眼科英文病历( 眼科检查)

Sample History and Physical Note Charting Plus? - Electronic Medical Records

https://www.wendangku.net/doc/327501401.html, Note for John Doe on 6/6/02 - Chart 1124

Chief Complaint: This 26 year old male presents today for a complete eye examination.

Allergies: Patient admits allergies to aspirin resulting in disorientation, GI upset.

Medication History: Patient is currently taking amoxicillin-clavulanate 125 mg-31.25 mg tablet, chewable medication was prescribed by A. General Practitioner MD, Adrenocot 0.5 mg tablet medication was prescribed by A. General Practitioner MD, Vioxx 12.5 mg tablet (BID).

PMH: Past medical history is unremarkable.

Past Surgical History: Patient admits past surgical history of (+) appendectomy in 1989.

Social History: Patient denies alcohol use. Patient denies illegal drug use. Patient denies STD history. Patient denies tobacco use.

Family History: Unremarkable.

Review of Systems:Eyes: (-) dry eyes (-) eye or vision problems (-) blurred vision Constitutional Symptoms: (-) constitutional symptoms such as fever, headache, nausea, dizziness Musculoskeletal: (-) joint or musculoskeletal symptoms

Eye Exam: Patient is a pleasant, 26 year old male in no apparent distress who looks his given age, is well developed and nourished with good attention to hygiene and body habitus.

Visual Acuity:

Visual acuity - uncorrected: OD: 20/10 OS: 20/10 OU: 20/15

Refraction:

Lenses - final:

OD: +0.50 +1.50 X 125 Prism 1.75

OS: +6.00 +3.50 X 125 Prism 4.00 BASE IN Fresnel

Add: OD: +1.00 OS: +1.00

OU: Far VA 20/25

Pupils: Pupil exam reveals round and equally reactive to light and accommodation.

Motility: Ocular motility exam reveals gross orthotropia with full ductions and versions bilateral. Visual Fields: Confrontation VF exam reveals full to finger confrontation OU.

IOP: IOP Method: applanation tonometry OD: 10 mmHg Medications: Alphagan; 0.2% Condition: improving.

Keratometry:

OD: K1 35.875K2 35.875

OS: K1 35.875K2 41.875

Lids/Orbit: Bilateral eyes reveal normal position without infection. Bilateral eyelids reveals white and quiet.

Slit Lamp: Corneal epithelium is intact with normal tear film and without stain. Stroma is clear and avascular. Corneal endothelium is smooth and of normal appearance.

Anterior Segment: Bilateral anterior chambers reveal no cells or flare with deep chamber.

Lens: Bilateral lenses reveals transparent lens that is in normal position.

Posterior Segment: Posterior segment was dilated bilateral. Bilateral retinas reveal normal color, contour, and cupping.

Retina: Bilateral retinas reveals flat with normal vasculature out to the far periphery. Bilateral retinas reveal normal reflex and color.

Test Results: No tests to report at this time

Impression: Eye and vision exam normal.

Plan: Return to clinic in 12 month(s).

Patient Instructions:

Patient was given verbal and written instructions regarding eye care following pupil dilation.

__________________________________ Dr. An. Ophthalmologist, MD

Sample Referral Letter Charting Plus? - Electronic Medical Records

https://www.wendangku.net/doc/327501401.html, 6/6/02

Marcus Welby, M.D.

1231 8th Street, Suite 222

West Des Moines, IA 50265

Dear Dr. Welby:

John Doe was seen in my office in consultation as requested by you as a new patient for evaluation and care. The following is a summary of my findings and recommendations:

Impression: Eye and vision exam normal.

Plan: Return to clinic in 12 month(s).

