英文病历书写手册.

简明病历书写手册1（英汉对照）简明病历书写手册（英汉对照）

郭航远编著

第一章病人身份

第二章主诉

第三章现病史

第四章过去史、系统回统和个人史

第五章月经、婚姻、生育史和家族史

第六章体检（一般项目）

第七章体检（头颈部）

第八章体检（胸腹部）

第九章体检（神经、骨骼和肌肉）

第十章体检（泌尿生殖道与其他）

第十一章标准化病人体检项目

第十二章实验室检查

第十三章辅助检查

第十四章诊断（疾病名称）

第十五章常用医嘱术语

第十六章常用药物及中草药

第十七章住院文书格式

第十八章附录

附1、常用解剖术语

附2、医学英语常用前后缀

附3、医学英语的特征

附4、医学英语常用短语

附5、英语问诊常用句子

附6、医学英语缩写一览表

附7、医院日常用品和设备

附8、医学院和医院相关名称

前言

本手册按病历书写的顺序进行编写，采用英中对照写法，内容详尽，条理清晰，形式新颖，适用于临床医生、出国人员、实习生和医学院校的学生。

在本手册的编写过程中，得到了美国罗马琳达大学医学院和日本福井大学医学院和邵逸夫医院领导的关心和支持。

谨以此书献给我的老师、同事、朋友和家人。

郭航远

2002.11.1于

浙江大学医学院

第一章病人身份[Identification]

·[Name] 姓名

·[Sex] 性别

·[Age] 年龄

·[Occupation] 职业

·[Date of birth] 出生日期

·[Marriage （Marital status）] 婚姻

·[Race] 民族

·[Place of birth (Birth place)] 籍贯

·[Identification No.(code of ID card No.)] 身份证号码

·[Department of work and TEL. No. (Unit and Business phone No.)] 工作单位及电话

·[Home address and phone No.] 家庭住址及电话

·[Post code] 邮政编码

·[Person to notify (Correspondent) and phone No.] 联系人及电话

·[Source (Complainer;offerer;supplier;provider) of history] 病史陈术者·[Reliability of history] 病史可靠程试

·[Medical security (Type of payment)] 医疗费用

·[Type of admission (Patient condition)] 住院类别（入院时病情）·[Medical record No.] 病历号

·[Clinic diagnosis] 门诊诊断

·[Date of admission (admission date)] 入院日期

·[Date of record] 记录日期

1、年龄的表示方法（以36岁为例）

·36 years old (y/o)

·Age 36

·36 year-old

·The age of 36

·36 years of 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

英文完全病例书写(呼吸科)

Medical Record of Admission Name: Guo XX Sex: Male Age: 41 years old Marital status: Married Race: Han Occupation: Worker Place of birth: Chenzhou City, Hunan province Address: Linwu County, Chenzhou City, Hunan province Date of admission: 11：12 AM, 05,12,2014 Date of records: 17:20PM, 05,12,2014 Complainer: Guo XX Chief complaint: Cough for two months, and tachypnea and chest pain for one month. History of present illness:The patient have no obvious cause cough in October this year, a small amount of white sticky sputum, blood in the sputum, no chest pain, no fever, occasionally night sweats, it has no special treatment. November 10th, the patients with fever, the highest temperature of 39.2 degrees, tachypnea, chest pain, hence clinic in Linwu county people's hospital, the number of WBC has been checked a little bit high, chest CT shows on the left side of the massive pleural effusion, a little right lung infection, diagnosis "left pleural effusion, pleurisy" to fight infection (specific drug use is unknown), no significant improvement in symptoms. Then transferred to the first people's hospital of Chenzhou, also the number of WBC has been checked a little bit high, calcitonin original high, c - reactive protein and blood sedimentation increase fast, pleural effusion as exudates, diagnosed as "check the left pleural effusion due to: tuberculosis likely, double lung infection", to the amp south + levofloxacin anti-infection, fever back slightly, but still has a low thermal afternoon, in the 2014-11-20 to diagnostic anti-tuberculosis (quadruple the chemotherapy plan: isoniazid 0.3 qd + rifampicin 0.45 g qd + pyrazinamide 0.5 tid + ethambutol 0.75 qd), patient with no fever, cough, chest pain, were compared with the previous improved patient for diagnosis hence to our hospital. Since the onset of the patient with a good spirit, appetite, sleep, and fever, occasionally cough, blood in phlegm, the feces and urine are both normal, regular anti-tb drugs, weight did not

