英文眼科病例模板描述

英文眼科病例模板描述
英文眼科病例模板描述

1、A Discribe Sample

A vertical OCT tomogram is acquired through the macula which shows from above down neurosensory retinal detachment to the inferior fovea in the scan fields. The fovea is obviously elevated to 1000μm,

2、ACUTE RETINAL NECROSIS

OCT shows cystoid macular edema and diffuse outer retinal edema and exudates.

3、AION

The papillary swells and is elevated obviously. The physiologic cup slmost disappears. The peripapillary retinal nerve fiber swells, the thickness of which is increased obviously.

4、BECHET

There is cystoid edema in the macula, with well-defined detachment of neurosensory retina in the fovea and diffuse periphery retinal edema. (serous detachment of neurosensory retina ) Retina in the fovea is thinned. Sporadic hyperreflective points due to the exudates of hard lipids shadows the reflection from the tissues below. The margin of the optic disc is elevated obviously, which represents papilledema. ( papilledema) The retina in the

fovea is thickened. Hyperreflective band just anterior to the neur

5、BEST DISEASE

RPE/choriocapillaris in the macula is elevated, in deeper layer of which there is moderate reflective band.(RPE solid elevation)There is serous pigment endothelium detachment in the superior of vitell

6、CENTRAL SEROUS CHORIORETINOPATHY There is serous retinal detachment in the macula, with retinal edema or cystoid edema. The neurosensory retina is elevated in the fovea, with the thickness of . Liquid dark area exists below. The RPE/choroicapillaris reflective band is clearly visible or damaged. The RPE may be elevated and detached.

7、CHOROIDAL HEMANGIOMA

Retina is sphere-like elevated. Neurosensory retinal detachment is visible in the margin of the tumor. The reflective band of RPE/choroidocapillay is disordered,only sporadic and thin choroidal reflective bands are visible in below. The retina is elevated, with serous retinal detachment around the tumor, intraretinal fluid in the retina above the tumor. (RPE damage) There is

intraretinal department with tissues connecting in between in the retina above the tumor. There is shallow retinal detachment in the

8、CHOROIDAL OSTEOMA

The RPE/choroid reflective band is enhanced and broadened irregularly, partially elevated and breaks in temperal papillary. The shallow neurosensory retinal detachment is observed in the macula, (neurosensory retinal detachment). The retina in the fovea is thinned, The retina is intraretinal departed with reflection of tissues in between, representing secondary retinoschisis in the macula and papillary, with disordered reflection. 9、CNV

The strongest reflective band (RPE/CC) ruptures. There is a multilayer hyperreflction subretinal elevation in the rupture. Neurosensory retinal detachment, retinal edema and exudation are visible.

10、CONTUSION OF RETINA

There is full-thickness retina loss in the macula, with surrounding neurosensory retina edema. (macular hole and edema) Moderate reflection in the fovea and the both sides hyperreflection of hemorrhage are observed when

RPE hemorrhagic detachment exists. The choroidal reflective band is enhanced in the temporal fovea, which represents choroid rupture.(choroid rupture with hemorrhagic RPE detachment) The RPE/choriocapillaris reflective band is broken and disordered in the temporal fovea, with the reflective

11、DIABETIC RETINOPATHY

(macular edema)The neurosensory retina shows thickened thickness and diffuse reduced interlaminar reflection in the macula and periphery retina. There are sporadic hyperreflective points in outer retina shadowing the reflection returning from below, due to hard exudates. The serous neurosensory retina detachment exists in the macula, with detachment cavity shown as fluid dark area. The local elevation of retinal nerve fiber layer shows enhanced reflection and shadows the reflection returning from below, wh

12、Drusen

Hard drusen shows the local elevation of RPE and tissues below, with hyperreflectivity. Soft drusen shows semispherical elevation of RPE.

13、Dry AMD

Hard drusen shows the local elevation of RPE and tissues below, with hyperreflectivity. Soft drusen shows semispherical elevation of RPE.