If I may be of any further assistance in the care of your patient, please let me know. Thank you for providing me the opportunity to participate in the care of your patients. Sincerely,

An. Ophthalmologist, MD

Sample Prescription Charting Plus? - Electronic Medical Records

https://www.wendangku.net/doc/327501401.html, Dr. An. Ophthalmologist, MD

DEA#:

_________________________________________________________

Doe

6/6/02

Date:

J

Name:

John

OD: +0.50 +1.50 X 125 Prism 1.75

OS: +6.00 +3.50 X 125 Prism 4.00 BASE IN Fresnel

Add: OD: +1.00 OS: +1.00

Dr._____________________________________________

Sample Billing Statement Charting Plus? - Electronic Medical Records

https://www.wendangku.net/doc/327501401.html,

Billing Statement - Thursday, June 06, 2002

Provider:An. Ophthalmologist, MD

Patient: John J Doe, Chart 1124

123 E. Freckle St.

Jersey City, NJ 07040

Diagnoses

1. V7

2.0 Examination Of Eyes And Vision

Treatments

1. 99213 Office or other outpatient visit - est. patient - 15 min.

Related Diagnoses: V72.0

Modifiers:

Units:

Referring Physician: A. General Practitioner, MD

Date Last Seen: 07/26/2001

Sample Patient Instructions Charting Plus? - Electronic Medical Records

https://www.wendangku.net/doc/327501401.html, Patient Instructions for John Doe on 6/6/02

YOUR EYES HAVE BEEN DILATED

Dilation drops temporarily increase the size of your pupils. This lets us accurately investigate the health of your eyes and other important general health aspects. Dilation of your eyes is a temporary inconvenience; however, benefits far outweigh the inconvenience.

The effects of eye dilation drops will gradually decrease. It typically takes TWO to SIX HOURS for the effects to wear off. During this time, reading may be more difficult and sensitivity to light may increase. For a short time, wearing sunglasses may help. Notify us if you feel your long distance vision is blurred excessively before attempting to drive. Your patience during this very important procedure is appreciated!

CALL MY OFFICE IMMEDIATELY AT 515-327-8850 IF YOU EXPERIENCE EXCESSIVE PAIN, DISCOMFORT OR NAUSEA

REMEMBER TO HAVE REGULAR MEDICAL EYE EXAMINATIONS.

Eye disease can occur at any age. Since most blindness is preventable if diagnosed and treated early, it is extremely important to have regular eye examinations. Keep in mind that many eye diseases are asymptomatic until after the damage to the eye has already occurred so early detection is the key. Use this as a reminder to plan for regular eye examinations to maintain sight throughout a lifetime.

_______________________________An. Ophthalmologist, MD

CATARACT

What is a cataract?

* A cataract is the loss of transparency of the lens of the eye. It often appears like a window that is fogged with steam.

What causes cataract formation?

* Aging, the most common cause.

* Family history.

* Steroid use.

* Injury to the eye.

* Diabetes.

* Previous eye surgery.

* Long-term exposure to sunlight.

How do I know if I have a cataract?

* The best way for early detection is regular eye examinations by your medical eye doctor. There are many causes of visual loss in addition to the cataract such as problems involving the optic nerve and retina. If these other problems exist, cataract removal may not result in the return or improvement of vision. Your eye doctor can tell you how much improvement in vision is likely.

Does it take a long time for a cataract to form?

* Cataract development varies greatly between patients and is affected by the cause of the cataract. Generally, cataracts progress gradually over many years. Some people, especially diabetics and younger patients, may find that cataract formation progresses rapidly over a few months making it impossible to know exactly how long it will take for the cataract to develop. What is the treatment for cataracts?

* The only way to remove a cataract is surgery. If the symptoms are not restricting your activity, a change of glasses may alleviate the symptoms at this time. No medications, exercise, optical devices or dietary supplements have been shown to stop the progression or prevent cataracts.

It is important to provide protection from excessive sunlight. Making sure that the sunglasses you wear screen out ultraviolet (UV) light rays or your regular eyeglasses are coated with a clear, anti-UV coating will help prevent or slow the progression of cataracts.

How do I know if I need surgery?

* Surgery is considered when your vision is interfering with your daily activities. It is important to evaluate if you can see to do your job and drive safely. Can you read and watch TV in comfort? Are you able to cook, do your shopping and yard work or take your medications without difficulty? Depending on how you feel your vision is affecting your daily life, you and your eye doctor will decide together when it is the appropriate time to do surgery.

