内科英文病历材料模板
HUAZHONG UNIVERSITY OF SCIENCE AND TECHNOLOGY TONGJI MEDICAL COLLEGE ACCESSORY TONGJI HOSPITAL
Hospitalization Records for None-operation Division Division: __________ Ward: __________ Bed: _________ Case No. ___________
Name: ______________ Sex: __________ Age: ___________ Nation: ___________ Birth Place: ________________________________ Marital Status:____________ Work-organization & Occupation: _______________________________________ Living Address & Tel: _________________________________________________ Date of admission: _______Date of history taken:_______ Informant:__________ Chief Complaint: ___________________________________________________
History of Present Illness:
___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________
Past History:
General Health Status: 1.good 2.moderate 3.poor
Disease history: (if any, please write down the date of onset, brief diagnostic
and therapeutic course, and the results.)
Respiratory system:
1. None
2.Repeated pharyngeal pain
3.chronic cough
4.expectoration:
5. Hemoptysis
6.asthma
7.dyspnea
8.chest pain
_______________________________________________________________ Circulatory system:
1.None
2.Palpitation
3.exertional dyspnea
4..cyanosis
5.hemoptysis
6.Edema of lower extremities
7.chest pain
8.syncope
9.hypertension
_______________________________________________________________ Digestive system:
1.None
2.Anorexia
3.dysphagia
4.sour regurgitation
5.eructation
6.nausea
7.Emesis
8.melena
9.abdominal pain 10.diarrhea
11.hematemesis 12.Hematochezia 13.jaundice
_______________________________________________________________ Urinary system:
1.None
2.Lumbar pain
3.urinary frequency
4.urinary urgency
5.dysuria
6.oliguria
7.polyuria
8.retention of urine
9.incontinence of urine
10.hematuria 11.Pyuria 12.nocturia 13.puffy face
_______________________________________________________________ Hematopoietic system:
1.None
2.Fatigue
3.dizziness
4.gingival hemorrhage
5.epistaxis
6.subcutaneous hemorrhage
_______________________________________________________________ Metabolic and endocrine system:
1.None
2.Bulimia
3.anorexia
4.hot intolerance
5.cold intolerance
6.hyperhidrosis
7.Polydipsia
8.amenorrhea
9.tremor of hands 10.character change 11.Marked obesity
12.marked emaciation 13.hirsutism 14.alopecia
15.Hyperpigmentation 16.sexual function change
_______________________________________________________________ Neurological system:
1.None
2.Dizziness
3.headache
4.paresthesia
5.hypomnesis
6. Visual disturbance
7.Insomnia
8.somnolence
9.syncope 10.convulsion 11.Disturbance of consciousness
12.paralysis 13. vertigo
_______________________________________________________________ Reproductive system:
1.None
2.others
_______________________________________________________________
Musculoskeletal system:
1.None
2.Migrating arthralgia
3.arthralgia
4.artrcocele
5.arthremia
6.Dysarthrosis
7.myalgia
8.muscular atrophy
_______________________________________________________________ Infectious Disease:
1.None
2.Typhoid fever
3.Dysentery
4.Malaria 4.Schistosomiasis
4.Leptospirosis 7.Tuberculosis 8.Epidemic hemorrhagic fever
9.others
_______________________________________________________________ Vaccine inoculation:
1.None
2.Yes
3.Not clear
Vaccine detail __________________________________________ Trauma and/or operation history:
Operations:
1.None
2.Yes
Operation details:_______________________________________ Traumas:
1.None
2.Yes
Trauma details:_________________________________________ Blood transfusion history:
1.None
2.Yes ( 1.Whole blood 2.Plasma
3.Ingredient transfusion)
Blood type:____________ Transfusion time:___________
Transfusion reaction
1.None
2.Yes
Clinic manifestation:_____________________________ Allergic history:
1.None
2.Yes
3.Not clear
allergen:________________________________________________
clinical manifestation:_____________________________________
Personal history:
Custom living address:____________________________________________ Resident history in endemic disease area:_____________________________ Smoking: 1.No 2.Yes
Average ___pieces per day; about___years
Giving-up 1.No 2.Yes (Time:_______________________) Drinking: 1.No 2.Yes
Average ___grams per day; about ___years
Giving-up 1.No 2.Yes(Time:________________________) Drug abuse:1.No 2.Yes
Drug names:_______________________________________ _______________________________________________________________
Marital and obstetrical history:
Married age: __________years old Pregnancy ___________times
Labor _______________times
(1.Natural labor: _______times 2.Operative labor: ________times
3.Natural abortion: ______times
4.Artificial abortion: _______times
5.Premature labor:__________times
6.stillbirth__________times)
Health status of the Mate:
1.Well
2.Not fine
Details: _______________________________________________ Menstrual history:
Menarchal age: _______ Duration ______day Interval ____days
Last menstrual period: ____________ Menopausal age: ____years old
Amount of flow: 1.small 2. moderate 3. large
Dysmenorrheal: 1. presence 2.absence Menstrual irregularity 1. No 2.Yes Family history: (especially pay attention to the infectious and hereditary disease
related to the present illness)
Father: 1.healthy 2.ill:________ 3.deceased cause: ___________________ Mother:1.healthy 2.ill:________ 3.deceased cause: ___________________ Others: ________________________________________________________ The anterior statement was agreed by the informant.