RPE/choriocapillaris is elevated well-defined. (hard drusen) The neurosensory retina is normal or thinned in corresponding area. The reflection band of RPE/choriocapillaris is elevated like semisphere or merged-semisphere. There is moderate density reflection band below, connecting with the choroidal reflection band. (soft drusen) . Retina above is thinned, while the reflection band of RPE/choriocapillaris is enhanced.(choroidoretinal geographic atrophy). The RPE reflection band disappears somewhere.(RPE a

14、EPIRETINAL HEMORRHAGE

Retina seems to be elevated, with dense hyperreflection anterior to the retina. All the reflection from tissues behind it disappears. It’s hard to identify the hemorrhage is located under the inner limiting membrane or behind the posterior limiting membrane of the vitreous.

15、EPIRETINAL MEMBRANE IN THE MACULA The epiretinal membrane appears as a streaky-like enhanced reflective band just attached anterior to the

neurosensory retina. The depression of the fovea disappears, and macular edema forms. The thickness of the retina is increased in the fovea, with steep contour and pseudohole forms.

16、EPIRETINAL MEMBRANE

The moderate and high reflective band is shown adhered tightly anterior to the retina, which may track the retina, resulting in retinal pucker and retinal edema.

17、GLAUCOMA RETINAL NERVE FIBER LAYER The reflection of retinal nerve fiber layer is thinned diffusely.

18、GLAUCOMA

The physiologic cup is enlarged and deepened, the reflective band is thinned or breaks in the superior cup wall. The cup is enlarged.

19、HARD EXUDATION

Potted and sheet hyperreflection is shown in outer plexiform layer, attenuating the reflection behind.

20、IDIOPATHIC CNV

Retina swells and is thickened. Serous retinal detachment is shown, while choroidal neovascular is visible under the macula.

21、IDIOPATHIC CNV-1

There is cystoid edema in the fovea. The hyperrefletive points in the outer retina which attenuate the tissues behind represent the hard exudation. Hemorrhagic or serous neurosensory retinal detachment forms. The RPE/choriocapillaris reflective band is fusiform-like enhanced in the upper macula, consistent with choroidal neovascular. The topography map shows that the retina is thickened, white and red, in the fovea and above (correspongding the CNV) .

22、JUVENILE RETINOSCHISIS

Cystoid alteration is seen in the macula, and the cavity is departed by tilted and vertical tissues. Peripheral neurosensory retina shows intraretinal department, with column tissues connecting in between. The thickness of the retina is increased in the fovea, especially in the inferonasal retina, with the superotemporal retina thinned. (cystoid macular edema). The inner wall ruptures after cystoid alteration in the macula, then the lamellar hole forms.(lamellar macula hole) . Neurosensory retinal detachme

23、MACULAR HOLE

Full-thickness hole: loss of full-thickness retina shows no reflection. Lamellar hole: The loss of the inner retina, part of the reflection is absent. stage I macular hole shows disappearance of the normal foveal contour and a low reflection field in below , but the inner layer of the retinal doesn’t break in the macula. Vitreous traction to the fovea is visible. Alleviation happens spontaneously in some cases. Stage II shows the breaks of inner surface and small full-thickness loss of the retina, accounti

24、MELANOMA OF CHOROID

The retina shows a flat and uneven elevation, the reflective band of the RPE/choriocapillaris is enhanced mildly, while the reflective band of the retina is almost normal. The pigment eddothelium is elevated in the fovea, with serous retinal detachment and disorders of the reflective band of RPE above the fovea. (RPE damage) Neurosensory retina is elevated and detached. (retinal detachment).

25、NORMAL MACULA

The thickness of the retina of the fovea is mm. There is no significant abnormality in the macular contour. 26、NORMAL OPTIC DISC

The superior, inferior and nasal margin of the optic disc is elevated mildly. The physiologic cup is small and shallow. The depression and the slope are symmetric. The moderate reflective band representing the tissues before the cribriform form is visible in the bottom of papillary, under which is the hyperreflective band of the cribriform plate. (normal optic disc).

