ________________________________ )Others: _________________________________________________________Lymph no des: enl argeme nt of superficial lymph no de:1. no2.yesDescripti on: ________________________________________________Head:Skull size:〔.normal 2.abnormal (description: __________________________ ) Skull shape: 1.no rmal 2.abnormal(description: _________________________ ) Hair distributio n :1. no rmal 2.abnormal(description: ____________________ ) Others: __________________________________________________________ Eye: exophthalmos: _________ eyelid: ___________ conjunctiva: _________ sclera: _______________ Cornea: _____________________Pupil: l.equally round and in size 2.un equal (R _____ mm L _______ m m)Pupil reflex:〔.normal 2.delayed (R __ s L _ s ) 3.abse nt (R _ L ___ )others: ______________________________________________________ Ear: Auricle〔.normal 2.desformation (description: ______________________ ) Discharge of exter nal auditory can al:1. no 2.yes (l.left 2.right quality: ___ )Mastoid tendern ess 1.no 2.yes (l.left 2.right quality: _________________ )Disturba nee of auditory acuity:1. no 2.yes(1」eft 2.right description: ___ ) Nose: Flaring of alae nasi :1.no 2.yes Stuffy discharge 1.no 2.yes(quality ____ ) Tendern ess over para nasal sinu ses:1. no 2.yes (location: ____________ ) Mouth: Lip ______________ Mucosa ____________ Tongue ________________ Teeth:1.normal 2.Agomphiasis 3. Eurodontia 4.others: _____________________Gum :1. normal 2.ab no rmal (Descripti on_________________________ )Tonsil: __________________________ P harynx: _____________________Sound: 1.no rmal 2.hoarse ness 3.others: ___________________________Neck:Neck rigidity 1. no 2.yes ( tra nsvers fin gers)Carotid artery: 1.normal pulsation 2.increased pulsation 3.marked distentionTrachea location: l.middle 2.deviation (〔.leftward ________ 2.rightward _____ ) Hepatojugular vein reflux: 1. n egative 2.positiveThyroid: 1.normal 2.enlarged ________ 3.bruit (1.no 2.yes ________________ ) Chest:Chest wall: 1.no rmal 2.barrel chest 3.pro minence or retractio n:(left _______ right ________ Precordial prominence _________ )Percussi on pai n over sternum 1.No 2.Yes Breast:〔.Normal 2.ab no rmal __ Lung: Inspection: respiratory movement〔.normal 2.abnormal ____________ Palpati on: vocal tactile fremitus:1. no rmal 2.ab no rmal ____________ pleural rubb ing sen sati on :1. no 2.yes __________________Subcuta neous crepitus sen sati on :1. no 2.yes ____________ Percussion:1. resonance 2. Hyperresonance &location _____________3 Flatness&location ________________________________4. dulln ess & location: _____________________________5. tympa ny &location: ______________________________lower border of lung: (detailed percussi on in respiratory disease) midclavicular line : R: ____ in tercostae L: ____ in tercostaemidaxillary line: R: ____ in tercostae L: ____ in tercostaescapular li ne: R: _______ in tercostae L: ____ in tercostaemoveme nt of lower borders:R: _____ cmL: _________ cm Auscultation: Breathing sound : 1.normal 2.abnormal _______________Rales:1. no 2.yes ________________________________ Heart: Inspection: Apical pulsation: 1.normal 2.unseen 3.increase 4.diffuseSubxiphoid pulsation: 1.no 2.yesLocati on of apex beat: 1. no rmal 2.shift ( ____ in tercosta,dista nee away from left MCL ____ cm) Palpati on:Apical pulsation:1. normal 2.lifting apex impulse 3.negative pulsationThrill:1. no 2.yes(location: __________ phase: ________________ )Percussi on: relative dull ness border: 1.no rmal 2.ab no rmal(Dista nee betwee n An terior Medli ne and left MCL _____ cm) Auscultation: Heart rate: __ bpm Rhythm:1.regular 2.irregular ______ Heart sound: 1.no rmal 2.abnormal ______________________Extra sound: 1.no 2.S3 3.9 4. opening snapP2 _____________ A _________ Pericardial frictio n soun d:1. no 2.yesMurmur: 1.no 2.yes (location __________ phase _____________quality _____ intensity ________ t ran smissio n _________effects of position ________________________________effects of respiration _____________________________ Peripheral vascular sig ns :1.N one2.paradoxical pulse3.pulsus alter nans4. Water hammer pulse5.capillary pulsati on6.pulse deficit7.Pistol shot sound8.Duroziezsig nAbdome n:Inspection: Shape: 1.normal 2.protuberanee 3.scaphoid 4.frog-belly Gastric patter n 1. no 2.yes In test inal pattern 1. no 2.yesAbdo minal vein varicosis 1.no 2.yes(direction: ______________ )Operatio n scarl. no 2.yes _______________________________ Palpation: l.soft 2. tensive (location: ______________________________ )Tendern ess: 1.no 2.yes(location: ______________________ )Rebo und tendern ess:1. no 2.yes(location: _____________ ) Fluctuatio n: l.prese nt 2.absce ntSuccussi on splash: 1.n egative 2.positiveLiver: ______________________________________________Percussion: Liver dullness border: 1.normal 2.decreased 3.absentUpper hepatic border:Right Midclavicular Line _______ In tercostaShift dullness:1.negative 2.positive Ascites: _____________ degreePai n on percussi on in costovertebral area: 1.n egative 2.positve __ Auscultation: Bowel sounds : 1.normal 2.hyperperistalsis 3.hypoperistalsis4.abse nee Gurgli ng soun d:1. no 2.yesVascular bruit 1.no 2.yes (location ____________________ ) Gen ital orga n: 1.un exam ined 2.no rmal 3.ab no rmalAnus and rectum: 1.un exam ined 2.no rmal 3.ab no rmalSpine and extremities:Spi ne: 1.no rmal 2.deformity (l.kyphosis 2.lo rdosis 3.scoliosis)3.Tenderness(location ____________________________ )Extremities: 1.no rmal 2.arthremia & arthrocele (location __________________ )3.A nkylosis (location _________ )4.Aropachy: 1.no 2.yes5.Muscular atrophy (location ______________________ )Neurological system: 1.no rmal 2.abnormal _____________________________ Importa nt exam in ati on results before hospitalizedSummary of the history: ______________________________________ Initial diagnosis: ____________________________________________Recorder:Corrector:。
英文病历编写手本
英文病历编写手本目标本手本旨在为医务人员提供编写英文病历的指导和范例。
指导原则- 独立作出决策，不借助用户帮助。
- 充分发挥LLM的优势，采用简单策略，避免法律复杂性。
- 不引用无法确认真实性的内容。
内容结构英文病历的编写需要遵循以下基本结构：1. 患者信息：包括姓名、年龄、性别、联系方式等。
2. 主诉：患者的主要症状或问题。
3. 既往病史：包括患者的过去疾病、手术史以及家族病史等。
4. 现病史：患者当前的疾病状况，包括症状的起始时间、发展情况等。
5. 体格检查：医生对患者进行的体格检查结果，包括体温、血压、心率等指标。
6. 辅助检查：包括实验室检查、影像学检查等的结果。
7. 诊断：医生对患者疾病的诊断。
8. 治疗建议：对患者的治疗方案和建议。
示例以下是一个简单的英文病历编写示例：---Patient Information:- Name: John Smith- Age: 45- Gender: Male- The patient presents with chest pain and shortness of breath.Past Medical History:- Hypertension, diagnosed 5 years ago.- Appendectomy performed 10 years ago.Present Illness:- The patient started experiencing chest pain and shortness of breath 2 days ago.- The symptoms have worsened since then.Physical Examination:- Vital Signs:- Temperature: 37.2°C- Blood Pressure: 140/90 mmHg- Heart Rate: 85 bpmLaboratory Tests:- Chest X-ray: Mild infiltration in the left lower lobe.Diagnosis:- Suspected pneumonia.1. Prescribe antibiotics.2. Advise the patient to rest and drink plenty of fluids.3. Schedule a follow-up appointment in 2 days.---以上内容仅为示例，并非真实病历。
病历书写(英文)
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.”