What is involved with cataract surgery?

* This surgery is generally performed under local anesthesia on an outpatient basis. With the assistance of a microscope, the cloudy lens is removed and replaced with a permanent intraocular lens implant.

Right after the surgery you should be able to immediately perform all your normal activities except for the most strenuous ones. You will need to take eye drops as directed by your eye doctor. Follow-up visits are necessary to make sure the surgical site is healing without problems.

This procedure is performed on over 1.4 million people each year in the United States alone, 95% without complications. With this highly successful procedure, 90% of the time vision improves unless a problem also exists with the cornea, retina or optic nerve. As with any surgery, a good result cannot be guaranteed.

_______________________________ An. Ophthalmologist, MD

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: ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________

医学病历英文缩写

?aa.-of each[各] ?Ab.-antibody[抗体] ?abd.-abdomen[腹部] ?ABG-arterial blood gas[动脉血气] ?abn.-abnormal[异常] ?ABp-arterial blood pressure[动脉压] ?Abs.-absent[无] ?abstr.-abstract[摘要] ?a.c.-before meals[饭前] ?Ach.-actylcholine[乙酰胆碱] ?ACH.-adrenal cortical hormone[肾上腺皮质激素] ?ACT.-active coagulative time[活化凝血时间] ?ACTH.-adrenocorticotripic[促肾上腺皮质激素] ?ad.(add.)-adde[加] ?ad effect.-ad effectum [直到有效] ?ADH.-antidiuretic hormone[抗利尿激素] ?ad lib-at liesure[随意] ?adm.(admin)-adminstration[给药] ?ad us est.-for external use[外用] ?af.-atrial fibrillation[房颤] ?aF.-atrial flutter[房扑] ?A/G ratio.-albumin-globulin ratio[白-球蛋白比] ?AIDS.-acquired immune deficiency syndrome[爱滋病] ?al.-left ear[左耳] ?alb.-albumin[白蛋白] ?AM.-before noon[上午] ?amb.-ambulance[救护车] ?amp.(ampul)-ampoule[安瓿] ?ANA.-anesthesia[麻醉] ?anal.-analgesic[镇痛药] ?ap.-before dinner[饭前] ?appr.(approx.)-approximately [大约] ?AR.-aortic regurgitation[主闭] ?AS.-aortic stenosis[主狭] ?ASA.-aspirin[阿斯匹林] ?ASD.-atrial septal defect[房缺] ?AST.-aspartate transaminase[谷草转氨酶] ?atm.(atmos.)-atomsphere[大气压] ?ATS.-antitetanic serum[抗破伤风血清] ?av.-average[平均] ?Ba.-Barium[钡] ?BBT.-basal body temperature[基础体温] ?BCG.-bacille Calmette- Guerin[卡介苗] ?biblio.-biliography[参考文献]

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/327501401.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）

常见疾病英文缩写

.

. ARDS 成人呼吸窘迫综合症 CAP 社区获得性肺炎 COPD 慢性阻塞性肺气肿 IPF 特发性肺纤维化 HAP 医院获得性肺炎 PAP 肺泡蛋白质沉积症 PIE 间质肺气肿 PTE 肺栓塞 TB 肺结核 PCP 卡式肺囊虫肺炎 AVB 房室传导阻滞 Af 房颤 ASD 房缺 AI 主闭 AS 主狭 ASO 闭塞性动脉硬化 AT 房速 AMI 急性心梗 AP 心绞痛 APB 房早 BBB 束支传导阻滞CHD冠心病 CHF 充血性心衰 CF 心衰 F3 法三 F4 法四 IHD 缺血性心脏病 PDA 动脉导管未闭 PS 肺狭 PAT 阵发性房性心动过速 MI 心梗 MVP 二间瓣脱垂 RBBB右束支传导阻滞 SSS 病态窦房结综合症 SBE 亚急性感染性心内膜炎 UA 不稳定性心绞痛 VSD 室缺 VDH 心脏瓣膜病 ALT 成人T细胞白血病 AA 再障 AIHA 自身免疫性溶血性贫血 CLL 慢淋 CGN 慢粒 DIC 弥漫性血管内凝血 ITP过敏性紫殿

