文档库 最新最全的文档下载
当前位置:文档库 › 英文病历标准模版

英文病历标准模版

英文病历标准模版
英文病历标准模版

Complete History

Name:Si Ruihua Department:Lumber electric power bureau Sex: female Present address: electric power bureau Age:80 years Date of admission:2003-5-17

Nationality: China xinjiang Date of record:2003-5-17

Marital status: be married Reliability:reliable

Occupation: family numbers History of allergy:deny

Chief complaints: Palpitation and breathlessnss for 1 hour

Present illness: The patient complained of palpitation with no precipitating factors an hour ago , at the same time she still feel breahlessness and precardial pain which didn’t radiated to other parts of body. This discomfort can’t be relieved by take a rest.As couldn’t suffer from that she had to came to hospital for help. In the course of the illness, he had no syncope, no cough, no headache, no diarrhea and vomiting. Her appetite, sleep, voiding and stool were normal.

Past history: The patient deny the hypertension ,diabetes mellitus,obesity and valvular heart disease history.deny the allegies to pollen,dust medications or food.Deny the surgical procedures and injuries.

Review of systems:

Respiratory system: no pharyngalgia; no chromic cough or hemoptysis; no dyspnea and thoracalgia;no afternoon fever or night sweats.

Circulatory system: no palpitation and breathlessness on exertion: no precordial pain, dizziness and persistent headache; no syncope and hypertension.

Digestive system: no sour regurgitation and dysphagia: no chronic abdominal ache, diarrhea and vomiting: no jaundice, hematemesis and melena.

Urinary system: no past history of edema and proteinuria; no pollakiuria; no urgency and painful micturition; no visible hematuria and hypertension. Endocrine and metabolic system: no irritability, hidrosis or profound fatigue and headache; no impaired vision, exceeding thirsty and polyuria; no excessive hairiness or hair loss; no pigmentation and sexuality change. Hematopoietic system: no pale shin, no dizziness, blurred vision and tinnitus; no impairment of memory; no petechia and jaundic over the skin and mucosa; no lymph node, liver and spleen enlargement; no abnormal bony pain.

Muscle, bone and joint system: no unusual pain, redness and swelling of the joints; no deformity of joints; no limbs and trunk limitation on motion; no myoasthenia and myoatrophy.

Nervous system: no persistent headache and syncope; no memorial impairment or speaking obstacle; no insomnia and consciousness obstacle; no paresthesia of skin; no paralysis and convulsion. Mental status: no hallucination, delirium and orientation obstacle; no abnormal emotion Personal history: The patien’s economic status is good.He has no chance to contact with poison.He consumed cigrettes 20 stickes per day,and a little of drinking.

Bearing history: The patient was be married when he was 27 years old.He bearing 3 boys and 2grils.His husband died of traffic accident.

Family history: He deny the family history of such disease.

Physical Examination

T:36.0℃ P:75bpm R:18bpm BP:104/53mmHg W:45kg

General condition: normally developed, moderately nourished; active position, alert and

cooperative.

Skin and mucosa: normal temperature; no jaundice, eruptions or bleeding spots; no pigmentation,mile to moderate edema.

Lymph gland: no superficial lymph nodes enlargement.

Head organ: normal shape of head; hair black and shining with average distriution; no scars.

Eyes: no edema of eyelids; no bleeding spots of conjunctiva; no sclera jaundice; cornea

clear, pupils round, symmetrical in size and acutely reactive to light.

Ears: normal hearing; no purulent secretion of the external canals; on tenderness over

mastoids.

Mouth: lips red without cyanosis; teeth in alignment, no carious teeth or gingival

hemorrhage; pharynx injected; no enlarged tonsils seen; smooth and glossy tongue

in midline.

Neck: supple without rigidity, symmetrical; no cervical venous distention; no abnormal carotid

impulse; trachea in midline; no enlargement of thyroid gland.

Chest: symmetrical; thoracic breathing predominately; rhythm normal.

Lung: Inspection : equal breathing movements on two sides.

Palpation : no difference of vocal fremitus over two sides; no friction rub felt,

Percussion : resonant on percussion over both lungs. The lower border of lungs lies on right mid-clavicular line at fifth inertcostal space and subscapular line at ninth intercostal space and left scapular line at tenth intercostal space. Shifting degree 4cm.

Auscultation : normal breath sound, no dry or moist rales audible. Heart : Inspection : no pericardial protuberance. Apex beat seen 1cm within left mid-clavicular line at fifth intercostal space. Diameter of impulse is

1.5cm.

Palpation : no thrill or friction felt; no lifting impulse: apex beat observed on the same location as on inspection.

Percussion : normal dullness of heart borders. Relative dullness of heart borders measured as

follow: Auscultation : heart rate: 75/ min; rhythm regular; no gallop thythm; no

murmur or pericardial

friction sound audible.

Peripheral vascular sign : full pulse, rhythm regular; no paradoxical pulse and deficient pulse; no water-hammer pulse and gunshot sound; no capillary pulsation.

Abdomen: Inspection : symmetrical; no abdominal distension or dilated veins; no skin rash or scar; no abnormal intestinal and peristaltic waves seen.

Palpation: abdominal wall flat and soft without tenderness or rebounding tenderness. no succession spleen and kidneys not palpable Percussio n: no shifting dullness; mild tympany. Dullness of liver borders within normal limit. The upper border of liver lies in right

mid-clavicular line at fifth intercostal space. No percussion tenderness over the kidney region.

Auscultation : normal bowel sounds. No vascular murmur heard. Anus and rectum: no anal fissure or proctoptosis; no fistulous tract or hemorrhoid.

Right(cm) Intercostal space left(cm)

2. II 3 2. III 4 3 IV 7 V 8.5

External genitalia: normal distribution if the pubic hair; normal development of external genitalia; no scars or ulcers.

Spine: normal spinal curvature without deformities; normal movements; no tenderness.

Extremities: moderate pitting edema found over both legs. No clubbed fingers(toes); no

myoatrophy, varicose veins or fracture; no redness and swelling of joints; no tenderness or deformities of joints. motor function normal. no limitation of joint

movement.

Neurological reflex: dermatographism. normal abdominal and bicipital muscular reflex; patellar and heel-tap reflex nomal; Babinski sign(-); Oppenhein sign(-); Gordon sign(-); Chaddock sign(-); Hoffmann sign(-); Kerning sign(-); Brudzinski sign(-).

Laboratory Data

ECG: supraventricular tachycardia

Summary Of Case History

Si Ruihua ,female, 80 years. Palpitation and breathlessnss for 1 hour is the chief complain. The patient complained of palpitation with no precipitating factors an hour ago , at the same time she still feel breahlessness and precardial pain . ECG: supraventricular tachycardia.

Primary

diagnosis: supraventricular tachycardia

The Plan of diagnosis and therapy:

1. Antiarrhythmic agents such as calcium channel antagonists may be tried to stop the supraventricular tachycardia.

2. The ablation therapy may be selected according to the patient’s age, phyisical condition and her attitude toward this disease.

Signature:

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/d91730889.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

相关文档