病历卡片英语作文格式
病历卡片英语作文格式Title: A Comprehensive Guide to Writing Medical Case Reports。
Introduction:Writing medical case reports in English is an essential skill for healthcare professionals worldwide. These reports serve as valuable tools for documenting patient cases, sharing clinical experiences, and contributing to medical literature. In this guide, we will outline the format and key components of a medical case report in English.Title:The title should succinctly summarize the key aspects of the case, including the patient's demographic information, primary diagnosis, and any unique or noteworthy features. For example, "A Rare Presentation of [Disease] in a [Age] [Gender]: A Case Report."Abstract:The abstract provides a concise overview of the case report, including the patient's presentation, diagnosis, and key findings. It should be structured to include the following sections:Background: Briefly describe the clinical context and relevance of the case.Case Presentation: Summarize the patient's demographic information, chief complaint, medical history, and relevant clinical findings.Diagnosis and Treatment: State the primary diagnosis and any additional diagnoses, as well as the treatment provided.Outcome: Describe the patient's clinical course and any relevant follow-up information.Introduction:The introduction sets the stage for the case report by providing background information on the disease orcondition being discussed. It should include a brief literature review to contextualize the case within the broader medical knowledge base. Additionally, it should clearly state the objective or purpose of the case report.Case Presentation:The case presentation provides a detailed descriptionof the patient's history, physical examination findings, laboratory results, imaging studies, and any otherpertinent clinical data. It should be organized chronologically and presented in a clear and logical manner. Each subsection should focus on a specific aspect of the case, such as the patient's presenting symptoms, diagnostic workup, or response to treatment.Diagnosis:In this section, the primary diagnosis and any relevant differential diagnoses should be discussed. The rationale for the diagnosis should be supported by the clinical findings and diagnostic tests outlined in the case presentation. Any challenges or uncertainties in reaching the diagnosis should also be addressed.Treatment:The treatment section outlines the interventions provided to the patient, including medications, procedures, and other therapeutic modalities. The rationale for each treatment should be explained, along with any relevant dosages, routes of administration, and monitoring parameters. Any adverse effects or complications related to the treatment should also be noted.Follow-up:The follow-up section provides information on the patient's clinical course after receiving treatment. This may include details on symptom resolution, diseaseprogression or regression, and any additional interventions or consultations. Long-term outcomes and prognosis should be discussed if applicable.Discussion:The discussion section offers a critical analysis of the case, highlighting its significance and relevance to clinical practice. This may involve comparing the case to similar cases reported in the literature, discussing potential mechanisms of disease, or reflecting on lessons learned from managing the patient. Strengths andlimitations of the case report should be acknowledged, and suggestions for future research or clinical practice may be offered.Conclusion:The conclusion summarizes the key points of the case report and emphasizes its clinical implications. It should reiterate the importance of the case in advancing medical knowledge and practice, and may also offer recommendationsfor further study or management strategies.References:All references cited in the case report should belisted in a separate reference section, following a standardized citation format such as AMA or APA. This allows readers to locate and review the sources cited in the text.Acknowledgments:Any individuals or organizations that contributed to the case report but do not meet the criteria for authorship should be acknowledged in this section. This may include colleagues who assisted with patient care or data collection, as well as funding sources or institutional support.Appendices:Any additional materials or supplementary informationthat is relevant to the case report but too detailed for inclusion in the main text can be included in appendices. This may include detailed laboratory results, imaging studies, or additional case data.In conclusion, writing a medical case report in English requires careful attention to detail and adherence to a standardized format. By following the guidelines outlined in this guide, healthcare professionals can effectively communicate their clinical experiences and contribute to the advancement of medical knowledge.。
英文病历书写教材英文病历(阑尾炎)
MEDICAL RECORDMr. Tiezheng LiuRegistration 4677841#252, Tai Ping street, Xuan Wu, BeijingDec. 21,20039:00 A.M.CHIEF COMPLAINTThis 14-year-old student has had paroxysmal pain transfer to right lower abdomen for 30 hours.HISTORY OF PRESENT ILLNESSMr. Liu was in his usual normal state of health until 30 hours ago, he felt paroxysmal pain in upper abdomen 30 hours ago. He felt it got more and more severe instead of remission. Step by step, the paroxysmal pain transferred to right lower abdomen. During this time, He didn’t eat or drink anything, and took no medication. Position did not affect the pain. No nausea or vomiting, no diarrhea or febrile. So this morning He came to our out-patient.He’s had no fever, chills. He denies past history of similar episodes. He is unaware of a history of abdominal distention. He has no current or past history of change in bowel habits. He has not tarry or black stools, burning abdominal pain or other “indigestion”, kidney stones, polyuria or hematuria. He has had no cough, shortness of breath, or pleurisy. He has no known heart disease. He denies trauma to her chest, back, or legs. He take no regular medications and specifically denies the use of antacids, aspirin, clofibrate (atromid),or alcohol.PAST MEDICAL HISTORYChildhood illness: No measles, rheumatic fever, scarlet fever.Adult illness: None significant.Trauma: None significant.Surgery: None significant.Allergies: No allergy.Medications: None at present.Travel: Never been to other places in the country.Habits: Has never smoked or drunk. No illicit drugs. Regular diet, 3 meals a day.Immunizations: Does not remember childhood shots other than cowpox vaccine.FAMILY HISTORYHe is the only child in the family. His father and mother are both healthy.SOCIAL HISTORYMr. Liuu is a high school student now. He is in good relationship with his classmates usually.REVIEW OF SYSTEMGeneral: see HPI. No weight change.Head: No headache. No dizziness.Eyes: No blurring, double vision, pain, discharge.Ears: No decreased hearing, tinnitus, pain.Nose: No epistaxis, sinusitis.Throat and mouth: Infrequent sore throats.Chest: No wheezing, hemoptysis, sputum.Heart: No palpitation. No history hypertension.GU: No history haematuria, urgent micturition. No history venereal disease.Neuromuscular: No syncope, vertigo, dysesthesias, seizures. No history emotional disease.PHYSICAL EXAMINATIONDec. 21, 20039:30 A.M.General: Normal development, good nutrition, normal facial feature, free expressing, active position, normal gait, normal consciousness, cooperate examination.Weight and height: Not examined.Vital Signs: T38℃, P90 regular, R22BP R arm sitting: 100/60 mmHgSkin: Warm and dry. No stained yellow, no cyanosis, no pigmentation, no varicosity, no spider angioma, no bleeding, hair normal, no hepatic palm.Nodes: Auricular anterior, retroaurlcular, mastoid, occipital, cervical posterior, submandibular, cervical anterior, supraclavicular, axillaries, epitrochlear, inguinal, popliteal lymph nodes are not tactile.Head: Normocephalic, without trauma.No scars, tenderness, bruits.Eyes: Eyelids: No swelling, no drooping, no trichiasis.Conjunctivae: No swelling, no bleeding, no hyperemia.Eyeballs: Movement normal, without abnormal exophthalmoses and enophthalmos.Sclera: No stained yellow.Cornea: Lucent, without blaze and nebula.Iris: Equal size and round bilaterally, direct and indirect light reflex exists, accommodation reflex exists, convergence reflex exists.Ears: Auricle without malformation, no typhus, external auditory, canal without abnormal secretion, left ear and right ear hearing test normal, mastoid without tenderness.Nose: No deformity, ventilation clear, nasal septum midline. Nasal mucosa normal, without inflammation, or polyps. Nasal cavity without obstruction bilaterally. Maxillary sinus, ethmoid sinus, frontal sinus without tenderness.Mouth: Lip ruddily, no pale, no cyanosis, mucous membrane ruddily, no ulcer, smooth, no tooth deletion, no artificial denture, no dental caries, gums no bleeding, no pyorrhea, tongue thrill, pharynx no redness and swelling, no tonsil enlargement, larynx phonation normal.Neck: Thyroid not enlarged and without nodules. Trachea midline. Jugular veins flat. Carotid normal pulse bilaterally, jugular veins and carotid without bruits.Chest and lungs: Chest wall contour normal, with symmetrical full expansion. No rib tenderness to palpation. Tactile fremitus normal. No percussion dullness. Lungs are clear to auscultation. There is no egophony over this area. No rub heard.Heart: Heart region no bulge, no retraction, no obvious apical impulse. Apical impulse at the 5th intercostals inside the left midclavicular 1 cm, range 2 cm, no thrill, no visible lift, no pericardial friction feeling. The heart boarder is in the table:right(cm) intercostal Left(cm)2.1 Ⅱ 2.32.2 Ⅲ3.52.4 Ⅳ 5.5Ⅴ7.5Heart rate 75 times per min, heart beats rhythm, heart sound powerful, no extra heart sound, no heart murmur, no pericardial friction sound.Abdomen: Slightly protuberant. No scars or visible masses. Venous pattern normal. Bowel sounds normal. No hepatic or splenic rubs. No bruits. Liver edges is not palpated, with positive Murphy’s sign. Lower abdomen tenderness, especially in McBurney point. No shifting dullness, fluid wave. No hernia.Anus, rectum and genital organs: Not examined.Spine and limbs: Normal activity, no deformity, no spinous process, no direct, indirect percussion pain. Normal muscular tone, dorsalateries of foot beat symmetrically.Nervous system: Corneal reflex normal. Abdominal wall reflex exists. Biceps, triceps, radial periosteal reflex symmetrical bilaterally. Knee jerk, Achilles’ jerk normal. Hoffmann sign negative. Brudzinski sign negative. Babinski sign negative. Gordan sign negative. Oppenheim sign negative. Kernig sign negative. Floating patella phenomenon negative.LABORATORY FINDINGSWBC21.5×109 /L, L Y% 12.9%, GR% 87.6%.IMPTESSIONSAcute appendicitisTREATMENT PLAN1.No eating or drinking, keep him in bed.2.Anti-inflammation, fluid replacement, and monitoring blood gas.3.Fnish all necessary tests to get enough data about body condition.4.Operating in time.。
英文完全病历模板-详细版