. IDA 缺铁贫 HD 霍奇金病 PNH 阵发性睡眠性血红蛋白尿 MM 多发性骨髓瘤 MDS 骨髓增生异常综合症 NHL 非霍奇金 RAEB 难治性贫血伴原始细胞增多型 TIP 血栓性血小板减少性紫殿 AIH 自身免疫性肝炎 AP 急性胰腺炎DU十二指肠溃疡 ERCP内镜逆行胰胆管造影术 FD 功能性消化不良 GU 胃溃疡 GERD胃食管反流病 HE 肝性脑病 IBS 肠易激综合症 IBD 炎症性肠病 SAP 急性重症胰腺炎 UC 溃疡性结肠炎 WD 肝豆状核变性 DM 糖尿病 T2DM 2型糖尿病 DR 糖尿病视网膜病变 DN 糖尿病肾病 DKA 糖尿病酮症酸中毒 DLE 盘状红斑狼疮 GD 甲亢Graves HNKHC 高渗性非酮症糖尿病昏迷 IGT 糖耐量减低 IDD 胰岛素依赖性糖尿病 IIM 特发性炎症性肌病 PKU 苯丙酮尿症 MAS或POED 多发性骨纤维结构不良 SSc 系统性硬化病 SLE 系统性红斑狼疮 AD 阿尔海默茨病 ARF 急性肾功能不全 AIN 急性间质性肾炎 AGN 急性肾炎 CGN 慢性肾炎 CRF 慢性肾功能不全 CIN 慢性间质性肾炎 HIE 新生儿缺血缺氧性脑病 PD 帕金森氏病

医学英文缩写一览表

医院日常用品、设备英文单词 Stethoscope[听诊器] Sphygmomanometer (Blood pressure gauge)[血压计] Thermometer[体温表] Tongue depressor (spatula)[压舌板] Needle[针头] Syringe[注射器] Cotton stick (ball)[棉签（球）] Bandage[绷带] Elastic bandage[弹力绷带] Esmarch`s bandage[橡皮绷带] Tourniquet[止血带] Gauze[纱布] Adhesive plaster[橡皮膏] Dressing[敷料] Splint[夹板] Rubber glove[橡皮手套] Sand bag[沙袋] Ice bag[冰袋] Hot water bottle[热水瓶] Bedpan[便盒] Urinal[尿壶] Catheter[导尿管] Rectal tube[肛管] Dilator[扩张器] Gastric tube[胃管] Lavage tube[洗胃管] Oxygen tube (cylinder)[吸氧管] Sengstaken-Blakemore tube[三腔二囊管] Visual testing chart[视力表] Incubator[保温箱] Plaster bed[石膏床] Sheet[被单] Bedding[被褥] Blanket[毛毯] Diaper[尿布] Pillow case[枕套] Bedside table[床头柜] Towel[毛巾] Basin[脸盒] Comb[梳子] Tooth-paste[牙膏] Tooth-brush[牙刷] Rubber cushion[橡皮圈] Air cushion bed[气垫床]