Signature of informant: Datetime:
Physical Examination
Vital signs:
Temperature:______0C Blood pressure:_______/_______mmHg Pulse: _____ bpm (1.regular 2.irregular_____________________________) Respiration: ___bpm (1.regular 2.irregular____________________________) General conditions:
Development: 1.Normal 2.Hypoplasia 3.Hyperplasia
Nutrition: 1.good 2.moderate 3.poor 4.cachexia
Facial expression: 1.normal 2.acute 3.chronic other_____________________ Habitus: 1.asthenic type 2.sthenic type 3.ortho-thenic type
Position: 1.active 2.positive https://www.wendangku.net/doc/0b12149831.html,pulsive 4.other_______________________ Consciousness: 1.clear 2.somnolence 3.confusion 4.stupor 5.slight coma
6.mediate coma
7.deep coma
8.delirium
Cooperation: 1Yes 2.No Gait: 1.normal 2.abnormal______
Skin and mucosa:
Color: 1.normal 2.pale 3.redness 4.cyanosis 5.jaundice 6.pigmentation
Skin eruption:1.No 2.Yes( type: __________distribution:__________________) Subcutaneous bleeding: 1.no 2.yes (type:_______distribution:______________) Edema:1. no 2.yes ( location and degree________________________________) Hair: 1.normal 2.abnormal(details_____________________________________) Temperature and moisture: normal cold warm dry moist dehydration Liver palmar : 1.no 2.yes Spider angioma (location:________________) Others: __________________________________________________________ Lymph nodes: enlargement of superficial lymph node:
1.no
2.yes
Description: ________________________________________________ Head:
Skull size:1.normal 2.abnormal (description:____________________________) Skull shape:1.normal 2.abnormal(description:___________________________) Hair distribution :1.normal 2.abnormal(description:______________________) Others:___________________________________________________________ Eye: exophthalmos:___________eyelid:____________conjunctiva:__________ sclera:________________Cornea:_______________________
Pupil: 1.equally round and in size 2.unequal (R______mm L_______mm)
Pupil reflex: 1.normal 2.delayed (R___s L___s ) 3.absent (R___L___)
others:______________________________________________________ Ear: Auricle 1.normal 2.desformation (description:_______________________) Discharge of external auditory canal:1.no 2.yes (1.left 2.right quality:_____)
Mastoid tenderness 1.no 2.yes (1.left 2.right quality:__________________)
Disturbance of auditory acuity:1.no 2.yes(1.left 2.right description:_______) Nose: Flaring of alae nasi :1.no 2.yes Stuffy discharge 1.no 2.yes(quality______) Tenderness over paranasal sinuses:1.no 2.yes (location:_______________) Mouth: Lip______________Mucosa_____________Tongue________________ Teeth:1.normal 2. Agomphiasis 3. Eurodontia 4.others:____________________
Gum :1.normal 2.abnormal (Description____________________________)
Tonsil:___________________________Pharynx:_____________________
Sound: 1.normal 2.hoarseness 3.others:_____________________________ Neck:
Neck rigidity 1.no 2.yes (______________transvers fingers)
Carotid artery: 1.normal pulsation 2.increased pulsation 3.marked distention Trachea location: 1.middle 2.deviation (1.leftward_______2.rightward______) Hepatojugular vein reflux: 1. negative 2.positive
Thyroid: 1.normal 2.enlarged _______ 3.bruit (1.no 2.yes ________________)
Chest:
Chest wall: 1.normal 2.barrel chest 3.prominence or retraction:
( left________right_________Precordial prominence__________) Percussion pain over sternum 1.No 2.Yes
Breast: 1.Normal 2.abnormal _______________________________________ Lung:Inspection: respiratory movement 1.normal 2.abnormal_____________ Palpation: vocal tactile fremitus:1.normal 2.abnormal _______________
pleural rubbing sensation:1.no 2.yes______________________
Subcutaneous crepitus sensation:1.no 2.yes________________ Percussion:1. resonance 2. Hyperresonance &location_____________