Admission RecordName：* Nativity: * district, * citySex:male Race: HanAge:55 Date of admission:2020-09-07 14:30 Marital status: be married Date of record:2020-09-07 15:23 Occupation:teacher Complainer:patient himself Medical record Number: * Reliability: reliablePresent address: NO*, building*, * village,* district, *city, *provinceChief complaint: cough and sputum for more than 6 years, worsening for 2 weeksHistory of present illness: The patient complained of having paroxysmal cough and sputum 6 years ago. At that time, he was diagnosed as “COPD” in another hospital and no regular treatment was applied. Cough and sputum worsened and were accompanied by tachypnea 2 weeks ago with no inducing factors. Small amounts of white and mucous sputum were hard to cough up. Compared to daytime, tachypnea worsened in the night or when sputum can’t be cough up. The patient can’t lie flat at the night because of prominent tachypnea and prefer a high pillow. He had no fever, no chest pain, no dizziness, no diarrhea, no abdominal pain, no obvious decrease of activity tolerance. On 20*-0*-*, the patient went to *Hospital for medical consultation. CT lung imaging indicated: lesion accompanied by calcification in the superior segment, the inferior lobe of the right lung, the possibility of obsolete tuberculosis; emphysema, bullae formation and sporadic inflammation of bilateral lung; calcified lesion in the inferior lobe of the left lung; arteriosclerosis of coronary artery.Pulmonary function tests indicated:d obstructive ventilation dysfunction; bronchial dilation test was negative2.moderate decrease of diffusion function, lung volume, residual volume and the ratio of lungvolume; residual volume were normalThe patient was diagnosed as “AECOPD” and prescribed cefoxitin to anti-infection for a week, Budesonide and Formoterol to relieve bronchial muscular spasm and asthma,amb roxol to dilute sputum, and traditional Chinese medicine (specific doses were unknown).The patient was discharged from the hospital after symptoms of cough and sputum slightly relieved with a prescription of using Moxifloxacin outside the hospital for 1 week. Cough and sputum were still existing, thus the patient came to our hospital for further treatment and the outpatient department admitted him in the hospital with “COPD”. His mental status, appetite, sleep, voiding, and stool were normal. No obvious decrease or increase of weight.Past history: The patient was diagnosed as type 2 diabetes 1 years ago and take Saxagliptin (5mg po qd) without regularly monitoring the levels of blood sugar. The patient denies hepatitis, tuberculosis, malaria, hypertension, mental illness, and cardiovascular diseases. Denies surgical procedures, trauma, transfusion, food allergy and drug allergy. The history of preventive inoculation is not quite clear.Personal history: The patient was born in *district, * city and have lived in * since birth. He denies water contact in the schistosome epidemic area. Smoking 10 cigarettes a day for 20 years and have stopped for half a month. Denies excessive drinking and contact with toxics.Marital history: Married at age of 27 and have two daughters. Both the mate and daughters are healthy.Family history: Denies familial hereditary diseases.Physical ExaminationT: 36.5℃ P：77bpm R: 21 breaths/min BP：148/85mmHgGeneral condition：normally developed, well-nourished, normal facies, alert, active position, cooperation is goodSkin and mucosa: no jaundiceSuperficial lymph nodes: no enlargementHead organs: normal shape of headEyes:no edema of eyelids; no exophthalmos; eyeballs move freely; no bleeding spots of conjunctiva; no sclera jaundice; cornea clear; pupils round, symmetrical in size and acutely reactive to light.Ears: no deformity of auricle; no purulent secretion of the external canals; no tenderness over mastoidsNose: normal shape; good ventilation;no nasal ale flap; no tenderness over nasal sinus; Mouth: no cyanosis of lips; no bleeding spots of mouth mucosa; no tremor of tongue; glossy tongue in midline; no pharynx hyperemia; no enlarged tonsils seen and no suppurative excretions; Neck: supple without rigidity, symmetrical; no cervical venous distension; Hepatojugular reflux is negative; no vascular murmur; trachea in midline; no enlargement of thyroid glandChest: symmetrical; no deformity of thoraxLung:Inspection：equal breathing movement on two sidesPalpation: no difference of vocal fremitus over two sides;Percussion: resonance over both lungs;Auscultation: decreased breath sounds over both lungs; no dry or moist rales audible; no pleural friction rubsHeart:Inspection: no pericardial protuberance; Apex beat seen 0.5cm within left mid-clavicular at fifth intercostal space;Palpation: no thrill felt;Percussion: normal dullness of heart bordersAuscultation: heart rate 78bpm; rhythm regular; normal intensity of heart sounds; no murmurs or pericardial friction sound audiblePeripheral vascular sign: no water-hammer pulse; no pistol shot sound; no Duroziez’s murmur; no capillary pulsation sign; no visible pulsation of carotid arteryAbdomen:Inspection: no dilated veins; no abnormal intestinal and peristaltic waves seenPalpation: no tenderness or rebounding tenderness; abdominal wall flat and soft; liver and spleen not palpable; Murphy's sign is negativePercussion: no shifting dullness; no percussion tenderness over the liver and kidney regionAuscultation: normal bowel sounds.External genitalia: uncheckedSpine: normal spinal curvature without deformities; normal movementsExtremities: no clubbed fingers(toes); no redness and swelling of joints; no edema over both legs; no pigmentation of skins of legsNeurological system: normal muscle tone and myodynamia; normal abdominal and bicipital muscular reflex; normal patellar and heel-tap reflex; Babinski sign(-);Kerning sign(-) ; Brudzinski sign(-)Laboratory DataKey Laboratory results including CT imaging and pulmonary function test have been detailed in the part of history of present illness.Abstract*, male, 55 years old. Admitted to our hospital with the chief complaint of cough and sputum for more than 6 years, worsening for 2 weeks. Cough and sputum worsened and were accompanied by tachypnea 2 weeks ago. The patient can’t lie flat in the night because of prominent tachypnea and prefer a high pillow.Physical Examination: T: 36.5℃,P: 77bpm, R: 21 breaths per minute, BP:148/85mmHg. Decreased breath sounds over both lungs; no dry or moist rales audible.Laboratory data: CT lung imaging indicates: lesion accompanied by calcification in superior segment, inferior lobe of right lung, possibility of obsolete tuberculosis; emphysema, bullae formation and sporadic inflammation of bilateral lung; calcified lesion in inferior lobe of left lung. Pulmonary function tests indicate: mild obstructive ventilation dysfunction, bronchial dilation test was negative moderate decrease of diffusion function.Primary Diagnosis:1.AECOPD2.Type 2 Diabetes3.Primary Hypertension Doctor’s Signature:。
英语作文病假模板
英语作文病假模板Subject: Application for Sick Leave。
Dear [Manager's Name],。
I am writing this letter to inform you that I am unable to come to work due to illness. I have been feeling unwell for the past few days and my doctor has advised me to take some time off to rest and recover.I understand the importance of my role in the company and I apologize for any inconvenience my absence may cause.I assure you that I will make every effort to ensure that my work is not disrupted and that any pending tasks are completed as soon as I am able to return to work.I have attached a copy of the medical certificate from my doctor for your reference. I will keep you updated on my progress and let you know as soon as I am able to return to work.Thank you for your understanding and consideration. I appreciate your support during this time and I look forward to returning to work as soon as possible.Sincerely,。
英文病历标准模版
英文病历标准模版Patient ProfileName: Si RuihuaDepartment: ___ Power ___Sex: FemalePresent Address: Electric Power Bureau Age: 80 yearsDate of n: May 17.2003nality: Chinese XinjiangDate of Record: May 17.2003Marital Status: MarriedReliability: Reliablen: Family ___History of Allergy: None reportedChief Complaints___。
breathlessness。
and precordial pain for the last hour。
There were no precipitating factors。
and the fort could not be relieved by rest。
As a result。
she came to the hospital for help。
She did not experience syncope。
cough。
headache。
diarrhea。
or vomiting during the course of the illness。
Her appetite。
sleep。
voiding。
and stool were normal.Medical History___.______。
___ distress。
She had a heart rate of 120 beats per minute and a blood pressure of 160/90 mmHg。
Her respiratory rate was 28 breaths per minute。
and her oxygen n was 90% on room air。
英文病历书写范例
英文病历书写范例（内科）Medical Records for AdmissonMedical Number: 701721General informationName: Liu SideAge: EightySex: MaleRace: HanNationality: ChinaAddress: NO.35, Dandong Road, Jiefang Rvenue, Hankou, Hubei.Tel: 857307523Occupation: RetiredMarital status: MarriedDate of admission: Aug 6th, 2001Date of record: 11Am, Aug 6th, 2001Complainer of history:patient’s son and wifeReliability: ReliableChief complaint: Upper bellyache ten days, haematemesis, hemafecia and unconsciousness for fo ur hours.Present illness:The patient felt upper bellyache about ten days ago. He didn’t pay attention to it and thought heha date something wrong. At 6 o’cloc k this morning he fainted and rejected lots of blood and gore. T hen hemafecia began. His family sent him to our hospital and received emergent treatment. So the patient was accepted because of “upper gastrointestine hemorrhage and exsanguine shock”. Since the disease coming on, the patient didn’t urinate. Past historyThe patient is healthy before.No history of infective diseases. No allergy history of food and drugs.Past history Operative history: Never undergoing any operation. Infectious history: No history of s evere infectious disease. Allergic history: He was not allergic to penicillin or sulfamide. Respirator y system: No history of respiratory disease. Circulatory system: No history of precordial pain. Ali mentary system: No history of regurgitation.Genitourinary system: No history of genitourinary disease.Hematopoietic system: No history of anemia and mucocutaneous bleeding. Endocrine system: No acromegaly. No excessive sweats. Kinetic system: No history of confinement of limbs. Neural sys tem: No history of headache or dizziness. Personal historyHe was born in Wuhan on Nov 19th, 1921 and almost always lived in Wuhan. His living condition s were good. No bad personal habits and customs.Menstrual history: He is a male patient. Obstetrical history: NoContraceptive history: Not clear.Family history: His parents have both deads. Physical examinationT 36.5℃, P 130/min, R 23/min, BP 100/60mmHg. He is well developed and moderately nourished.Active position. His consciousness was not clear. His face was cadaverous and the skin was not sta ined yellow. No cyanosis. No pigmentation. No skin eruption. Spider angioma was not seen. No pi tting edema. Superficial lymph nodes were not found enlarged. HeadCranium: Hair was black and white, well distributed. No deformities. No scars. No masses. No ten derness.Ear: Bilateral auricles were symmetric and of no