眼科常见疾病地药物治疗学

眼科常见疾病的药物治疗学 少远 眼是人体重要的视觉器官，包括眼球及其附属器，其体表面积和容积虽小，但结构精细，即使轻微损伤，也可能引起结构改变和明显的视觉功能障碍，甚至完全失明。本章主要介绍几种眼科常见疾病的药物治疗。 第一节结膜炎 结膜（conjunctiva）是由眼睑缘间部末端开始，覆盖于眼睑后和眼球前的一层半透明黏膜组织，由睑结膜、球结膜和穹窿结膜三部分组成，正常情况下结膜的特异性和非特异性防护机制可使其对外界环境的理化刺激和微生物具有一定的防御能力，但当眼表防御能力降低或病原菌的致病能力增强时，将引起结膜组织炎症的发生，其特征为血管充血、渗出和细胞浸润，这种炎症统称为结膜炎（conjunctivitis）。 （一）病因与分类 结膜炎是眼科最常见的疾病之一，根据其致病原因可分为感染性和非感染性两大类。感染性结膜炎可为外源性或源性，也可由临近组织炎症蔓延而致（如慢性泪囊炎、睑缘炎、睑腺炎等），致病微生物可为细菌（如肺炎链球菌、流感嗜血杆菌、金黄色葡萄球菌、脑膜炎双球菌、淋球菌等）、病毒、衣原体，偶见真菌、立克次体和寄生虫感染等。非感染性结膜炎致病因素包括物理刺激（如风沙、烟尘、紫外线等）和化学损伤（如医用药物、酸碱或有毒气体等）、免疫性病变（过敏性）、眼部刺激因素、屈光不正未经矫治等。 根据病情及病程结膜炎可分为超急性、急性、亚急性和慢性结膜炎，病程少于三周者为急性结膜炎，超过三周者为慢性结膜炎。 （二）临床表现及诊断 结膜炎的主要症状为异物感、烧灼感、痒、畏光、流泪及脓性或粘液分泌物，检查可见结膜充血水肿、分泌物增多，有时伴有乳头增生、滤泡、伪膜和真膜、肉芽肿、耳前淋巴结肿大。 根据病史和基本症状体征可以作出结膜炎的诊断，但要确诊结膜炎的具体病原还需要实验室检测，最常用微生物学检测分泌物涂片、培养及药敏，怀疑过敏时可以做过敏原检测。 病史及临床表现有助于对病因的判断，感染性结膜炎多为双眼发病，从一只眼传染到另一只眼，也会传染至家人或社区人群，分泌物俗称“眼屎”，是结膜炎共有的体征，不同的致病原因，眼屎的性状常有差别，临床上应仔细询问分泌物的情况，有助于初步判断病原。其中细菌感染引起的结膜炎分泌物为粘液脓性，把睫毛黏在一起，患者早晨醒来可出现睁眼困难，但视力一般不受影响；病毒性结膜炎的分泌物一般为水样或浆液性，常合并结膜出血，耳前淋巴结肿大，后期出现角膜病变影响视力；沙眼一般为慢性病程，以上睑板滤泡、瘢痕为主，晚期眼睑翻倒睫、角膜混浊严重影响视力。春季结膜炎为免疫性结膜炎，以眼痒为主，分泌物呈粘稠丝状，发病和外界过敏原有关。 （三）治疗原则 结膜炎要针对病因治疗，一般局部给药为主，滴眼液点眼，夜间可涂眼膏或眼用凝胶，必要时全身给药。急性期禁忌包扎患眼。

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.

常见疾病英文缩写

常见疾病英文缩写集团标准化工作小组 #Q8QGGQT-GX8G08Q8-GNQGJ8-MHHGN#

ARDS 成人呼吸窘迫综合症CAP 社区获得性肺炎 COPD 慢性阻塞性肺气肿 IPF 特发性肺纤维化 HAP 医院获得性肺炎 PAP 肺泡蛋白质沉积症 PIE 间质肺气肿 PTE 肺栓塞 TB 肺结核 PCP 卡式肺囊虫肺炎 AVB 房室传导阻滞 Af 房颤 ASD 房缺 AI 主闭 AS 主狭 ASO 闭塞性动脉硬化 AT 房速 AMI 急性心梗 AP 心绞痛 APB 房早 BBB 束支传导阻滞CHD冠心病

CHF 充血性心衰 CF 心衰 F3 法三 F4 法四 IHD 缺血性心脏病 PDA 动脉导管未闭 PS 肺狭 PAT 阵发性房性心动过速 MI 心梗 MVP 二间瓣脱垂 RBBB右束支传导阻滞 SSS 病态窦房结综合症 SBE 亚急性感染性心内膜炎UA 不稳定性心绞痛 VSD 室缺 VDH 心脏瓣膜病 ALT 成人T细胞白血病 AA 再障 AIHA 自身免疫性溶血性贫血CLL 慢淋 CGN 慢粒