医学英语阅读：英文病历

医学英语阅读：英文病历 a sample of complete history patient's name： mary swan chart number： 660518 date of birth：10-5-1993 sex： female date of admission： 10-12-2000 date of discharge： 10-15-2000 final discharge summary chief complaint： coughing, wheezing with difficult respirations. present illness： this is the first john hopkins hospital admission for this seven-year-old female with a history of asthma since the age of 3 who had never been hospitalized for asthma before and had been perfectly well until three days prior to admission when the patient development shortness of breath and was unresponsive to tedral or cough medicine. the wheezing progressed and the child was taken to john hopkins hospital emergency room where the child was given epinephrine and oxygen. she was sent home. the patient was brought back to the er three hours later was admitted.past history：

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

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]

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

医学英语病历书写重点

Case History 病史 ?In-Patient Case History 住院病历 Items of Case History 1. General Data, Biographical Data 一般项目 2. Chief Complaints (C. C.) 主诉 3. Present Illness (P. I.) 现病史 4. Past (Medical) History (P. H.) 既往病史 5. Personal History (Per. H.)/ Social History 个人史/社会史 6. Family History (F. H.) 家族史 7. Medications 曾用药物 8. Allergies 过敏史 9. System Review, Review of Systems 系统回顾 10. Physical Examination (P. E.) 体格检查/查体 11. Laboratory Data 实验室与其他检查/检查资料 12. Impression (Imp.) (Diagnosis) 诊断 13. Hospital Course 住院治疗情况记录 14. Discharge Instructions/ Recommendations出院医嘱 15. Discharge Medications 出院后用药 General Data, Biographical Data 一般项目 ?Reliability (病历可靠性): Reliable(可靠)/ Not Entirely(不完全可靠)/ Not Clearly Defined (不够准确)/ Confused and Uncertain (混乱不清)/ Unobtainable (无法获得) ?Supplier/ Complainer of History (供史者/病史陈述者): Patient/ Husband/ Wife/ Father/ Mother/ Colleague/ Neighbor Chief Complaints (C. C.) 主诉: 病例重要部分之一，通常包括患者年龄、简要的相关的既往史、患者的就诊原因及目前症状持续的时间等。 ?Language Characteristics 1) Common expressions ①symptom+since+time(时间点) ②symptom+for+time(时间段) ③symptom+of+time (时间段名词所有格)+duration ④symptom+time(时间段)+in duration ⑤time(时间段合成词)+history+of+symptom ⑥complete sentence: The duration of +symptom+was/ has been+time(时间段)（少见） 2) Common sentence patterns for chief complaints ①…was admitted/seen with a chief complaint of… ②…complain chiefly of… ③…presented/entered with/came to the office with a chief complaint of ④…was admitted because of… ⑤…was involved in… ⑥…was transferred to…because… 下面是书写主诉是最常用的格式： CC：The patient is a (age)-year-old (race,ethnic,group,occupation,sex and/or very pertinent PMH),who is admitted to the hospital with a chief complaint of (symptom,not a sign or diagnosis) of (number followed by a unit of time) duration. Example 主诉：患者是一个48岁的妇女。入院主诉，6个月来，出力后心悸和呼吸困难。 CHIEF COMPLAINT: The patient is a 48-year-old female, admitted with the chief complaint of palpitation and dyspnea following physical exertion for 6 months. History of Present Illness 现病史：是从医生的角度，进一步表述主诉内容，全面表述现有疾病的发病时间、主要症状、病情发展过程、症状间的联系、诊疗过程、目前患者身体状况、与现有疾病有直接关系的既往史等。记录患者入院情况时，多用一般过去时或过去完成时；记录目前病情时，用一般现在时或现在完成时。 ?Language Characteristics 1) Sentence Patterns with Patients to Be Subject 以病人做主语的句型 ①start having 开始有……的症状 ②begin having episodes of… 开始发生……的症状/疾病