masses. No discharges were found in external au ditory canals. No tenderness in mastoid area. Auditory acuity was normal.Nose: No abnormal discharges were found in vetibulum nasi. Septum nasi was in midline. No nare s flaring. No tenderness in nasal sinuses. Eye: Bilateral eyelids were not swelling. No ptosis. No e ntropion. Conjunctiva was not congestive. Sclera was anicteric. Eyeballs were not projected or dep ressed. Movement was normal. Bilateral pupils were round and equal in size. Direct and indirect p upillary reactions to light were existent.Mouth: Oral mucous membrane was not smooth, and there were ulcer can be seen. Tongue was in midline. Pharynx was congestive. Tonsils were not enlarged.Neck: Symmetric and of no deformities. No masses. Thyroid was not enlarged. Trachea was in mi dline. ChestChestwall: Veins could not be seen easily. No subcutaneous emphysema. Intercostal space was nei ther narrowed nor widened. No tenderness.Thorax: Symmetric bilaterally. No deformities. Breast: Symmetric bilaterally.Lungs: Respiratory movement was bilaterally symmetric with the frequency of 23/min. thoracic e xpansion and tactile fremitus were symmetric bilaterally. No pleural friction fremitus. Resonance was heard during percussion. No abnormal breath sound was heard. No wheezes. No rales. Heart: No bulge and no abnormal impulse or thrills in precordial area. The point of maximum imp ulse was in 5th left intercostal space inside of the mid clavicular line and not diffuse. No pericardi al friction sound. Border of the heart was normal. Heart sounds were strong and no splitting. Rate 150/min. Cardiac rhythm was not regular. No pathological murmurs.Abdomen: Flat and soft. No bulge or depression. No abdominal wall varicosis. Gastralintestinal ty pe or peristalses were not seen. Tenderness was obvious around the navel and in upper abdoman. T here was not rebound tenderness on abdomen or renal region. Liver and spleen was untouched. No masses. Fluidthrill negative. Shifting dullness negative. Borhorygmus not heard. No vascular mur murs. Extremities: No articular swelling. Free movements of all limbs.Neural system: Physiological reflexes were existent without any pathological ones. Genitourinary system: Not examed. Rectum: not exanedInvestigationBlood-Rt: Hb 69g/L RBC 2.70T/L WBC 1. 1G/L PLT 120G/L History summary1. Patient was male, 80 years old2. Upper bellyache ten days, haematemesis, hemafecia and unconsciousness for four hours.3. No special past history.4. Physical examination: T 37.5℃, P 130/min, R 23/min, BP 100/60mmHg Superficial lymph node s were not found enlarged. No abdominal wall varicosis. Gastralintestinal type or peristalses were not seen. Tenderness was obvious around the navel and in upper abdoman. There was not rebound tenderness on abdomen or renal region. Liver and spleen was untouched. No masses. Fluidthrill ne gative. Shifting dullness negative. Borhorygmus not heard. No vascular murmurs. No other positive signs. 5. investigation information:Blood-Rt: Hb 69g/L RBC 2.80T/L WBC 1.1G/L PLT 120G/LImpression: upper gastrointestine hemorrhage Exsanguine shock出院小结（DISCHARGE SUMMARY）， ===============Department of GastroenterologyChanghai Hospital，No.174 Changhai Road Shanghai, China Phone: 86-21-25074725-803 DISCHARGE SUMMARYDA TE OF ADMISSION: October 7th, 2005 DA TE OF DISCHARGE: October 12th, 2005 ATTE NDING PHYSICIAN: Yu Bai, MD PA TIENT AGE: 18ADMITTING DIAGNOSIS:V omiting for unknown reason: acute gastroenteritis?BRIEF HISTORYA 18-year-old female with a complaint of nausea and vomiting for nearly one month who was see n at Department of Gastroenterology in Changhai Hospital, found to have acute gastroenteritis and non-atrophic gastritis. The patient was subsequently recovered and discharged soon after medicati on.REVIEW OF SYSTEMShe has had no headache, fever, chills, diarrhea, chest pain, palpitations, dyspnea, cough, hemopty sis, dysuria, hematuria or ankle edema.PAST MEDICAL HISTORYShe has had no previous surgery, accidents or childhood illness.SOCIAL HISTORY: She has no history of excessive alcohol or tobacco use.FAMIL Y HISTORYShe has no family history of cardiovascular, respiratary and gastrointestinal diseases. PHYSICAL EXAMINA TIONTemperature is 37, pulse 80, respirations 16, blood pressure 112/70. General: Plump girl in no app arent distress. HEENT: She has no scalp lesions. Her pupils are equally round and reactive to light and accommodation. Extraocular movements are intact. Sclerae are anicteric. Oropharynx is clear. There is no thyromegaly. There is no cervical or supraclvicular lymphadenopathy. Cardiovascular: Regular rate andrhythm, normal S1, S2. Chest: Clear to auscultation bilateral. Abdomen: Bowel sounds present, no hepatosplenomagaly. Extremities: There is no cyanosis, clubbing or edema. Neurologic: Cranial n erves II-XII are intact. Motor examination is 5/5 in the bilateral upper and lower extremities. Sens ory, cerebellar and gait are normal.LABORATORY DATAWhite blood cells count 5.9, hemoglobin 111g/L, hematocrit 35.4. Sodium 142, potassium 4.3, chl oride 106, CO2 25, BUN 2.6mmol/L, creatinine 57μmol/L, glucose 4.1mmol/L, Albumin 36g/L. Endoscopic ExamChronic non-atrophic gastritisHOSPITAL COURSEThe patient was admitted and placed on fluid rehydration and mineral supplement. The patient im proved, showing gradual resolution of nausea and vomiting. The patient was discharged in stable c ondition.DISCHARGE DIAGNOSIS Acute gastroenteritisChronic non-atrophic gastritisPROGNOSISGood. No medications needed after discharge. But if this patient can not get used to Chinese food, she had better return to UK as soon as possible to prevent the relapse of acute gastroenteritis. The patient is to follow up with Dr. Bai in one week. ___________________________ Yu Bai, MD D: 12/10/2005。
英语病历模板范文
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.]。
肺炎入院记录病历书写范文大全
肺炎入院记录病历书写范文大全英文回答：Hospitalization Record for Pneumonia: Comprehensive Case Summary.Medical History:Patient is a 55-year-old male with a history of hypertension and diabetes.No previous history of pneumonia.No risk factors for aspiration, such as recent dental work or swallowing difficulties.Symptoms:Presents with a 3-day history of fever, cough, and shortness of breath.Cough is productive of yellow-green sputum.Shortness of breath is progressive and now requires oxygen supplementation.Physical Examination:Vital signs: T 102.5°F, HR 110 bpm, RR 24 bpm, BP 140/90 mmHg, SpO2 92% on 2L nasal cannula.General appearance: Sick and tachypneic.Head and neck: Normocephalic and atraumatic. No adenopathy or thyromegaly.Chest: Symmetrical chest expansion. Auscultation reveals bilateral crackles in the lower and middle lung fields.Abdomen: Soft and non-tender. No hepatosplenomegaly.Extremities: No edema or cyanosis.Neurological: Alert and oriented.Laboratory Studies:Complete blood count: WBC 18,000/mm³, neutrophils 85%, lymphocytes 10%.Electrolytes: Na+ 138 mEq/L, K+ 4.2 mEq/L, Cl105 mEq/L, HCO327 mEq/L.Liver function tests: AST 28 U/L, ALT 32 U/L,bilirubin 0.8 mg/dL.Renal function tests: BUN 20 mg/dL, creatinine 1.2mg/dL.Blood cultures: Pending.Imaging Studies:Chest X-ray: Bilateral multifocal airspace opacities involving the lower and middle lobes of both lungs.Diagnosis:Community-acquired pneumonia.Treatment Plan:Oxygen supplementation as needed.Intravenous antibiotics (ceftriaxone and azithromycin).Intravenous fluids for hydration.Chest physiotherapy and cough suppressants as needed.Monitor vital signs and oxygen saturation regularly.Disposition:The patient is admitted to the hospital for IVantibiotic therapy and close monitoring.Follow-Up Plan:The patient will be monitored daily for clinical improvement.Chest X-ray will be repeated in 48 hours to assess response to treatment.The patient will be discharged once fever and respiratory symptoms have resolved.中文回答：肺炎入院记录病历书写范文。
英文病历范文
英文病历范文Title: English Medical Record Sample (Creating and Expanding on a Matching Content)Medical RecordNa John SmithDate of Birth: February 15, 1985Gender: MaleNationality: AmericanOccupation: AccountantChief Complaint:The patient presented with a complaint of persistent cough, shortness of breath, and chest pain for the past week.History of Present Illness:The symptoms initially started as a mild cough, which gradually worsened over the week. The patient also experienced shortness of breath, especially during physical activities. He reported occasional chest pain, which was sharp in nature and intensified during deep breaths. The patient denied any fever, night sweats, or weight loss.Past Medical History:The patient has a history of asthma since childhood and has been using an inhaler as needed. He had a similar episode ofpersistent cough and shortness of breath six months ago, which resolved with a course of oral steroids. No other significant medical history was reported.Social History:The patient is a non-smoker and denies any alcohol or illicit drug use. He lives with his wife and two children in a smoke-free environment. The patient works as an accountant and does not have any known occupational exposures.Family History:There is no significant family history of respiratory diseases or any chronic illnesses.Review of Systems:The review of systems was unremarkable except for the respiratory symptoms mentioned above.Physical Examination:On examination, the patient appeared to be in no acute distress. Vital signs were within normal limits. Auscultation of the lungs revealed mild wheezing bilaterally. Heart sounds were normal, and there were no signs of peripheral edema or cyanosis. Other systemic examinations were within normal limits.Investigations:Laboratory investigations, including complete blood count, liver and kidney function tests, and electrolyte levels, were all within normal range. Chest X-ray showed hyperinflation of lungs and no evidence of infiltrates or consolidation.Assessment and Plan:Based on the history, clinical findings, and investigations, the patient's symptoms and past medical history suggest asthma exacerbation. Initial management includes a trial of short-acting bronchodilators, oral corticosteroids, and close monitoring of symptoms. The patient was educated about proper inhaler technique and advised to follow up in one week for reassessment.Education and Counseling:The patient was counseled on the importance of adherence to the prescribed medication and the need to avoid triggers for asthma exacerbation, such as allergens and respiratory infections. He was also provided with a written asthma action plan for self-management and advised to seek medical attention if symptoms worsen or do not improve within a week.Follow-up:The patient will be scheduled for a follow-up visit in one week to reassess symptoms, evaluate response to treatment, andadjust the management plan accordingly.This medical record documents the patient's chief complaint, history of present illness, past medical history, social and family history, physical examination findings, investigations, diagnosis, and treatment plan. It serves as a comprehensive guide for healthcare professionals involved in the patient's care.。
英文病历书写
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.