DIC 弥漫性血管内凝血 ITP过敏性紫殿 IDA 缺铁贫 HD 霍奇金病 PNH 阵发性睡眠性血红蛋白尿 MM 多发性骨髓瘤 MDS 骨髓增生异常综合症 NHL 非霍奇金 RAEB 难治性贫血伴原始细胞增多型TIP 血栓性血小板减少性紫殿 AIH 自身免疫性肝炎 AP 急性胰腺炎DU十二指肠溃疡ERCP内镜逆行胰胆管造影术 FD 功能性消化不良 GU 胃溃疡 GERD胃食管反流病 HE 肝性脑病 IBS 肠易激综合症 IBD 炎症性肠病 SAP 急性重症胰腺炎 UC 溃疡性结肠炎

眼科简写

七、眼科常用简写字 R.E Right eye 右眼 L.E Left eye 左眼 O.D Oculus dexter 右眼 O.S Oculus sinister 左眼 O.U Oculus uterque 双眼 AX、X、Cx、 Axis 轴 C、Cy1 Cylindrical lens Cylinder 柱镜 S、Sph、 Sperical lens 球镜 D Diopter 屈光度 + Plus（Convex lens）凸透镜 - Minus (Concave lens) 凹透镜IOL Intraocular lens 人工晶状体 IOP Intraocular pressure 眼内压 KP Keratic precipitates 角膜后沉淀物F1 Fluorescein stain 荧光素染色 PD Interpupillary distance 瞳距 TYN Tyndalls phenmnon 丁达尔现象FC Finger counting 指数 HM Hand movement 手动 LP Light perception 光感 LR

Light reaction 光反应 Combined with 联合 D Degree （Mesurement of strabismus angle）斜视角测量度△ Prism diopter 三棱镜屈光度 P．D Papilla diameter 视乳头直径 C．K Cornael thickness 角膜厚度 C/D Cup/disk 杯/盘 ERG Electroretinogram 视网膜电图 EOG Electro-oculogram 眼电图 VER Visual evoked response 视诱发电位

眼科常用中英文缩写

美国眼科英文缩写对照表 abd┃abdominal 腹部的 ABK┃aphakic bullous keratopathy无晶体性大泡性角膜病变 abn┃abnormal异常 ac┃before meals餐前 AC┃anterior chamber前房 ACC┃accommodation调节 ACG┃angle-closure glaucoma闭角青光眼 ACIOL┃anterior chamber intraocular lens前房型眼内晶体 add┃adduction or reading additional power内收；阅读另加屈光力 ad lib┃as desired当需要时 adv┃advanced高度 AIBSE┃acute idiopathic blind spot enlargement急性特发性盲点扩大综合征 AIDS┃acquired immunodeficiency syndrome艾滋病 AION┃arteritic ischemic optic neuropathy动脉缺血性视神经病变 ┃anterior ischemic optic neuropathy前部缺血性视神经病变 AKS┃ankylosing spondylitis强直性脊椎炎 AL┃argon laser氩激光 ALPI┃argon laser peripheral iridoplasty氩激光周边虹膜成形术 ALT┃argon laser trabeculoplasty氩激光小梁成形术 AMA┃against medical advice违反医疗忠告 ambl┃amblyopia弱视 AMD┃age-related macular degeneration年龄相关性黄斑变性 AMN┃acute macular neuroretinopathy急性黄斑神经视网膜病变 AMPPE┃acute multifocal placoid pigment epitheliopathy 急性多病灶性盾鳞状色素上皮病变AMPPPE┃acute multifocal posterior placoid pigment epitheliopathy急性多病灶性后部盾鳞状色素上皮病变 ANA┃antinuclear antibody抗核抗体 ant┃anterior前 APMPPE┃acute posterior multifocal placoid pigment epitheliopathy 急性后部多病灶性盾鳞状色素上皮病变 AODM┃adult-onset diabetes mellitus成人（发病）型糖尿病 AP┃anteroposterior前后 APD┃afferent pupillary defect瞳孔传入缺陷 approx┃approximately大约 APTT┃activated partial thromboplastin time激活部分促凝血酶原激酶时间 ARC┃anomalous retinal correspondence异常视网膜对应 ARMD┃age-retinal pigment epitheliitis年龄相关性黄斑变性 ARN┃acute retinal necrosis急性视网膜坏死 ARPE┃acute retinal pegment epitheliitis急性视网膜色素上皮炎 art┃artificial tears人工泪液 AS┃anterior synechia前粘连 ASA┃aspirin(acetylsalicylic acid)阿司匹林