27、OPTIC DISC PIT

The vertical scan through the optic disc shows a dark area without reflection, because of loss of cribriform plate in the inferior papillary, which represents optic disc pits. Horizontal scan shows loss of cribriform plate in the temporal optic disc, which connects with outer retinal retinoschisis and edema in the macula. Neurosensory retinal detachment exists in the macula, and there is only inner tissue with thin-wall, which represents outer wall hole. (optic disc hole and retinal edema and retinoschisis 28、OPTIC NERVE ATROPHY

The normal elevation of the papillary margin disappears. The physiologic cup shallows, with thinning of the peripapillary retina and reflection band of the retinal nerve fiber layer.

29、OPTIC NEURITIS

(epiretinal hemorrhage) The reflection in front of the retina is enhanced and attenuates, while hemorrhage is shaped in fluid level, attenuating the tissues below. The inner limiting membrane departs from the retina in superior of hemorrhage level.(intraretinal hemorrhage)The retina is elevated where retina hemorrhage exists. The intraretinal hemorrhage is shown as dark area, attenuating the reflection from below. The retinal detachment exists above the hemorrhage field.(subretinal hemorrhage) neurosensory

30、Papilledema

The margin of the papillary is moderately or mildly elevated. The physiologic cup gets shallow and elevated. (mild edema) Papillary is elevated obviously like mountain, and the cup almost disappears. (obvious edema) The papillary is elevated highly, and the cup disappears. (high cranial pression papilledema) The papillary is elevated, with papilledema, peripheral retina edema, cystoid macular edema, obvious retina edema in the posterior pole.(stasis retina edema) The papillary gets edema, with margin eleva

31、PATHOLOGIC MYOPIA

OCT shows thinning of the neurosensory retina in the central macula. The intralamellar department exists in the outer retina and inner retina, with columns connecting in between. The reflectivity of outer neurosensory retina in the inner side of RPE is visible (secondary retinoschisis) , as well as detachment of neurosensory retina. Neurosensory retina in the macula losses partially and epiretinal membrane forms.(retinoschisis and lamellar hole)OCT shows loss of full-thickness neurosensory retina in the m

32、PCV

Polypoidal choroidal vasculopathy shows cone-like steep elevation. There is thin discontinuous streaky-like hyperreflective band departing from RPE in the side of elevation, which is consistent with polypoidal choroidal vasculopathy. The neurosensory retina is thin above the elevation. Moderate reflective points are visible below the elevation, attenuating the reflection from choroid. There is neurosensory retinal detachment, with exudation in outer retina and hemorrhage pigment endothelium detachment besi

33、PIGMENT ENDOTHELIUM DETACHMENT Retinal pigment endothelium is elevated, with fluid dark area or reflective points below, shadowing the reflection from bruch membrane and choroid.

34、POSTERIOR VITREOUS DETACHMENT

A moderate reflective band departs with the retina, floating in the posterior vitreous cavity like an irregular curve or a semiarc.

35、RAO

(In the early stages of CRVO) There is cystoid macular edema, uncomplete posterior vitreous detachment tracking the macula. Retina shows edema and enhanced reflection, is thickened. The dark area of photoreceptor is broadened. (CRAO edema recedes)The cystoid edema in the macula recedes, uncomplete posterior vitreous detachment is thinned and weak. The dark area of photoreceptor is broadened. (CRAO atrophy stage)the thickness of the retina in the centre is mildly thinned, uncomplete posterior vitreous detac

36、REDIATION RETINOPATHY

There are retinal cystoid edema ,intraretinal exudation and neurosensory retinal detachment in the macular,

(neurosensory retinal detachment)OCT shows serous neurosensory retinal detachment, neurosensory retinal cystoid edema and diffuse edema in the macular.(papilledema)papillary elevates, the physiologic cup almost disappears.(retinal exudates)Well-defined edema and elevation of retinal nerve fiber layer consistent with the soft exudates attenuates the reflection from below. The exudates appear as the