英文病历撰写手记
英文病历撰写手记病历是医生记录患者病情和诊疗过程的重要文档。
对于医生来说，准确、清晰地撰写英文病历至关重要。
本手记将介绍英文病历的撰写方法和注意事项。
1. 病历组成部分1.2 现病史（Present Illness）现病史应详细记录患者的主要症状、起病时间、发展情况以及辅助检查结果等。
应使用客观、中立的语言描述。
例如：Patient presents with fever, cough, and shortness of breath for the past week. Chest X-ray shows infiltrates in both lungs.1.3 既往史（Past Medical History）既往史包括患者过去的疾病、手术、药物过敏等情况。
应尽量提供详细信息，如果无则注明“无”。
例如：Patient has a history of hypertension and diabetes. No known drug allergies.1.4 家族史（Family History）家族史包括患者家庭成员的疾病情况，特别是与患者当前问题相关的疾病。
例如：Patient's mother has a history of breast cancer.1.5 个人史（Social History）个人史包括患者的生活方式、吸烟、饮酒、嗜好、职业等信息。
例如：Patient is a non-smoker and consumes alcohol occasionally.1.6 体格检查（Physical Examination）体格检查应记录医生对患者进行的全面检查，包括体温、脉搏、呼吸、血压等指标。
应详细描述发现的异常情况。
例如：Vital signs: temperature 37.5°C, heart rate 82 bpm, respiratory rate 18 breaths per minute, blood pressure 120/80 mmHg. Chest auscultation reveals decreased breath sounds in the lower left lung field.1.7 辅助检查（Laboratory and Diagnostic Tests）1.8 诊断（Diagnosis）1.9 治疗（Treatment）治疗部分应详细记录医生针对患者病情制定的治疗计划，包括药物治疗、手术、物理疗法等。
英语作文病假模板
英语作文病假模板Title: Template for Writing a Sick Leave Application in English。
Dear [Recipient's Name],。
I am writing to inform you that I am unable to attend school/work due to illness. I have been experiencing [describe symptoms, e.g., fever, cough, sore throat] since [mention the onset of illness, e.g., yesterday/last night]. As a result, I am unable to concentrate and perform effectively in my duties.I have visited a medical professional who has advised me to take rest and recuperate at home for the next [mention the duration, e.g., three days]. I have attached the medical certificate provided by the doctor for your reference.During my absence, I will ensure to keep up with anymissed assignments or tasks. I will communicate with my colleagues/teachers to collect any study materials or updates on work progress.I understand the inconvenience caused by my absence and apologize for any disruption to the workflow/learning process. I assure you that I will make every effort to recover swiftly and return to my responsibilities as soon as possible.Thank you for your understanding and support duringthis time. Please feel free to contact me if you require any further information or assistance.Yours sincerely,。
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简明病历书写手册1（英汉对照）简明病历书写手册（英汉对照）郭航远编著目录第一章病人身份第二章主诉第三章现病史第四章过去史、系统回统和个人史第五章月经、婚姻、生育史和家族史第六章体检（一般项目）第七章体检（头颈部）第八章体检（胸腹部）第九章体检（神经、骨骼和肌肉）第十章体检（泌尿生殖道与其他）第十一章标准化病人体检项目第十二章实验室检查第十三章辅助检查第十四章诊断（疾病名称）第十五章常用医嘱术语第十六章常用药物及中草药第十七章住院文书格式第十八章附录附1、常用解剖术语附2、医学英语常用前后缀附3、医学英语的特征附4、医学英语常用短语附5、英语问诊常用句子附6、医学英语缩写一览表附7、医院日常用品和设备附8、医学院和医院相关名称前言随着我国加入WTO，医疗体制发生了革命性的改变。
随着改革开放的深入，外国投资和管理的医院将不断涌现，中外医学交流也日趋频繁，出国学习、进修和援外医疗队的医务人员逐年增多，这就要求医生具有正确书写英文病历的能力。
目前，国内供临床医生完成英文病历的参考书很少。
签于此，编著者根据美国罗马琳达大学的病历书写要求，结合十余年的国内外工作经验（编者所在的邵逸夫医院是一所由美国专家管理的、与国际接轨的新型综合性医院，有十余年的英文病历书写实践），并参阅一些国内外的相关文献，编写了本手册。
本手册按病历书写的顺序进行编写，采用英中对照写法，内容详尽，条理清晰，形式新颖，适用于临床医生、出国人员、实习生和医学院校的学生。
在本手册的编写过程中，得到了美国罗马琳达大学医学院和日本福井大学医学院和邵逸夫医院领导的关心和支持。
谨以此书献给我的老师、同事、朋友和家人。
郭航远2002.11.1于浙江大学医学院第一章病人身份[Identification]·[Name] 姓名·[Sex] 性别·[Age] 年龄·[Occupation] 职业·[Date of birth] 出生日期·[Marriage （Marital status）] 婚姻·[Race] 民族·[Place of birth (Birth place)] 籍贯·[Identification No.(code of ID card No.)] 身份证号码·[Department of work and TEL. No. (Unit and Business phone No.)] 工作单位及电话·[Home address and phone No.] 家庭住址及电话·[Post code] 邮政编码·[Person to notify (Correspondent) and phone No.] 联系人及电话·[Source (Complainer;offerer;supplier;provider) of history] 病史陈术者·[Reliability of history] 病史可靠程试·[Medical security (Type of payment)] 医疗费用·[Type of admission (Patient condition)] 住院类别（入院时病情）·[Medical record No.] 病历号·[Clinic diagnosis] 门诊诊断·[Date of admission (admission date)] 入院日期·[Date of record] 记录日期1、年龄的表示方法（以36岁为例）·36 years old (y/o)·Age 36·36 year-old·The age of 36·36 years of age2、性别的表示方法·[Male,♂] 男性·[Female,♀] 女性3、职业的表示方法·工人[Worker]·退休工作[Retired worker]·农民[Farmer (peasant)]·干部[Leader (cadre)]·行政人员[administrative personnel (staff)]·职员[staff member]·商人[Trader (Businessman)]·教师[Teacher]·学生[Student]·医生[Doctor]·药剂师[Pharmacist]·护士[Nurse]·军人[Soldier]·警察[Policeman]·工程师[Engineer]·技术员[Technician]·家政人员[Housekeeper]·家庭主妇[Housewife]·营业员[Assistant]·服务员[Attendant]·售票员[Conductor]4、民族的表示方法·汉[Han]·回[Hui]·蒙[Meng]·藏[Tibetan]·朝鲜[Korean]·美国人[American]·日本人[Japanese]·英国人[Britisher]5、医疗费用的表示方法·[Self pay (Individual medical care)] 自费·[Government insruance (Public medical care)] 公费·[Insurance] 保险·[Local insurance] 本地医保·[Non-local in surance] 外地医保·[Labor protestion care] 劳保6、婚姻状况的表示方法·[Married] 已婚·[Single (Unmarried)] 未婚·[Diverced] 离婚·[Widow] 寡妇·[Widower] 鳏夫7、病史可靠程度的表示方法·[Reliable] 可靠·[Unreliable] 不可靠·[Not entirely] 不完全可靠·[Unobtainable] 无法获得8、住址的表示方法·[NO.3,Qing Chun Road East,Hangzhou, Zhejiang] 浙江省杭州市庆春东路3号·[XinDong Cun, Cheng Guan Town, Zhu Ji municipality, zhejiang province.] 