住院病历中英文对照

随着中外交流的加强，专业英语对医院也是越来越重要！花了点时间整理了下“住院病历的英汉对照”的格式，发上来和大家分享，希望对能用到的人有所帮助！ 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 姓名年龄性别婚否籍贯民族 Occupation Date of admission Informant History 职业入院日期病史叙述者病史 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 预防接种史过敏史无有临床表现 allergen: Trauma: Surgery: 过敏原外伤史手术史 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

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.

住院病历中英文对照

1.POMR (Problem-Oriented Medical Records)表格式住院病历 2.Biographical data:一般项目： https://www.360docs.net/doc/474192083.html, Age Sex Marital status Nativity Race 姓名年龄性别婚否籍贯民族 4.Occupation Date of admission Informant History 职业入院日期病史叙述者病史 5.Chief complaint主诉 6.History of present illness现病史 Past history既往史： 7.Previous health status: well ordinary bad Infectious diseases 平素健康状况：良好一般较差传染病史8.Immunizations Allergies: N Y clinical manifestation 预防接种史过敏史无有临床表现 9.allergen: Trauma: Surgery: 过敏原外伤史手术史 10.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) 11.Respiratory system:呼吸系统 12.Sore throat chronic cough sputum hemoptysis wheezing 咽痛慢性咳嗽咳痰咯血哮喘 13.dyspnea chest pain 呼吸困难胸痛 14.cadiovascular system: 循环系统 15.Palpitation dyspnea on exertion hemoptysis syncope 心悸活动后气促咯血晕厥 16.edema of lower limbs precordial pain hypertention3 m4 G: a6 ] h 下肢水肿心前区疼痛高血压 Digestive system: 消化系统 Anorexia sour regurgitation belching nausea vomitting; L. N) o# e w! A$ H* W 食欲减退反酸嗳气恶心呕吐abdominal distention abdominal pain constipation diarrhea 8 G1 d; G# P$ `( ] 腹胀腹痛便秘腹泻8 t) }/ q7 i' v# ]6 V hematemesis melena hematochezia jaundice% c2 h& ^) w% r/ G% s# i9 c- h 呕血黑便便血黄疸 Urinary system: 泌尿系统 Lumbago frequent micturition urgent micturition urodynia 腰痛尿频尿急尿痛7 D) {2 U/ K# ?5 L9 L V9 G dysuria hematuria nocturia polyuria oliguria facial edema 排尿困难血尿夜尿多尿少尿面部水肿Hematopoietic system 造血系统 Fatigue dizziness blurred vision gingival bleedig 乏力头昏牙龈出血" j9 w, N. P5 j m! C subcutaneous hemorrhage ostealgia epistaxis ' z$ {% i; V4 r7 {- S 皮下出血骨痛鼻衄0 b* ?5 ] ~ R* a# b( A" g e* H Metabolic and endocrine system: 代谢及内分泌系统 Excessive appetite anorexia sweats cold intolerance 食欲亢进食欲减退多汗畏寒" f8 X: \! j |4 A r6 z polydipsia tremor hands change of character obvious obesity 0 [: z) L! A& M/ {+ y$ l 多饮双手震颤性格改变显著肥胖* D* N. t& S& i# | p- _& ] - E. ^% k" v5 ]6 A* g emaciation hirsutism hair losing pigmentation 消瘦多毛毛发脱落色素沉着: N d4 x! B5 R chang of sexual function amenorrhea 性功能改变闭经. T' J. A; Y, Z# ]2 f Musculoskeletal system - \+ }/ L6 H8 e8 A9 H; {# G

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

住院病历中英文对照

. 随着中外交流的加强，专业英语对医院也是越来越重要！花了点时间整理了下“住院病历的英汉对照”的格式，发上来和大家分享，希望对能用到的人有所帮助！ 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 姓名年龄性别婚否籍贯民族 Occupation Date of admission Informant History 职业入院日期病史叙述者病史 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 预防接种史过敏史无有临床表现 allergen: Trauma: Surgery: 过敏原外伤史手术史 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

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

怎样写英文病历

How to write patient's case history 怎样写英文病历 PA TIENT HISTORY 病史 A detailed patient history and physical exam form the foundation of patient uation and vital patient data that enables efficient, quality patient rounds. 一份详细的病史和体检是评估患者的基础，也可为组织高质量、高效率的查房提供重要的资料。 On the other hand, a poorly documented history and physical may leads to confusion, serious omission of vital data and inefficiency on patient rounds. In this age of modern technology with equipment such as CT, MRI and PET scanners, the history and physical exam seem to be slowly evolving into a relic of a past era! Both attending physicians as well as residents in training seem to rely more heavily on laboratory and imaging modalities than history to establish the diagnosis. “However no part of the patient uation is more essential to diagnosis than the patient history. The importance of skillful data collection is underscored by the widely accepted understanding that the medical history contributes 60% to 80% of the information needed for accura te diagnoses.” Thus to neglect the patient history denies the physician of a “vital” diagnostic tool. 另一方面，写得差的病史和体检可能会引起混淆，导致重要资料的遗漏和查房效率的低下。在这个具有现代化设备如CT、MRI、PET的年代里，病史和体格检查似乎已慢慢地成为一种历史遗物。无论是主治医生或住院医生都似乎越来越依赖于实验室和影像学检查而不是病史来明确诊断。然而对诊断来说，没有一种评估手段比病人的病史更重要。尽管普遍认为病史可提供准确诊断所需的60％一80％的信息，但有效地收集资料的技能仍被低估了。所以若忽略了患者的病史就意味着剥夺了医生的一种最重要的诊断工具。 The basic outline structure for the patient history and physical exam usually includes the following: Identification: patient name, age, gender, race, and occupation Chief Complaint: (in the patient’s words) HPI: (history of present illness) PMHx: (past medical history) Medications: should include current meds as well as medication allergies 病史和体格检查的基本框架内容通常包括以下内容：身份证明：患者姓名，年龄，性别，种族和职业主述：(用患者的话表达)