医学英语病历书写范文住院病历书写的范文

医学英语病历书写范文住院病历书写的范文中医(中西医结合)病历书写范文住院病历姓名：. 性别：男年龄：5岁民族：. 出生地： . 婚况：未婚职业：. 单位：. 邮政编码：.. 常住地址：... 入院时间：xx年4月13日10时病史采集时间：xx年4月13日10时病史陈述者：患儿母亲可靠程度：基本可靠发病节气：清明后主诉：反复发热、咳嗽5天现病史：缘患儿5天前无明显诱因下开始出现发热，咳嗽，有痰，鼻塞，呕吐胃内容物一次，曾多次到我院门诊求治，予中药及静滴先锋VI、鱼腥草治疗，症状未见改善。于今天再次来我院门诊

求治，为求进一步系统治疗，遂由门诊收入院。入院时症见：患儿精神疲倦，发热，咳嗽，有痰，无气促，呕吐胃内容物一次，耳痛，无耳鸣，纳呆，睡眠差，大便烂，日三次，小便调。既往史：既往健康，否认水痘，麻疹，结核，肝炎病史。个人史：母孕期健康，足月顺产，第一胎，出生时体重、身高不详。出生时无窒息、缺氧史，无病理性黄疸，混合喂养，按时添加辅食，生长发育正常，智力正常，按时预防接种。过敏史：自诉清开灵过敏史，否认其他食物及药物过敏史。月经婚育史：家族史：父母健康。否认家族遗传病史。体格检查 T 37℃ P 92次/分 R 20次/分 bp 整体状况：

望神：神志清楚，精神疲倦，表情正常。望色：正常面容，色泽偏白。望形：发育正常，营养一般，体型偏瘦。望态：体位正常，姿势自然，步态正常。声音：语言清晰，语言强弱适中，咳嗽，无呃逆、嗳气、哮鸣、呻吟等异常声音。气味：无特殊气味。舌象：舌红，苔白。脉象：脉浮数。皮肤、粘膜及淋巴结：皮肤粘膜：皮肤粘膜无黄染，纹理、弹性等均正常，皮肤稍热，无汗，无斑疹、疮疡、疤痕、肿物，无腧穴异常征、血管征、蜘蛛痣、色素沉着等，无皮肤划痕征。

英文病历书写手册.

简明病历书写手册1（英汉对照）简明病历书写手册（英汉对照）郭航远编著目录第一章病人身份第二章主诉第三章现病史第四章过去史、系统回统和个人史第五章月经、婚姻、生育史和家族史第六章体检（一般项目）第七章体检（头颈部）第八章体检（胸腹部）第九章体检（神经、骨骼和肌肉）第十章体检（泌尿生殖道与其他）第十一章标准化病人体检项目第十二章实验室检查第十三章辅助检查第十四章诊断（疾病名称）第十五章常用医嘱术语第十六章常用药物及中草药第十七章住院文书格式第十八章附录附1、常用解剖术语附2、医学英语常用前后缀附3、医学英语的特征附4、医学英语常用短语附5、英语问诊常用句子附6、医学英语缩写一览表附7、医院日常用品和设备附8、医学院和医院相关名称前言