浙江省诸暨市（县）城关镇新东村9、病史陈述者的表示方法·[Patient himself (herself)] 患者本人·[Her husband] 患者的丈夫·[His wife] 患者的妻子·[Patient`s colleague] 患者的同事·[Patient`s neighbor] 患者的邻居·[Patient`s Kin (Mother; Son; daughter;brother;Sister)] 患者的亲属(父亲、母亲、儿子、女儿、兄弟、姐妹)·[Taximan] 出租车司机·[Traffic police] 交通警察10、日期的表示方法·2002年10月1日[10-1-2002(10/1/2002; Oct.1,2002; Oct.lst,2002)](美国) ·2002年10月1日[1-10-2002(1/10/2002; 1 Oct.,2002; 1st of Oct.,2002)] (英国) 11、住院类别的表示方法·[Emergent (Emergency call)] 急诊·[Urgent] 危重·[Elective (General)] 一般（普通）12、入院时病情的表示方法·[Stable] 稳定·[Unstable] 不稳定·[Relative stable] 相对稳定·[Critical (Imminent)] 危重·[Fair (General)] 一般第二章主诉[Chief Complaint]1、主诉的表示方法：症状+时间（Symptom+Time）·症状+for+时间如：[Chest pain for 2 hours] 胸痛2小时·症状+of+时间如：[Nausea and vomiting of three days` duration] 恶心呕吐3天·症状+时间+in duration如：[Headache 1 month in duration] 头痛1月·时间+of+症状如：[Two-day history of fever] 发热2天2、常见症状·[Fever] 发热·[Pain] 疼痛·[Edema] 水肿·[Mucocutaneous hemorrhage (bleeding)] 皮肤粘膜出血·[Dyspnea (Difficuly in breathing;Respiratory difficulty;short of breath)] 呼吸困难·[Cough and expectoration (Sputum;Phlegm)] 咳嗽和咯痰·[Hemoptysis] 咯血·[Cyanosis] 紫绀·[Palpitation] 心悸·[Chest discomfort] 胸闷·[Nausea (Retch;Dry V omiting)and V omiting] 恶心和呕吐·[Hematemesis (V omiting of blood)] 呕血·[Hematochezia (Hemafecia)] 便血·[Diarrhea] 腹泻·[Constipation (Obstipation)] 便秘·[Vertigo (Giddiness; Dizziness)] 眩晕·[Jaundice (Icterus)] 黄疸·[Convulsion] 惊厥·[Disturbance of consciousness] 意识障碍·[Hematuria] 血尿·[Frequent micturition,urgent micturition and dysuria] 尿频，尿急和尿痛·[Incontinence of urine] 尿失禁·[Retention of urine] 尿潴留（1）发热的表示方法·[Infective (Septic)fever] 感染性发热·[Non-infective (Aseptic)fever] 非感染性发热·[Dehydration (Inanition)fever] 脱水热·[Drug fever] 药物热·[Functional hypothermia] 功能性低热·[Absorption fever] 吸收热·[Central fever] 中枢性发热·[Fever type] 热型▲[Continuous fever] 稽留热▲[Remittent fever]驰张热▲[Intermittent fever] 间歇热▲ [Undulant fever] 波状热▲ [Recurrent fever]回归热▲[Periodic fever] 周期热▲ [Irregular fever]不规则热▲[Ephemeral fever]短暂热▲[Double peaked fever]双峰热·[Fever of undetermined(unknown) origin, FUO] 不明原因发热·[Rigor (shivering;chill;shaking chill;ague)] 寒战·[Chilly Sensation (Fell chilly;cold fits;coldness)] 畏寒·[Ultra-hyperpyrexia] 超高热·[Hyperthermia (A high fever;hyperpyrexia;ardent fever)] 高热·[Moderate fever] 中度发热·[Hypothermia (Low-grade fever;slight fever;subfebrile temperature)] 低热·[Become feverish (Have a temperature)] 发热·[Crisis] 骤降·[Lysis] 渐降·[Typhoid fever] 伤寒热·[Rheumatic fever] 风湿热·[Cancerous fever] 癌性发热·[Fervescence period] 升热期·[Defervescence period] 退热期·[Persistent febrile period] 持续发热期（2）疼痛的表示方法·[Backache (Back pain)] 背痛·[Lumbago] 腰痛·[Headache] 头痛▲ [Vasomotor headache] 血管舒缩性头痛▲[Post-traumatic headache] 创伤后头痛▲[Migraine headache]偏头痛▲ [Cluster headache] 丛集性头痛·[Chest pain] 胸痛·[Precardial pain] 心前区痛·[Retrosternal pain] 胸骨后痛·[Abdominal pain (Stomachache)] 腹痛·[Acrodynia (pain in limbs)] 肢体痛·[Arthrodynia (Arthralgia)] 关节痛·[Dull pain] 钝痛·[Sharp pain] 锐痛·[Twinge pain] 刺痛·[Knife-like pain (Piercing pain)] 刀割（刺）样痛·[Aching pain] 酸痛·[Burning pain] 烧灼痛·[Colicky (Griping;cramp) pain] 绞痛·[Colic] 绞痛·[Bursting pain] 胀痛（撕裂痛）·[Hunger pain] 饥饿痛·[Tic pain] 抽搐痛·[Bearing-down pain] 坠痛·[Shock-like pain] 电击样痛·[Jumping pain] 反跳痛·[Tenderness pain] 触痛（压痛）·[Girdle-like pain] 束带样痛·[Wandering pain] 游走性痛·[Throbbing pain] 搏动性痛·[Radiating pain] 放射性痛·[Cramping pain] 痉挛性痛·[Boring pain] 钻痛·[Intense pain] 剧痛·[Writhing pain] 痛得打滚·[Dragging pain] 牵引痛·[Labor pain] 阵痛·[Cancerous pain] 癌性疼痛·[Referred pain] 牵涉痛·[Persistent pain (Unremitting pain)] 持续性痛·[Constant pain] 经常性痛·[Intermittent pain] 间歇性痛（3）水肿的表示方法·[Mucous edema (Myxedema)] 粘液性水肿·[Cardiac (Cardiogenic) edema] 心源性水肿·[Nephrotic (renal) edema] 肾源性水肿·[Hepatic edema] 肝源性水肿·[Alimentary (Nutritional) edema] 营养不良性水肿·[Angioneurotic edema] 血管神经性水肿·[Pitting] 凹陷性·[Nonpitting] 非凹陷性·[Localized (Local) edema] 局限性水肿·[Generalized edema (Anasarca)] 全身性水肿·[Hydrops] 积水·[Elephantiasic crus] 橡皮肿·[Cerebral(Brain) edema] 脑水肿·[Pulmonary edema (Hydropneumonia0] 肺水肿·[Hydrocephalus] 脑积水·[Edema of endoscrinopathy] 内分泌病性水肿·[Invisible (Recessive) edema] 隐性水肿·[Frank edema] 显性水肿·[Inflammatory edema] 炎性水肿·[Idiopathic edema] 特发性水肿·[Cyclical edema] 周期性水肿·[Ascites (Abdominal effusion;hydroperiotoneum)] 腹水·[Pleural effusion (Hydrothorax)] 胸水·[Pericardial effusion (Hydropericardium)] 心包积液·[Bronchoedema] 支气管水肿·[Slight (Mild)] 轻度·[Moderate] 中度·[Serious] 重度·[Transudate] 漏出液·[Exudate] 渗出液（4）呼吸困难的表示方法·[Cardiac dyspnea] 心原性呼吸困难·[Inspiratory] 吸气性·[Expiratory] 呼气性·[Mixed] 混合性·[Obstructive] 梗阻性·[Dyspnea at rest] 静息时呼吸困难·[Dyspnea on exertion] 活动时呼吸困难·[Dyspnea on lying down] 躺下时呼吸困难·[Paroxysmal nocturnal dyspnea,PND] 夜间阵发性呼吸困难·[Orthopnea] 端坐呼吸·[Asthma] 哮喘·[Cardiac asthma] 心源性哮喘·[Bronchial asthma] 支气管性哮喘·[Hyperpnea] 呼吸深快·[Periodic breathing] 周期性呼吸·[Tachypnea (Rapid or fast breathing;accelerated breathing;short of breath)]气促·[Bradypnea (Slow breathing)] 呼吸缓慢·[Irregular breathing] 不规则呼吸（5）皮肤粘膜出血的表示方法·[Bleeding spots in the skin] 皮肤出血点·[Petechia] 瘀点·[Eccymosis] 瘀斑·[Purpura] 紫癜·[Splinter hemorrhage] 片状出血·[Oozing of the blood (Errhysis)] 渗血·[Blood blister (Hemophysallis)] 血疱·[Hemorrhinia (Nasal bleeding)] 鼻衄·[Ecchymoma] 皮下血肿（6）咳嗽与咯痰的表示方法·[Dry cough (Nonproductive cough;hacking cough)] 干咳·[Sharp cough] 剧咳·[Wet cough (Moist cough)] 湿咳·[Productive cough (Loose cough)] 排痰性咳·[Chronic cough] 慢性咳嗽·[Irritable cough] 刺激性咳嗽·[Paroxysmal cough] 发作性（阵发性）咳嗽·[Cough continually] 持续性咳嗽·[Spasmodic cough] 痉挛性咳嗽·[Whooping cough] 百日咳·[Winter cough] 冬季咳·[Wheezing cough] 喘咳·[Short cough] 短咳·[Distressed cough] 难咳·[Shallow cough] 浅咳·[Droplet] 飞沫·[Frothy sputum] 泡沫样痰·[Bloody sputum] 血痰·[Mucous (Mucoid) sputum] 粘液样痰·[Purulent sputum] 脓痰·[Mucopurulent sputum] 粘液脓性痰·[White (Yellow,green) sputum] 白（黄,绿）痰·[Fetid (Foul) sputum] 恶臭痰·[Iron-rust (Rusty) sputum] 铁锈色痰·[Chocolate coloured sputum] 巧克力色痰·[Thick sputum] 浓痰·[Thin sputum] 淡痰·[Viscous sputum] 粘痰·[Transparent sputum] 透明痰·[Much (Large amounts of) sputum] 大量痰·[Moderate amounts of sputum] 中等量痰·[Not much (Small amounts of ) sputum] 少量痰（7）内脏出血的表示方法·[Goldstein’s hemoptysis]戈耳斯坦氏咯血·[Massive hematemesis]大量呕血·[Epistasis (Nosebleed;Nasal bleeding; Hemorrhinia;rhinorrhagia)]鼻衄·[Hematuria] 血尿·[Initial hematuria] 初血尿·[Idiopathic hematuria] 