大病例中英文对照

住院病历（一） (Medical Records for Admission) 入院记录 (General Information for Hospital Record) 姓名(Name)：邮编(Post Code)：性别(Sex)：MALE单位或现住址（Address)：年龄(Age)：56years old身份证号码(Identification No.)：婚姻(Marital Status)：Married户口地址(Registered Residence Address)：民族(Race)：汉族联系电话(Contact Number): 出生地(Place of Birth):FUDING入院日期(Date of Admission)：2013-08-0513:04:22 职业(Occupation):病史陈述者(Complainer of History): 主诉(Chief Complaint)：headache and fever for10days. 现病史(History of the Present Illness)： 10days ago,the patient had headache for no obvious reasons.There was persistent pain on the external parietal part of the head.The pain was not related to postural changes.The trigger was unclear but was accompanied by

病历常见英文缩写及中文释义对照表

病历常见英文缩写及中文释义对照表 A A 白蛋白（单位g/L） AA 再障 AB 实际碳酸氢盐 ABG 动脉血气 ACEI 血管紧张素转换酶抑制剂 ACT 激活凝血时间 AD 阿尔海默茨病 Af 房颤 AFP 甲胎蛋白定量（单位ng/ml） AG 离子间隙 AGN 急性肾炎 a-HBD a-羟丁酸（单位U/L） AI 主闭 AIHA 自身免疫性溶血性贫血 AIH 自身免疫性肝炎 AIN 急性间质性肾炎 AKP 碱性磷酸酶（单位u/L） ALT 谷丙转氨酶（单位u/L） ALT 成人T细胞白血病 AMI 急性心梗 ANA 抗核抗体 AP 心绞痛 AP 急性胰腺炎DU十二指肠溃疡 APB 房早 APOA-1 载脂蛋白A1（单位mg%） APOB-100 载脂蛋白B100（单位mg%） APTT 活化部分凝血活酶时间（单位秒） ARDS 急性呼吸窘迫综合征 ARF 急性肾功能不全 AS 主狭 ASD 房缺 ASO 抗链球菌溶血素“0” ASO 闭塞性动脉硬化 AST 谷草转氨酶（单位u/L） AT 房速 ATP 三磷酸腺苷 AVB 房室传导阻滞 AVNRT 房室结折返性心动过速 AVRT 房室折返性心动过速

B Babinski征指锥体束病损时大脑失去了对脑干和脊髓的抑制作用而出现的异常反射BB 缓冲碱 BBB 束支传导阻滞 BE 碱剩余（单位mmol/L） BEE 基础能量消耗 BIL 胆红素 Bicarbonate 碳酸盐 BLO 潜血 BP 血压 BS 空腹血糖（单位mmol/L） BT 出血时间 BUN 尿素氮（单位mmol/L） C C 反应蛋白（单位vg/ml） Ca 钙 CAP 社区获得性肺炎 CBC 全血球计数 CCU 心血管监护室 CEA 癌胚抗原（单位vg/ml）（辅助恶性肿瘤诊断） CF 心衰 CGN 慢粒 CGN 慢性肾炎 CHD 冠心病 CHE 胆碱酯酶 CHF 充血性心衰 CIN 慢性间质性肾炎 CK 肌酸激酶（单位U/L） CK-MB 肌酸激酶同工酶（单位U/L） CL 氯化物（单位mmol/L） CLL 慢淋 cm 厘米 COPD 慢性阻塞性肺气肿 CO2Cp 二氧化碳结合力（单位mmol/L） CPAP 持续正压通气 CPR 心肺复苏 Cr 肌酐（单位vmol/L） CRF 慢性肾功能不全 CT 凝血时间（单位秒） CT 断层扫描 CVP 中心静脉压 C3 补体C3（单位mg/ml）（降低见于急性肾炎）

病历中中英文对照

病历中中英文对照第一章病人身份[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 age 2、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

肿瘤内科病历中英文对照

Xie Yanhua Xie yanhua, bed 38,female, 40 years old, was born in Fuyang, Anhui province.The patient was admitted to our department for gastric cancer for more than 2 years and pelvic metastasis for more than 10 months. The patient was treated at the people's hospital of Taihe county for "six years of abdominal pain and eight days of melena",On May 28, 2014.She underwent radical operation of gastric cancer at the People’s Hospital of Taihe County on June,2014. The pathology report:Gastric ulcer type adenocarcinoma, partially signet-ring cell carcinoma, invading muscular layer, size of 3cm x 3cm; the upper and lower margin negative;4 of 10 lymph nodes positive around lesser curvature and 3 of 3 lymph nodes positive around greater curvature.After the operation, the patient underwent 6 courses of PCF regimen chemotherapy in this hospital, which is not clear enough.The patient was admitted to radiotherapy and chemotherapy department of our hospital on December 14th,2016 for pelvic mass after gastric cancer surgery .CA199 was slightly elevated in the local hospital, and there was