随着我国加入WTO，医疗体制发生了革命性的改变。随着改革开放的深入，外国投资和管理的医院将不断涌现，中外医学交流也日趋频繁，出国学习、进修和援外医疗队的医务人员逐年增多，这就要求医生具有正确书写英文病历的能力。目前，国内供临床医生完成英文病历的参考书很少。签于此，编著者根据美国罗马琳达大学的病历书写要求，结合十余年的国内外工作经验（编者所在的邵逸夫医院是一所由美国专家管理的、与国际接轨的新型综合性医院，有十余年的英文病历书写实践），并参阅一些国内外的相关文献，编写了本手册。本手册按病历书写的顺序进行编写，采用英中对照写法，内容详尽，条理清晰，形式新颖，适用于临床医生、出国人员、实习生和医学院校的学生。在本手册的编写过程中，得到了美国罗马琳达大学医学院和日本福井大学医学院和邵逸夫医院领导的关心和支持。谨以此书献给我的老师、同事、朋友和家人。郭航远 2002.11.1于浙江大学医学院

英文病历书写范例

英文病历书写范例（内科） Medical Records for Admisson Medical Number: 701721 General information Name: Liu Side Age: Eighty Sex: Male Race: Han Nationality: China Address: NO.35, Dandong Road, Jiefang Rvenue, Hankou, Hubei. Tel: 857307523 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 bellyache ten days, haematemesis, hemafecia and unconsciousness for four hours. Present illness: The patient felt upper bellyache about ten days ago. He didn’t pay attention to it and thought he had ate something wrong. At6 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 because of “upper gastrointestine hemorrhage and exsanguine 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. Past history Operative history: Never undergoing any operation. Infectious history: No history of severe infectious disease. Allergic history: He was not allergic to penicillin or sulfamide. Respiratory system: No history of respiratory disease. Circulatory system: No history of precordial pain. Alimentary system: No history of regurgitation. Genitourinary system: No history of genitourinary disease. Hematopoietic system: No history of anemia and mucocutaneous bleeding. Endocrine system: No acromegaly. No excessive sweats. Kinetic system: No history of confinement of limbs. Neural system: No history of headache or dizziness. 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. Menstrual history: He is a male patient. Obstetrical history: No

英文大病例写作示例

英文大病例写作示例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” retrostern al 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.360docs.net/doc/558684204.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） Relieving/exacerbating factors缓解与恶化因素 GTN（glyceryl trinitrate）provided no relief although normally relieves pain in minutes，no other relieving/exacerbating factors.（硝酸甘油平时能在数分钟内缓解疼痛，但本次无效，无其它缓解和恶化因素。）Associated symptoms相关症状 Nausea，vomiting×2，sweating，dizzy（恶心、呕吐2次、出汗、眩晕） 1997:external chest tightness and dyspnea initially controlled atenolol. 1997年：出现胸外疼痛与呼吸困难，最终经服atenolol控制。 4/12 symptoms worse，exercise tolerance 200 yards on flat，limited by chest pain 4月12日，症状加重，受胸痛限制，仅耐受平地行走200码 No rest pain，no orthopnoea，no PND 无静息时疼痛，无端坐呼吸、无阵发性夜间呼吸困难 Risk factors危险因素 Hypertension-no高血压：无 Smoking-20 cigarettes per day for 16 years吸烟：16年来每天20支 1

口腔科英文病历

Oral and Maxillofacial Surgery Complete Medical History （Zhang te） Medical Number: 182786 General information Name:Tao lili Age: Forty eight Sex: Female Race:Han Occupation: worker Nationality:China Marital status: Married Address:NO.138,mawangdui Rvenue,changsha, Hunan. Tel: 84722500 Date of admission: Jun 20st, 2013 Date of record: 11Am, Jun20st, 2013 Complainer of history: the patient herself Reliability: Reliable Chief complaint: lower incisors gingivae mass found for more than 3 month. Present illness: 3 month ago, the patient suddenly found a small mass on lower incisors gingivae. After touching it, she found a mass tendness, She did not get fever ,dizziness, vertigo and headache. th e patient didn’t pay attention it. Then the mass became more and more bigger, so the patient 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. Allergic history: She was not allergic to penicillin or sulfamide. Respiratory system: No history of respiratory disease. Circulatory system: No history of precordial pain. Alimentary system: No history of regurgitation. Genitourinary system: No history of genitourinary disease.