37、RETINAL ANEURYSM

(epiretinal hemorrhage) The reflection in front of the retina is enhanced and attenuates, while hemorrhage is shaped in fluid level, attenuating the tissues below. The inner limiting membrane departs from the retina in superior of hemorrhage level.(intraretinal hemorrhage)The retina is elevated where retina hemorrhage exists. The intraretinal hemorrhage is shown as dark area, attenuating the reflection from below. The retinal detachment exists above the hemorrhage field.(subretinal hemorrhage) neurosensory

38、RETINAL DETACHMENT

Neurosensory retina is elevated. The fluid below shows liquidity dark area with non-reflection, or potted or sheet

moderate or high reflection in the liquidity dark area. 39、RETINAL DETACHMENT-1 Rhegmatogenous retinal detachment (mild and moderate retinal detachment in the macula)Retinal detachment exists in the macula and inferior retina, with retinal edema. (highly retinal detachment in the macula)highly retinal detachment exists in the macula, OCT cann’t show RPE/choriocapillaris reflective band.(neurosensory retinal department)Outer and inner neurosensory retinal departs。(wavy alteration of retina)Outer neurosensory retina shows wavy alteration (neurosensory retinal edema)Outer retinal shows

40、RETINAL EDEMA

Retina shows cystoid alteration in the fovea, with reflection in the cavity reduced and inner surface of the retina elevated.(with the height of mm) The retina is thickened diffusely in the macula. The reflection of the outer retina is influenced, and the IS/OS and RPE reflection is decreased, because of the retinal edema. 41、RETINITIS PIGMENTOSA

The macula shows cystoid edema, with large sac, retinal pigment endothelium proliferation and migration towards

the inner retina. The retina is thinned, while the RPE/choriocapillaris reflective band is sporadicly enhanced. (migration and proliferation of RPE).

42、RETINOSCHISIS

The reflection of the retinal focus is reduced. Outer plexiform layer is teared and enlonged, with bridge-like junction.

43、RVO

(retinal hemorrhage)【shallow retinal hemorrhage】Cystoid edema exists in the macula. The reflection of the retina is enhanced in the fovea, but doesn’t attenuate the reflection from deeper, which represents shallow retinal hemorrhage. 【deep retinal hemorrhage】The neurosensory retina superior to the papillary is elevated and enhanced, and attenuates rapidly, with dark area below and RPE/choriocapillaris reflective band shadowed.(retinal exudation)【soft exudation】There is cystoid edema in the macula and diffu

44、SOFT EXUDATION

The small occlusion focus of nerve fiber layer shows local elevated hyperflection in the retinal nerve fiber layer, attenuating the reflection behind.

45、STARGARDT

The dark area of retinal photoreceptor in the macula disappears, and the retina is thinned, the reflective band of RPE/choriocapillaris around the fovea is enhanced unevenly, the neurosensory retina in the macula almost disappears.

46、SYMPATHETIC OPHTHALMIA

There are multiple serous neurosensory retinal detachment and exudation in the macula and posterior pole.(serous neurosensory retinal detachment) The margin of the papillary is elevated mildly.(papilledema) Retina in the macula is thinned, while the reflective band of the choroid in the parafovea is enhanced and thickened unevenly.(retina thinning).

47、UVEITIS

Diffuse retinal edema exists in the fovea and temporal retina, with neurosensory retina thickened, cystoid macula edema, serous neurosensory retinal detachment and enhanced reflection of inner retina. Pigment endothelium detachment exists, with spongy retina edema. The margin of the optic disc shows moderate elevation, representing papilledema. The retina is thinned

in the fovea. Outer retina shows sporadic hyperreflective points in the macula, attenuating the tissues behind, representing the hard exudatio

48、VITREOMACULAR TRACYION SYDROME The moderate and high reflective band of the vitreous posterior limiting membrane adheres with the macula, especially with the fovea. The fovea is tracked, elevated and thickened with edema.( μm) The neurosensory retina reflection from below is shadowed, and retina reflection rupture is visible sometimes due to the hole.(macular edema)