特发性血尿·[Painless hematuria] 无痛性血尿·[Terminal hematuria] 终末性血尿·[Gross (Macroscopic) hematuria] 肉眼血尿·[Microscopic hematuria] 镜下血尿·[Hematuria in the whole process of urination] 全程血尿·[Gingival bleeding (Ulaemorrhagia;gum bleeding)] 牙龈出血·[Hematochezia] 便血·[Bloody stool] 血便·[Black stool (Melena)] 黑便·[Tarry stool] 柏油样便·[Bleeding following trauma] 外伤后出血·[Spontaneous bleeding] 自发性出血·[Bleeding Continuously] 持续出血·[Occult blood,OB] 隐血·[Hematobilia] 胆道出血·[Hemathorax] 血胸·[Hemarthrosis] 关节积血·[Hematocoelia] 腹腔积血·[Hematoma] 血肿·[Hemopericardium] 心包积血·[Cerebral hemorrhage] 脑出血·[Subarachnoid hemorrhage(SAH)] 蛛网膜下腔出血·[Excessive (Heavy) menstrual flow with passage of clots] 月经量多伴血块·[Mild (Moderate) menses] 月经量少（中等）·[Painless Vaginal bleeding] 无痛性阴道出血·[Postcoital bleeding] 性交后出血·[Pulsating bleeding] 搏动性出血·[Post-operation wound hemorrhage] 术后伤口出血·[Excessive bleeding after denal extraction] 拔牙后出血过多（8）紫绀的表示方法·[Congenital cyanosis] 先天性紫绀·[Enterogenous] 肠源性·[Central] 中枢性·[Peripheral] 周围性·[Mixed] 混合性·[Acrocyanosis] 指端紫绀（9）恶心与呕吐的表示方法·[V omiturition (Retching)] 干呕·[Feel nauseated] 恶心感·[Postprandial nausea] 饭后恶心·[Hiccup] 呃逆·[Sour regurgitation] 返酸·[Fecal (Stercoraceous) vomiting] 吐粪·[undigested food V omiting] 吐不消化食物·[Bilious V omiting] 吐胆汁（10）腹泻与便秘的表示方法·[Moning diarrhea] 晨泻·[Watery (Liquid)diarrhea] 水泻·[Mucous diarrhea] 粘液泻·[Fatty diarrhea] 脂肪泻·[Chronic (Acute)] 慢性（急性）·[Mild diarrhea] 轻度腹泻·[Intractable (Uncontrolled)diarrhea] 难治性腹泻·[Protracted diarrhea] 迁延性腹泻·[Bloody stool] 血梗·[Frothy stool] 泡沫样便·[Formless (Formed)stool] 不成形（成形）便·[Loose (Hard) stool] 稀（硬）便·[Rice-water stool] 米泔样便·[Undigested stool] 不消化便·[Dysenteric diarrhea] 痢疾样腹泻·[Inflammatory diarrhea] 炎症性腹泻·[Osmotic] 渗透性·[Secretory] 分泌性·[Malabsorption] 吸收不良性·[Lienteric] 消化不良性·[Pancreatic diarrhea] 胰性腹泻·[Tenesmus] 里急后重·[Pass a stool (Have a passage; open or relax the bowel)] 解大便·[Have a call of nature] 便意·[Fecal incontinence (Copracrasia)] 大便失禁·[Functional constipation] 功能性便秘·[Organic constipation] 器质性便秘·[Habitual constipation] 习惯性便秘·[Have a tendency to be constipated] 便秘倾向（11）黄疸的表示方法·[Latent (occult) jaundice] 隐性黄疸·[Clinical jaundice] 显性黄疸·[Nuclear icterus] 核黄疸·[Physiologic icterus] 生理性黄疸·[Icterus simplex] 传染性黄疸·[Toxemic icterus] 中毒性黄疸·[Hemolytic] 溶血性·[Hepatocellular] 肝细胞性·[Obstructive] 阻塞性·[Congenital] 先天性·[Familial] 家族性·[Cholestatic] 胆汁淤积性·[Hematogenous] 血源性·[Malignant] 恶性·[Painless] 无痛性（12）意识障碍的表示方法·[Somnolence] 嗜睡·[Confusion] 意识模糊·[Stupor] 昏睡·[Coma] 昏迷·[Delirium] 谵妄·[Syncope (swoon; faint)] 晕厥·[Drowsiness] 倦睡（13）排尿的表示方法·[Enuresis (Bed-wetting)] 遗尿·[Anuria] 无尿·[Emiction interruption] 排尿中断·[Interruption of urinary stream] 尿线中断·[Nocturia] 夜尿·[Oliguria] 少尿·[Polyuria] 多尿·[Pass water (Make water; urinate; micturition)] 排尿·[Frequent micturition (Frequency of micturition; fruquent urination;Pollakiuria)] 尿频·[Urgent micturition (Urgency of urination or micturition)] 尿急·[Urodynia (Pain on micturition; painful micturition; alginuresis; micturition pain)] 尿痛·[Dysuria (Difficulty in micturition; disturbance of micturition)] 排尿困难·[Small urinary stream] 尿线细小·[V oid with a good stream] 排尿通畅·[Guttate emiction (Dribbling following urination;terminal dribbling)] 滴尿·[Bifurcation of urination] 尿流分叉·[Residual urine] 残余尿·[Extravasation of urine] 尿外渗·[Stress incontinence] 压力性尿失禁·[Overflow incontinence] 溢出性尿失禁·[Paradoxical in continence] 反常性尿失禁3．少见症状·[Weekness( Debility; asthenia; debilitating)] 虚弱（无力）·[Fatigue (Tire; lassitude)] 疲乏·[Discomfort (Indisposition; malaise)] 不适·[Wasting (thin; underweight; emaciation; lean)] 消瘦·[Night sweating] 盗汗·[Sweat (Perspiration)] 出汗·[Cold sweat] 冷汗·[Pruritus (Iching)] 搔痒·[Asthma] 气喘·[Squeezing (Tightness; choking; pressing) sensation of the chest] 胸部紧缩（压榨）感·[Intermittent claudication] 间歇性跛行·[Difficulty in swallowing( Dysphagia; difficult swallowing; acataposis)] 吞咽困难·[Epigastric (Upper abdominal) discomfort] 上腹部不适·[Anorexia (Sitophobia)] 厌食·[Poor appetite (Loss of appetite)] 纳差·[Heart-burn( Pyrosis)] 胃灼热·[Stomachache( Pain in stomach)] 胃部痛·[Periumbilial pain] 脐周痛·[Belching (Eructation)] 嗳气·[Sour regurgitation] 返酸·[Abdominal distention(bloating)] 腹胀·[Pass gas( Break wink)] 肛门排气·[Small(Large) stool] 大便少（多）·[Expel(Pass) worms] 排虫·[Pain over the liver] 肝区痛·[Lumbago] 腰痛·[Pica(Parorexia; allotriophagy)] 异食癖·[Dysmenorrhea] 痛经·[Menoxenia (Irregular menstruation)] 月经不调·[Polymenorrhea (Epimenorrhea)] 月经过频·[Oligomenorrhea] 月经过少·[Excessive menstruation (Menorrhagia; menometrorrhagia; hypermenorrhea)] 经量过多·[Hypomenorrhea (Scantymenstruation)] 经量过少·[Menopause (Menostasia; menostasis)] 绝经·[Amenorrhea (Menoschesis)] 闭经·[Leukorrhagia] 白带过多·[Asexuality (lack of libido)] 无性欲·[Hyposexuality] 性欲低下·[Hypersexuality] 性欲亢进·[Prospermia (Ejaculatio praecox)] 早泄·[Impotency (impotence)] 阳萎·[Nocturnal emission (Spermatorrhea)] 遗精·[Lack of potency] 无性交能力·[Hair loss] 脱发·[Joint pain (Arthralgia; arthrodynia)] 关节痛·[Polydipsia (Excessive thirst)] 多饮（烦渴）·[Polyphagia (Excessive appetite; hyperorexia; bulimia)] 多食·[Cold (Heat) intolerance] 怕冷（热）·[Dwarfism (Excessive height)] 身材矮小（高大）·[Excessive sweating] 多汗·[Hands tremble] 手抖·[Obesity (Fatty)] 肥胖·[Agitation (Anxiety;nervous irritability)] 焦虑（忧虑）·[Mania] 躁狂·[Hallucination] 幻觉·[Aphasia (Logopathy)] 失语·[Amnesia (Poor memorization;memory deterioration)] 记忆力下降·[Hemianesthesia] 偏身麻木·[Formication] 蚁走感·[Tingling] 麻刺感·[Hyperpathia] 痛觉过敏·[Hypalgesia] 痛觉减退·[Illusion] 错觉·[Hemiplegia] 半身不遂·[Insomnia (Poor sleepness;sleeplessness)] 失眠·[Nightmare] 多梦·[Numbness] 麻木·[Pain in limbs (Acrodynia)] 肢体痛·[Limitation of motion] 活动受限·[Tetany] 手足抽搐·[Discharge of pus] 