3 Flatness&location_________________________________
4. dullness & location:_______________________________
5.tympany &location:_______________________________
lower border of lung: (detailed percussion in respiratory disease)
midclavicular line : R:_____intercostae L:_____intercostae
midaxillary line: R:______intercostae L:_____intercostae
scapular line: R:______intercostae L:_____intercostae
movement 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.diffuse
Subxiphoid pulsation: 1.no 2.yes
Location of apex beat: 1.normal 2.shift (______ intercosta,
distance away from left MCL______cm) Palpation:
Apical pulsation:1. normal 2.lifting apex impulse 3.negative pulsation
Thrill:1.no 2.yes(location:___________ phase:_________________)
Percussion: relative dullness border: 1.normal 2.abnormal
Auscultation: Heart rate:___bpm Rhythm:1.regular 2.irregular_______
Heart sound: 1.normal 2.abnormal________________________
Extra sound: 1.no 2.S3 3.S4 4. opening snap
P2_________ A2_________Pericardial friction sound:1.no 2.yes
Murmur: 1.no 2.yes (location____________phase_____________
quality______intensity________ transmission___________
effects of position_________________________________
effects of respiration______________________________
Peripheral vascular signs:
1.None
2.paradoxical pulse
3.pulsus alternans
4. Water hammer pulse
5.capillary pulsation
6.pulse deficit
7.Pistol shot sound
8.Duroziez sign
Abdomen:
Inspection: Shape: 1.normal 2.protuberance 3.scaphoid 4.frog-belly
Gastric pattern 1.no 2.yes Intestinal pattern 1.no 2.yes
Abdominal vein varicosis 1.no 2.yes(direction:______________ )
Operation scar1.no 2.yes ________________________________ Palpation: 1.soft 2. tensive (location:____________________________)
Tenderness: 1.no 2.yes(location:_______________________)
Rebound tenderness:1.no 2.yes(location:________________)
Fluctuation: 1.present 2.abscent
Succussion splash: 1.negative 2.positive
Liver:_______________________________________________
Gallbladder: __________________Murphy sign:____________
Spleen:______________________________________________
Kidneys:____________________________________________
Abdominal mass:______________________________________
Others:______________________________________________ Percussion: Liver dullness border: 1.normal 2.decreased 3.absent
Upper hepatic border:Right Midclavicular Line ________Intercosta
Shift dullness:1.negative 2.positive Ascites:_____________degree
Pain on percussion in costovertebral area: 1.negative 2.positve ____ Auscultation: Bowel sounds : 1.normal 2.hyperperistalsis 3.hypoperistalsis
4.absence Gurgling sound:1.no 2.yes
Vascular bruit 1.no 2.yes (location_____________________) Genital organ: 1.unexamined 2.normal 3.abnormal
Anus and rectum: 1.unexamined 2.normal 3.abnormal
Spine and extremities:
Spine: 1.normal 2.deformity (1.kyphosis 2.lordosis 3.scoliosis)
3.Tenderness(location______________________________)
Extremities:1.normal 2.arthremia & arthrocele (location_________________)
3.Ankylosis (location__________)
4.Aropachy: 1.no 2.yes
5.Muscular atrophy (location_______________________) Neurological system:1.normal 2.abnormal_______________________________ _____________________________________________________________________
Important examination results before hospitalized
___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ Summary of the history:______________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ Initial diagnosis:_____________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________
Recorder:
Corrector:
内科英文病历材料模板