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，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）

医学英语病历报告书写(简易版)

?Case History ?Definition A case history is a medical record of a patient’s illness. It records the whole medical case and functions as the basis for medical practitioners to make an accurate diagnosis and proposes effective treatment or preventive measures. Case histories fall into two kinds: in-patient case histories and out-patient case histories. ?Language Features History and Physical usually involves past tense ( for history of present illness, past medical history, family history and review of systems concerning past information), and present tense ( review of system, physical examination, laboratory data, and plans ). Structurally, noun phrases are frequently used in physical examination, and ellipsis of subject is very common in review of system. ?In-patient Case Histories An in-patient case history is also termed as History and Physical. It is an account of a patient’s present complaints with descriptions of his past medical history,and the description of the present conditions as well as physical examinations and impression about the conditions.Format It usually consists of chief complaint, history of present illness, past medical history, review of systems, physical examination, impression, family history, social history, medications, allergies, laboratory on admission, and plan. However, what parts are included depends on the needs. 住院病人病历完整模式病历（Case History）姓名(Name) 职业(Occupation) 性别(Sex) 住址(Address) 年龄(Age or DOB) 供史者(Supplier of history) 婚姻(Marital status) 入院日期(Date of admission) 籍贯(Place of birth) 记录日期(Date of record) 民族(Race) 主述(C.C.) 现病史(HPI or P.I.) 过去史(PMH or P.H.) 社会活动史/个人史(SHx or Per.H.) 家族史(FHx or F.H.) 曾用药物(Meds) 过敏史(All) To be continued 系统回顾(ROS) 体格检查(PE or P.E.) 体温(T) 呼吸(R) 血压(BP) 脉搏(P) 一般状况(General status) 皮肤黏膜(Skin & mucosa) 头眼耳鼻喉(HEENT) 颈部(Neck) 胸部与心肺(Chest, Heart and Lungs) 腹部(Abdomen) 肛门直肠(Anus & rectum) 外生殖器(External genitalia) 四肢脊柱(Extremities & spine)

医学英语病历报告书写

Case History Definition A case history is a medical record of a patient’s illness. It records the whole medical case and functions as the basis for medical practitioners to make an accurate diagnosis and proposes effective treatment or preventive measures. Case histories fall into two kinds: in-patient case histories and out-patient case histories. Language Features History and Physical usually involves past tense ( for history of present illness, past medical history, family history and review of systems concerning past information), and present tense ( review of system, physical examination, laboratory data, and plans ). Structurally, noun phrases are frequently used in physical examination, and ellipsis of subject is very common in review of system. In-patient Case Histories An in-patient case history is also termed as History and Physical. It is an account of a patient’s present complaints with descriptions of his past medical history,and the description of the present conditions as well as physical examinations and impression about the It usually consists of chief complaint, history of present illness, past medical history, review of systems, physical examination, impression, family history, social history, medications, allergies, laboratory on admission, and plan. However, what parts are included depends on the needs. 住院病人病历完整模式病历（Case History）姓名(Name) 职业(Occupation) 性别(Sex) 住址(Address) 年龄(Age or DOB) 供史者(Supplier of history) 婚姻(Marital status) 入院日期(Date of admission) 籍贯(Place of birth) 记录日期(Date of record) 民族(Race) 主述.) 现病史(HPI or .) 过去史(PMH or .) 社会活动史/个人史(SHx or .) 家族史(FHx or .) 曾用药物(Meds) 过敏史(All) To be continued 系统回顾(ROS) 体格检查(PE or .) 体温(T) 呼吸(R) 血压(BP) 脉搏(P) 一般状况(General status) 皮肤黏膜(Skin & mucosa) 头眼耳鼻喉(HEENT) 颈部(Neck) 胸部与心肺(Chest, Heart and Lungs) 腹部(Abdomen) 肛门直肠(Anus & rectum) 外生殖器(External genitalia) 四肢脊柱(Extremities & spine)