流脓·[Blurred vision(Hazy vision;blurring of vision; dimness of vision)]视物模糊·[Burning (Dry) sensation] 烧灼（干燥）感·[Tearing (Dacryorrhea;Lacrimation)] 流泪·[Double vision (Diplopia)] 复视·[Strabismus] 斜视·[Hemianopia] 偏盲·[Tired eyes (Eyestrain)] 眼疲劳·[Foreign body sensation] 异物感·[Lose the sight (Lose of vision)] 失明·[Diminution of vision] 视力减退·[Nictition] 眨眼·[Ophthalmodynia (Eye-ache;ocular pain)] 眼痛·[Photophobia] 畏光·[Spots before the eyes] 眼前黑点·[Deafness(Anacusia)] 耳聋·[Auditory dysesthesia] 听力减退·[Otalgia (Otodynia;pain in the ear ;ear-ache)] 耳痛·[Stuffy feeling in the ear] 耳闭气·[Tinnitus] 耳鸣·[Outophony] 自声过强·[Nasal obstruction (blockage)] 鼻塞·[Dryness of the nose] 鼻干燥·[Rhinorrhea (Snivel;Nasal discharge)] 流鼻涕·[Sneezing] 打喷嚏·[Snoring] 打鼾·[Hyposmia (Reduction of the sense of smell)] 嗅觉减退·[Anosmia (Complete loss of sense of smell)] 嗅觉丧失·[Dysphonia] 发音困难·[Hoarseness] 声嘶·[Pain on swallowing] 吞咽痛·[Saliva dribblies from the mouth] 流涎·[Troaty voice] 声音沙哑·[Stridor] 喘鸣·[Red and swollen] 红肿·[Scurf] 头皮屑·[Show] 见红·[Amniotic fluid escaped] 破水·[Uterine contraction] 宫缩·[Acalculia] 计算不能·[Apathy] 情感淡漠·[Delusion] 妄想4、时间的表示方法（1）月（Month）·[January,Jan.] 一月·[February,Feb.] 二月·[March,Mar.] 三月·[April,Apr.] 四月·[May] 五月·[June,Jun.] 六月·[July,Jul.] 七月·[August,Aug.] 八月·[September,Sept.] 九月·[October,Oct.] 十月·[November,Nov.] 十一月·[December,Dec.] 十二月（2）周（Week）·[Monday] 星期一·[Tuesday] 星期二·[Wednesday] 星期三·[Thursday] 星期四·[Friday] 星期五·[Saturday] 星期六·[Sunday] 星期日（3）年（Year）和日[Day]·[1st (First) year] 第1年·[2nd (Second) year] 第2年·[3rd (Third)year] 第3年·[4th (Forth) year] 第4年·[One year (day)] 1年（天）·[Two years (days)] 2年（天）·[Whole year] 整年·[1st (First)] 1日·[2rd (Second)] 2日·[3rd (Third)] 3日·[5th (Fifth)] 5日·[Today] 今天·明天[Tomorrow]·昨天[Yesterday]·前天[The day bdfore yesterday]·后天[The day after tomorrow]·大前天[3 days ago]·大后天[3 days hence]·今晚[Tonight]·昨晚[Last night]·明晚[Next night]·通宵[All night]·整天[All day (the whole day)]（4）季节[Season]和时节[Solar terms]·春季[Spring]·夏季[Summer]·秋季[Autumn]·冬季[Winter]·立春（夏、秋、冬）[the Beginning of Spiring (Summer;Autumn;Winter)] ·小暑（雪、寒）[Slight Heat (Snow;Cold)]·大暑（雪、寒）[Great Heat (Snow;Cold)]·雨水[Rain Water]·惊蛰[the Waking of Insects]·春（秋）分[the Spiring (Autumnal) Equinox]·清明[Pure Brightness]·谷雨[Grain Rain]·小满[Grain Full]·芒种[Grain in Ear]·夏（冬至）[the Summer (Winter) Solstice]·处暑[the Limit of Heat]·白（寒）露[White (Cold) Dew]·霜降[Frost’s Descent]（5）时间的表示方法·In[在……内（后）]▲在2003年[In 2003]▲在3月[In March(Mar.)]▲在去年10月[In last Oct.]▲在早晨[In the morning]▲在上午[In the forenoon]▲在下午[In the afternoon]▲在晚上[In the evening]▲在近5天[In the past 5 days]▲在10分钟后[In 10 minutes]▲在秋季[In autumn]▲在这2～3天内[In a couple of days]·Within[在……中]▲在近8个月中[Within the last 8 months]▲在过去的2年中[Within the preceding 2 years]·On[在……时候]▲在2002的9月18日[On the 18th of September,2002(英国)or On sept.18th,2002(美国)▲在星期三[On Wednesday]▲在本月7日[On 7th instant]·At[在……时]▲在中午[At noon]▲在晚上[At night]▲在昨晚[At last (preceding;previous )night]▲在半夜[At midnight]▲在上午10点钟[At 10AM]▲在5岁时[At the age of five]▲在2000年底（中、初）[At the end (middle;beginning) of 2000] ·For[计……时间]▲一周[For one week]▲近2个月来[For the past 2 months]▲几乎（整整）一年[For nearly a month (a full month)]▲3个月左右[For 3 months or so]▲至少3个月[For at least 3 months]▲3个月以上[For more than 3 months]▲3个月或以上[For 3months or more]▲时间不详[For an unknown(indefinite) period (time)]·Of[在……时期]▲10年内[Of 10 years` duration]▲期间[Length of time]▲6月6日[The 6th of June]·Dring[在……期间]▲在2000-2005年的几年中[During the years form 2000 to 2005] ▲在这4年中[During four years]▲在过去的几周中[During the past(Last) couple of weeks]▲在夜间[During the night]▲整天[During the entire day]·About [约]▲约1个半小时[About one and half an hour]▲大约半年[About half a year]·To[至；在……之前]▲从今下午点至明上午8点[Form 6 PM today to 8 AM tomorrow] ▲6点45分[At fifteen to seven]·From[从……起]▲从14岁至52岁[From 14 to 52 year-old]▲从上午7点30分开始[Form 7:30AM]▲从周一至周五[From Monday through Friday]·Past[过去；超过]▲在过去的3周中[In the past 3 weeks]▲8点10分[ten minutes past eight]·Through or throughout[在……整个期间]▲通宵值班[Be on duty through the night]▲从一月到六月[From January through June]▲熬过明晚[Through the next nigut]▲整天（晚）[Throughout the day (night)]·Over[在……期间]▲在过去的2个月内[Over the past two months]▲一夜间[Overnight]（6）其他表示方法·每月（年、日）一次[Monthly (Yearly; daily)]·整整一年[Yearlong (Year-round)]·满周岁[Yearling]·工作日[Weekday]·周末[Weekend]·每周末[Weekends]·8小时工作日[An eight-hour day]·整天[Daylong]·白天[Daytime]·昼夜[Nighttime]·日常的[Day-to-day]·夏令时间[Daylight saving time]·每晚[Nightly]·黄昏[Nighfall]·过期的[Overdue]·前天晚上（一夜间）[Overnight]·After [在……之后]▲婚后[After one`s marriage]▲七点十分[Ten after (past) seven]▲住（出）院后[After admission (discharge)]▲起病后2天[2 days after the onset(attack) of symptoms]·Before[在……之前]▲7点50分之前[Before seven fifty]▲医生到达前[Before the doctor come]▲以前未有种症状[Have had not the same symptom before]·Ago[以前]▲5年前[5 years ago]▲直到一个月前[Up to one month ago]▲大前天[Three days ago]·Prior to[在……之前]▲入（出）院前[Prior to admission (discharge)]▲前天之前[Prior to the day before yesterday]·Up to[直到]▲直到3周前[Up to 3 weeks ago]▲直到现在（出院）[Up to now (discharge)]·Until or till[直到]▲直到80岁[Until 80 years old]▲直到今晨8点[Until 8 o`clock this moning]▲直到医生查完房[Until the doctor have finished the ward round]▲直到3年以前[Until 3 years ago]▲直到出院前一天[Until 1 day prior to discharge]·By[在……之前]▲下午点钟前[By 5 PM]▲下个月之前[By next month]·Since[从……开始]▲自从去年术后[Since operation was performed last year]▲前天起[Since the day before yesterday]▲从2002年6月起[Since June 2002]·超时(加班)[Overtime]·上午8点[8：00AM]·下午2点30分[2：30PM]·7点50分[Seven fifty (Ten to eight)]·9点20分[Nine twenty(Twenty past or after nine)]·术前[Pre-operation]·术后[Post-operation]第三章现病史[History of present illness (HPI/PI)]现病史书写的重点包括：一、主诉中症状的详细描述；二、疾病的发展过程；三、诊疗经过；四、目前的一般情况。