HUAZHONG UNIVERSITY OF SCIENCE AND TECHNOLOGY TONGJI MEDICAL COLLEGE ACCESSORY TONGJI HOSPITAL Hospitalization Records for None-operation Division Division: __________ Ward: __________ Bed: _________ Case No. ___________ Name: ______________ Sex: __________ Age: ___________ Nation: ___________ Birth Place: ________________________________ Marital Status:____________ Work-organization & Occupation: _______________________________________ Living Address & Tel: _________________________________________________ Date of admission: _______Date of history taken:_______ Informant:__________ Chief Complaint: ___________________________________________________ History of Present Illness: ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________
英语大病历模板
英文大病例写作示例 时间:2007-06-04 17:19来源:中国医师协会作者: 点击: 355 次 撰写大病例是实习医师与住院医师的日常工作，也是上级医师作进一步诊断治疗的原始依据，国外的英文大病例并无统一格式，但是基本内容大致相仿，本节介绍的许多医疗记录的词汇值得借鉴。 Details个人资料 Name: Joe Bloggs (姓名：乔。伯劳格斯) Date: 1st January 2000（日期：2000年1月1日） Time: 0720(时间：7时20分) Place: A&E（地点：事故与急诊登记处） Age: 47 years（年龄：47岁） Sex: male（性别：男） Occupation: HGV(heavy goods vehicle ) driver（职业：大型货运卡车司机） PC(presenting complaint)（主诉） 4-hour crushing retrosternal chest pain（胸骨后压榨性疼痛４小时） HPC(history of presenting complaint)（现病史） Onset: 4 hours of “crushing tight” retrosternal chest pain, radiating to neck and both arms, gradual onset over 5-10 minutes.（起病特征：胸骨后压榨性疼痛４小时，向颈与双臂放 https://www.wendangku.net/doc/0b12149831.html,，5-10分钟内渐起病） Duration: persistent since onset（间期：发病起持续至今） Severe: “worst pain ever had”（严重性：“从未痛得如此厉害过）
英文病历样本
General information Name Age Sex Race Nationality Address Occupation Marital status Date of admission Date of record Complainer of history Reliability: Reliable Chief complaint The patient has a cough producing thick rusty sputum and a high fever that is accompanied by shaking chills. He has a right chest pain when breathing. History of present illness The patient has had a cold after swimming in the cold water recently. He had a cough with thick rusty sputum. He had shaking chills and felt a chest pain on the right side. He saw a doctor. A week after, he thought he was over it and didn’t pay attention to it, w ent swimming again. Now the condition is more serious. He has a high fever with 39℃that is accompanied by shaking chills. He has a bad cough with no-blood sputum. When he takes a deep breath, it even hurts. Past medical history The patient is health before. No history of infective disease. No allergy history of food and drugs. No operative history. No disease history in other system. Personal history He was born in XXX on XXXX and almost always lives in XXX. His living conditions were good. No bad personal habits and customs. Menstrual history: He is a male patient. Family history: His parents are both alive. Physical examination General: T P R BP W H. The patient is a well-developed, well-nourished adult male. HEENT: PERRL, EMOI, small oral aperture. Neck: JVP to angle of jaw, 2+ carotid pulses, full range of motion. Cardiac: RRR, normal S1,S2, distant heart sounds. Chest wall: No subcutaneous emphysema. No tenderness. Thorax: Symmetric bilaterally. Breast: Symmetric bilaterally. Lungs: Respiratory movement is bilaterally asymmetric with the frequency of 24/min. We can hear coarse breathing when listening to a portion of the chest with a stethoscope. There are moist rales on bilateral inferior lung. Heart: Border of the heart is normal. Heart sounds are strong and no splitting. Rate 150/min. No pathological murmurs. Abdomen: Flat and soft. No abdominal wall varicose. There is no rebound tenderness on abdomen or renal region. Liver and spleen are untouched. Skin: No pigmentation. No pitting edema. No skin eruption. Extremities: No articular swelling. All limbs can free move. Genitourinary system: Not examed. Rectum: Not examed. Neural system: Physiological reflexes are existent without pathological ones. Investigation Chest X-ray: Lamellar shadow can be seen in middle and inferior lobe of right lung. The right lung is seriously infected. The volume of useful lung is reduced because of the collection of fluid around the lung.