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.

医院各个科室里常用的英文缩写的分类对照表

医院各个科室里常用的英文缩写的分类对照 meｄicａl depaｒtment/departmeｎｔof interｎal medicine:内科 ｓurgical deparment;ｄepａrtｍｅnt of sｕｒgery：外科 pediatricｓｄepartmeｎt: 小儿科 oｂsteｔricｓand gynecology deparｔｍｅｎt: 妇产科 oｐｈｔalｍoｌogy department:眼科 ｄeｎｔal deｐartｍeｎt:牙科 ENT(eaｒ-nose-ｔhroat)depaｒtｍent: 耳鼻喉科 urｏlｏgｙdeｐartment:泌尿科 dｅrmatoｌｏｇｙdｅpartｍｅｎt; skｉn ｄepaｒtment：皮肤科 ｄepartment of genｅral surgeｒｙ普通外科 orthopｅｄic suｒgery deｐａrｔmｅnｔ：矫形外科 traumatolｏｇy depaｒtｍent:创伤外科 plａsｔic surgery: 整形外科 anesthesｉologｙdeｐartment: 麻醉科 pathologｙｄeparｔment:病理科 cardｉoｌogy dｅpartｍent:心脏病科 psｙｃhiatry ｄｅpartment：精神病科 oｒｔhopeｄics deparｔmｅnt: 骨科 deｐartｍｅｎｔof ｃardiac sｕｒgeｒy:心脏外科 deparｔment of cerｅbrａl surｇery: 胸外科 neｕrolｏgy dｅｐarｔment: 神经科 neurosuｒｇery deｐａｒtmｅｎt: 神经外科 thoracｉcｓurgery depaｒｔmｅnｔ：脑外科 depａrtmｅnt of anus ＆ｉntｅsｔine surgery 肛肠外科 dｅｐartment of hepaｔobiliaｒy surｇery 肝胆外科 deｐａｒｔmeｎt ｏf traditioｎaｌChinｅｓe mｅdiciｎｅ：中医科 depａrｔmenｔofｉnfｅｃｔiｏuｓdｉｓｅaｓｅs 传染病科 gerｉatrｉcs departmeｎｔ: 老人病专科 hｅmatｏlｏｇy ｄｅｐａrtmeｎｔ: 血液科 ｄｅpartｍent oｆrｈeumａtｉsｍ风湿科 deｐaｒtment of eｎｄocrｉnology 内分泌科 dｅpａｒtｍenｔof plastiｃsurgery 医学整形科 heｐａtｏｌogｙdepaｒtmenｔ: 肝病专科 nephroｌoｇｙdepartｍｅnt：肾脏科 dｅpartment oｆvｅnereology 性病专科 deｐarｔmｅnｔof phyｓiotherapｙ理疗科 ｅlｅｃtrｏｔherapy roｏm 电疗科 heliotherａｐy roｏm 光疗科 ｗax－therａpｙrooｍ蜡疗科