49、VKH

OCT shows multifocal serous detachment of neurosensory retina at the fovea, department of inner and outer retina in macula and papillary. Retinal detachment is shown in the macula, serous retinal detachment in the superior macular and exudative retinal detachment in the inferior macula. Moderate density exudates exist between the RPE and the detached neurosensory retina. Exudative retinal detachment is seen in the macula and inferior retina. Hyperreflective bands due to the exudates of hard lipids are seen

50、W-AMD

RPE/chorocapillaris reflective band breaks, and it is fusiform-like broadened in the subretinal fovea. The retina shows cystoid edema. RPE/chorocapillaris reflective band breaks, and it is broadened irregularly, (occult CNV) with serous neurosensory retinal detachment above. Retinal pigment endothelium is elevated with moderate and high reflection below (CNV membrane), neurosensory retina cystoid edema above. There is hyperreflective mass in the neurosensory retina, attenuating the retinal tissues behind,(

英文病例报告的写作技巧

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3、讨论 讨论部分就是要解释病例叙述中不明确的一些情况,并提供对结果的解释。例如,报道肝酶升高,但未发现显著的肝功能异常,给读者讲明为何肝酶升高。在讨论部分的时态运用上,由于提供的是自己现在的推断和观点,故采用一般现在时。如:

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

全英文病例报告表模板

CASE REPORT FORM TEMPLATE Version: 6.0 (8 November 2012) PROTOCOL: [INSERT PROTOCOL NUMBER] [INSERT PROTOCOL TITLE] Participant Study Number: Study group:

BASELINE DATA General Instructions for Completion of the Case Report Forms (CRF) Completion of CRFs ? A CRF must be completed for each study participant who is successfully enrolled (received at least one dose of study drug) ?For reasons of confidentiality, the name and initials of the study participant should not appear on the CRF. General ?Please print all entries in BLOCK CAPITAL LETTERS using a black ballpoint pen. ?All text and explanatory comments should be brief. ?Answer every question explicitly; do not use ditto marks. ?Do not leave any question unanswered. If the answer t o a question is unknown, write “NK” (Not Known). If a requested test has not been done, write “ND” (Not Done). If a question is not applicable, write “NA” (Not Applicable). ?Where a choice is requested, cross (X) the appropriate response. Dates and Times ?All date entries must appear in the format DD-MMM-YYYY e.g. 05-May-2009. The month abbreviations are as follows: January = Jan May = May September = Sep February = Feb June = Jun October = Oct March = Mar July = Jul November = Nov April = Apr August = Aug December = Dec In the absence of a precise date for an event or therapy that precedes the participant’s inclusion into the study, a partial date may be recorded by recording “NK” in the fields that are unknown e.g. where the day and month are not clear, the following may be entered into the CRF: N K N K 2 0 0 9 DD MMM YYYY ?All time entries must appear in 24-hour format e.g. 13:00. Entries representing midnight should be recorded as 00:00 with the date of the new day that is starting at that time. Correction of Errors ?Do not overwrite erroneous entries, or use correction fluid or erasers. ?Draw a straight line through the entire erroneous entry without obliterating it. ?Clearly enter the correct value next to the original (erroneous) entry. ?Date and initial the correction. Protocol Number: Page 1 of 15

2、心内科常用英文病历模板

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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 2. Past history(既往史) 这一部分应首先总结既往一般健康状况、Operative history(手术史)、Infectious history(传染病史)、Allergic history(过敏史)等,然后对各系统健康状况进行回顾,包括Respiratory system(呼吸系统)、Circulatory system (循环系统)、Alimentary system(消化系统)、Genitourinary system(泌尿生殖系统)、Hematopoietic system(血液系统)、Endocrine system(内分泌系统)、Kinetic system(运动系统)和Neural system(神经系统)。基本格式示例如下: 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

英语大病历模板

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英语 病例 模板

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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

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)

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

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 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)

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

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