英语 病例 模板
CASE Medical Number: 682786 General information Name:Wang Runzhen Age: Forty three Sex: Female Race:Han Occupation: Teacher Nationality:China Marital status: Married Address: NO.38, Hangkong Road, Jiefang Rvenue, Hankou, Hubei. Tel: 82422500 Date of admission:Jan 11st, 2001 Date of record: 11Am, Jan 11st, 2001 Complainer of history: the patient herself Reliability: Reliable Chief complaint: Right breast mass found for more than half a month. Present illness: Half a month ago, the patient suddenly felt pain in her right chest when she put up her hand. After touching it, she found a mass in her right breast, but no tendness, and the patient didn’t pay attention it. Then the pain became more and more serious, so the patient went to tumour hospital and received a pathology centesis. Her diagnosis was breast cancer. Then she came to our hospital and asked for an operation. Since onset, her appetite was good, and both her spiritedness and physical energy are normal. Defecation and urination are normal, too. Past history Operative history: Never undergoing any operation. Infectious history:No history of severe infectious disease.
儿科英文病历模板
Nanjing children’s hospital Medical Records for Admisson Ward:321 Bed Number:32178 Medical Number: 696235 General information Name:Son of *** Sex: Male Age: 3 h Birthplace: *** county,Anhui province Race:Han Address:***town,***county,Anhu i province Date of admission:3:31pm Oct 16th,2015 Date of record: 3:31pm Oct 16th,2015 Parents Name: father *** Mother *** Complainer of history: patient’s father Reliability: Reliable Chief complaint: Shortness of breath and moaning for 3h Present illness: The afflicted baby was delivered 3h ago and had instaneous shortness of breath along with obtuse response and moaning.No aspnea or seizure or scream were observed. In local Hospital he received treatment of “naloxone、mezlocillin and Vit K1”, but his symptoms didn’t abate. So the parents took him to our hospital, he was admitted with a diagnosis of “acute respiratory dyspnea syndrome” .Breast feed has not been initiated.He has not vomitted,defecated or urinated since he was born,.
英文病例模板
Medical Records for Admission Medical Number: 701721 General information Name:Liu Side Age: Eighty Sex: Male Race:Han Nationality:China Address: NO.**, Dandong Road, Jiefang Rvenue, Hankou, Hubei. Tel: ****** Occupation: Retired Marital status: Married Date of admission: Aug 6th, 2001 Date of record: 11Am, Aug 6th, 2001 Complainer of history: patient’s son and wife Reliability: Reliable Chief complaint: Upper abdominal pain for ten days, hematemesis, hematochezia and unconsciousness for four hours. Present illness: The patient felt upper abdominal pain for about ten days ago. He didn’t pay attention to it and thought he had ate something wrong. At 6 o’clock this morning he fainted and rejected lots of blood and gore. Then hemafecia began. His family sent him to our hospital and received emergent treatment. So the patient was accepted as “upper gastrointestine hemorrhage and hemorrhagic shock”. Since the disease coming on, the patient didn’t urinate. Past history The patient is healthy before. No history of infective diseases. No allergy history of food and drugs. Personal history He was born in Wuhan on Nov 19th, 1921 and almost always lived in Wuhan. His living conditions were good. No bad personal habits and customs. Family history: His parents have both deads. Physical examination
住院病历的英文
POMR (Problem-Oriented Medical Records)表格式住院病历Biographical data: 一般项目： Name Age Sex Marital status Nativity Race 姓名年龄性别婚否xx民族 Occupation Date of admission Informant History 职业入院日期病史叙述者病史 主诉 History of present illness 现病史 Past history 既往xx： Previous health status: well ordinary bad Infectious diseases 平素健康状况： 良好一般较差传染病xx Immunizations Allergies: N Y clinical manifestation 预防接种xxxxxx无有临床表现 allergen: Trauma:
Surgery: 过敏原外伤xx手术xx Review of systems: (Tick if positive, cross out if negative. If postive, you should write down your disease history and brief course of diagnose and therapy) 系统回顾： (有打√无打×阳性病史应在下面空间内填写发病时间及扼要诊疗经 过)Respiratory system: 呼吸系统 Sore throat chronic cough sputum hemoptysis wheezing 咽痛慢性咳嗽咳痰咯血哮喘 dyspnea chest pain 呼吸困难胸痛 cadiovascular system: 循环系统 Palpitation dyspnea on exertion hemoptysis syncope 心悸活动后气促咯血晕厥 edema of lower limbs precordial pain hypertention 下肢水肿心前区疼痛高血压 Digestive system: 消化系统 Anorexia sour regurgitation belching nausea vomitting