眼科常见病诊疗常规

眼科常见病诊疗常规 一、白内障 （一）术前检查和准备 1.眼科入院常规检查 2.验光（双眼） 3.测双眼角膜曲率（电脑测量、手动测量相互参照，必要时可参考角膜地形图测量结果） 4.眼科A/B超检查 5.根据验光（包括对侧眼）和A超测量结果确定拟植入的人工晶体度数（注意A常数）和角膜内皮计数 6.必要时做眼视觉电生理检查（VEP、ERG、多焦ERG） （二）入院医嘱 长期医嘱： 眼科护理常规 三级护理 普食 盐酸左氧氟沙星眼液0.1ml 点×眼4/日 裂隙灯检查1/日 临时医嘱： 裂隙灯检查、视功能检查、小瞳孔眼底检查、非接触眼压检查、散瞳查眼底、间接检眼镜检查、电脑验光、角膜曲率、黑白超声检查（单系统＋床旁）、医学影像工作站、A型超声波测厚、静脉抽血、血常规、凝血四项、尿常规、乙型肝炎表面抗原、血糖、肌酐、丙氨酸氨基转移酶、胸正位片、心电图 （三）术前交待要点 1.手术的目的是摘除混浊的晶体，植入人工晶体，提高视力。 2.如同时伴有眼底病和其它眼病，术后视力提高不理想或不能提高。 3.有可能不合适放人工晶体，最多见的原因是后囊破裂、悬韧带断裂，术中医生根据情况植入不同类型的人工晶体或不植入人工晶体。 4.可能继发青光眼、视网膜脱离、角膜水肿失代偿和交感性眼炎，瞳孔可能变形。 5.手术中若晶体核沉入玻璃体中，需尽快行玻璃体切除手术。 6.术后如有晶体后囊混浊，影响视力者需激光治疗或再次手术。 7.有继发眼内感染的可能，虽然大部分经治疗能够好转，但仍极少数病人由于严重的感染，不仅视力丧失，重者还可能丧失眼球。 8.极少数有眼内驱逐性出血的可能，导致术中眼压突然增高，不能缝合切口，严重者甚至需要当场摘除眼球。 9.术后人工晶体发生排斥反应或偏位，甚至脱落。 10.术后可能仍有屈光不正，需要配带眼镜才能达到最好视力。

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,.

常见疾病英文缩写

常见疾病英文缩写 Prepared on 22 November 2020

ARDS 成人呼吸窘迫综合症CAP 社区获得性肺炎 COPD 慢性阻塞性肺气肿 IPF 特发性肺纤维化 HAP 医院获得性肺炎 PAP 肺泡蛋白质沉积症 PIE 间质肺气肿 PTE 肺栓塞 TB 肺结核 PCP 卡式肺囊虫肺炎 AVB 房室传导阻滞 Af 房颤 ASD 房缺 AI 主闭 AS 主狭 ASO 闭塞性动脉硬化 AT 房速 AMI 急性心梗 AP 心绞痛 APB 房早 BBB 束支传导阻滞CHD冠心病

CHF 充血性心衰 CF 心衰 F3 法三 F4 法四 IHD 缺血性心脏病 PDA 动脉导管未闭 PS 肺狭 PAT 阵发性房性心动过速 MI 心梗 MVP 二间瓣脱垂 RBBB右束支传导阻滞 SSS 病态窦房结综合症 SBE 亚急性感染性心内膜炎UA 不稳定性心绞痛 VSD 室缺 VDH 心脏瓣膜病 ALT 成人T细胞白血病 AA 再障 AIHA 自身免疫性溶血性贫血CLL 慢淋 CGN 慢粒

DIC 弥漫性血管内凝血 ITP过敏性紫殿 IDA 缺铁贫 HD 霍奇金病 PNH 阵发性睡眠性血红蛋白尿 MM 多发性骨髓瘤 MDS 骨髓增生异常综合症 NHL 非霍奇金 RAEB 难治性贫血伴原始细胞增多型TIP 血栓性血小板减少性紫殿 AIH 自身免疫性肝炎 AP 急性胰腺炎DU十二指肠溃疡ERCP内镜逆行胰胆管造影术 FD 功能性消化不良 GU 胃溃疡 GERD胃食管反流病 HE 肝性脑病 IBS 肠易激综合症 IBD 炎症性肠病 SAP 急性重症胰腺炎 UC 溃疡性结肠炎

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