英文住院病例模板
Division: __________ Ward: __________ Bed: _________ Case No. ___________ Name: ______________ Sex: __________ Age: ___________ Nation: ___________ Birth Place: ________________________________ Marital Status:____________ Work-organization & Occupation: _______________________________________ Living Address & Tel: _________________________________________________ Date of admission: _______Date of history taken:_______ Informant:__________ Chief Complaint: ___________________________________________________ History of Present Illness: ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ Past History:
儿科英文病历模板
Medical Records for Admisson Medical Number: 696235 General information Name:Zhang Yi Age: thirteen Sex: Female Race:Han Nationality:China Address: NO.23, Yunchun Road, Jiefang Rvenue, Hankou, Hubei. Tel: 85763723 Parents Name: father Zhang Hesheng Mother Yang Chiulian Date of admission: May 8th, 2001 Date of record: 11Am, May 8th, 2001 Complainer of history: patient’s mother Reliability: Reliabl Chief complaint: Pharyngalgia and fever for four days. Present illness: The patient felt pharyngalgia and weak about four days ago. She ate some medicine (not clear), but it do nothing. Then she found ulcer in her mouth and fever all along, but she felt no nausea and never vomited. So her parents took her to Wuhan Children’s Hospital, there s he received treatment of antibiotics, but her symptoms didn’t abate. So her parents took her to our hospital, she was admitted with a diagnosis of “fever of unknown” Since onset, her appetite was not good, and both her spiritedness and physical energy are bad. Defecation and urination are normal. Past history The patient is healthy before. No history of “measles” or “pertussis” etc and no contact history with T.B or other infective diseases. No allergy history of food but she was allergy to sulfa. Personal history 1.Natal: First birth born, uneventfully and on full term with birth weight 2.7 Kg. The state of her at birth was good, no cyanosis, apnea, convulsion or bleeding. 2.Development: Able to raise head at second month. The first tooth erupted at 6th. She began to walk at one. Her intelligence was normal. 3.Nutrition: She was only feeded with breast milk before she was 6 months old. Then the additives were added. She was weaned from the breast at 14th month. 4.Immunization: Inoculated on schedule after birth (such as B.C.G, D.P.T and smallpox vaccination). Physical examination T 39.5℃, P 120/min, R 30/min, BP 110/90mmHg. She is well developed and moderately nourished. Active position. The skin was not stained yellow. No cyanosis. No
英文病历模版
Divisio n: Ward: Bed: Case No. Name: ______________ S ex: __________ Age: ___________ Natio n: __________ Birth Place: _______________________________ Marital Status: ___________ Work-orga nizatio n & Occupatio n: _____________________________________ Livi ng Address & Tel: ________________________________________________ Date of admissio n: ______ Date of history taken: _______ Informant: _________ Chief Complaint: ___________________________________________ History of Present Illness: Past History: General Health Status: 1.good 2.moderate 3.poor Disease history :(if any, please write dow n the date of on set, brief diag no stic and therapeutic course, and the results.)
Respiratory system: 1. None 2.Repeated pharyngeal pain 3.chronic cough 4.expectoration: 5. Hemoptysis 6.asthma 7.dysp nea 8.chest pa in Circulatory system: 1.N one 2.Palpitatio n 3.exerti onal dysp nea 4..cya no sis 5.hemoptysis 6. Edema of lower extremities 7.chest pain 8.s yn cope 9.hyperte nsion Digestive system: 1.None 2.Anorexia 3.dysphagia 4.sour regurgitation 5.eructation 6.nausea 7.Emesis 8.melena 9.abdominal pain 10.diarrhea 11. hematemesis 12.Hematochezia 13.ja un dice Urinary system: 1.N one 2.Lumbar pain 3.uri nary freque ncy 4.uri nary urge ncy 5.dysuria 6.oliguria 7.polyuria 8.retention of urine 9.ineontinence of urine 10.hematuria ll.Pyuria 12.n octuria 13.puffy face Hematopoietic system: 1.N one 2.Fatigue 3.dizz in ess 4.gi ngival hemorrhage 5.epistaxis 6.subcuta neous hemorrhage Metabolic and endocrine system: 1.None 2.Bulimia 3.anorexia 4.hot intoleranee 5.cold intoleranee 6.hyperhidrosis 7.Polydipsia 8.amenorrhea 9.tremor of hands 10.character cha nge II.Marked obesity 12. marked emaciati on 13.hirsutism 14.alopecia 15.Hyperpigme ntatio n 16.sexual fun cti on cha nge Neurological system: 1.N one 2.Dizz in ess 3.headache 4.paresthesia 5.hypo mn esis 6. Visual disturbanee 7.lnsomnia 8.somnolence 9.s yn cope 10.c onv ulsi on II.Disturba nee of con scious ness 12.paralysis 13. vertigo Reproductive system: 1.No ne 2.others Musculoskeletal system: 1.None 2.Migrating arthralgia 3.arthralgia 4.artrcocele 5.arthremia 6.Dysarthrosis 7.myalgia 8.muscular atrophy
英文病历书写模板 medical-history-questionnaire
Medical History Questionnaire NAME: _________________________________________ TODAY’S DATE: __________________ First Middle Initial Last DATE 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 Latex Y N Sedatives N Aspirin Y N Local anesthetics Y N Sleeping pills N Barbiturates Y N Metals Y N Sulfa drugs N Codeine Y N Penicillin Y N N Iodine Y N Plastic Y N Other ______________________ ________________________ _________________________ LIST ANY MEDICATIONS CURRENTLY BEING TAKEN: Medication Dosage/Frequency Reason _________________________ _____________________ _______________________________________________ _________________________ _____________________ _______________________________________________ _________________________ _____________________ _______________________________________________ _________________________ _____________________ _______________________________________________ MEDICAL HISTORY: (Please indicate dates on items marked current or past) Medical Condition Medical Condition Acid reflux Insomnia Adenoids Removed Intestinal disorder Anemia Jaw joint surgery Arteriosclerosis Kidney problems Arthritis liver disease Asthma Low energy Autoimmune disorder Meniere's disease Bleeding easily Menstrual cramps Blood pressure - High Multiple sclerosis Blood pressure - Low Muscle aches Botox Muscle shaking (tremors) Bruising easily Muscle spasms or cramps Cancer Muscular dystrophy Chemotherapy Nasal allergies Chronic cough Needing extra pillow to help Chronic fatigue breathing at night Chronic pain Nervous system irritability Cold hands and feet Nervousness COPD Neuralgia Depression Numbness of fingers Diabetes Osteoarthritis Difficulty concentrating Osteoporosis Patient Signature ______________________________ Date _________________________ Page 1
临床病症病历英文单词
Case Records 表格式住院病历 Biographical data: 一般项目 Name Age Sex Marital status Native place Race 姓名年龄性别婚否籍贯 民族 Occupation Date of admission Informant 职业入院日期病史叙述者 History 病史 Chief complaint: 主诉 History of present illness: 现病史 Past history: 既往史 previous health status: well ordinary bad infectious diseases 平素健康状况良好一般较差传染病史 immunizations allergies: N Y clinical manifestation: allergen: 预防接种史过敏史无有临床表现过敏原 trauma history: surgery history: 外伤史手术史 Review of systems: (Tick if positive, cross out if negative. If positive, you should write down your disease history and brief course of diagnose and therapy) 系统回顾(有打√无打×阳性病史应在下面空间内填写发病时间及扼要诊疗经过)
Respiratory system: 呼吸系统 sore throat chronic cough sputum hemoptysis wheezing dyspnea chest pain 咽痛慢性咳嗽咳痰咯血哮喘呼吸困难胸痛 Cardiovascular system: 循环系统 palpitation dyspnea on exertion hemoptysis syncope edema of lower limbs precordial pain hypertention 心悸活动后气促咯血晕厥下肢水肿心前区痛高血压 Digestive system: 消化系统 anorexia sour regurgitation belching nausea vomit abdominal distention abdominal pain 食欲减退反酸嗳气恶心呕吐腹胀腹痛 constipation diarrhea hematemesis melena hematochezia jaundice 便秘腹泻呕血黑便便血黄疸 Urinary system: 泌尿系统 lumbago frequent micturition urgent micturition urodynia dysuria hematuria nocturia 腰痛尿频尿急尿痛排尿困难血尿夜尿 polyuria oliguria facial edema 多尿少尿面部水肿 Hemopoietic system: 造血系统 fatigue dizziness blurred vision gingival bleeding subcutaneous hemorrhage ostealgia epistaxis 乏力头昏眼花牙龈出血皮下出血骨痛