英语病历
医学英语病历范文
医学英语病历范文Medical RecordPatient Information:Name: John SmithAge: 45Gender: MaleDate of admission: [Date]Date of birth: [Date]Weight: [Weight]Height: [Height]Chief complaint:Mr. Smith presents with a severe headache that has been ongoing for the past two days.History of present illness:The patient reports experiencing a sudden onset of throbbing headache, localized primarily on the left side of his head. The pain is aggravated by physical exertion and is accompanied by nausea and sensitivity to light and sound. The patient denies any recent head trauma or sinus congestion. Over-the-counter pain relievers have provided minimal relief.Medical history:Mr. Smith has a history of hypertension, for which he takes medication. He does not have any known allergies, and there is no family history of migraines or neurological disorders.Social history:The patient is a smoker, consuming approximately 10 cigarettes per day. He drinks alcohol in moderation, primarily on social occasions. He denies any illicit drug use. His occupation involves long hours of computer work.Physical examination:On examination, the patient appears to be in mild distress due to the headache. His vital signs are within normal limits. Neurological examination reveals no focal deficits, and his cranial nerves appear to be intact. There is no evidence of meningeal irritation. His neck is supple, and there is no nuchal rigidity. The remainder of the physical examination is unremarkable. Laboratory tests:Blood tests, including a complete blood count and comprehensive metabolic panel, were performed. All results were within normal limits.Imaging studies:A brain MRI was ordered to rule out any structural abnormalities. The scan revealed no evidence of intracranial hemorrhage, mass, or other abnormalities.Assessment and plan:Mr. Smith is presenting with a severe headache consistent with a migraine without aura. He will be prescribed a triptan medication for acute management of his headache. He will also be counseled on lifestyle modifications, including smoking cessation and stress reduction techniques. A follow-up appointment will be scheduled in two weeks to evaluate the effectiveness of the treatment plan.Additionally, the patient is advised to seek immediate medical attention if his symptoms worsen or if he develops any new neurological symptoms.Signature: [Physician's Name]Date: [Date]。
英语病历报告作文格式
英语病历报告作文格式English:A medical record report in English typically follows a specific format to ensure clear and organized documentation of a patient's medical history, diagnosis, treatment, and progress. The report usually starts with the patient's demographic information, including their name, age, gender, address, and contact information. This is followed by the reason for the patient's visit or hospitalization, including the chief complaint and any relevant medical history. The report then details the physical examination findings, laboratory and imaging test results, diagnosis, treatment plan, and prognosis. It is important to use clear and concise language, medical terminology, and abbreviations to accurately convey the patient's medical information. Additionally, proper grammar, spelling, and punctuation should be used to ensure professionalism and accuracy in the medical record report.中文翻译:英文病历报告通常遵循特定的格式，以确保清晰有序地记录患者的病史、诊断、治疗和进展情况。
英语病历作文格式模板
英语病历作文格式模板英文回答：Medical History Template。
Patient Information。
Name:Date of Birth:Address:Phone Number:Email:Insurance Information:Chief Complaint。
A brief summary of the patient's primary reason for the visit.Example: "The patient presents with a 3-day history of fever and chills."History of Present Illness。
A detailed description of the patient's symptoms, including:Onset: When did the symptoms first appear?Duration: How long have the symptoms been present?Severity: How severe are the symptoms?Location: Where are the symptoms located?Associated symptoms: Any other symptoms that are present, such as nausea, vomiting, or headache.Past Medical History。
A list of any previous medical conditions, surgeries, or hospitalizations.Example: "The patient has a history of hypertension and hyperlipidemia."Family History。
英语病历卡作文
英语病历卡作文Patient Name: Jane SmithAge: 45 years oldGender: FemaleOccupation: TeacherDate of Admission: August 15th, 2021Chief Complaint:Patient presents with a two-week history of persistent cough, shortness of breath, and fatigue.History of Present Illness:The patient reports that she first noticed the symptoms two weeks ago. The cough is dry and has been keeping her up at night. She also feels short of breath with minimal exertion and has been feeling extremely tired and weak.Past Medical History:The patient has a history of asthma, which is well-controlled with an inhaler. She also has a history of seasonal allergies.Medications:- Albuterol inhaler for asthma- Loratadine for allergiesAllergies:The patient is allergic to penicillin.Family History:There is a family history of asthma on the patient's mother's side.Social History:The patient is a non-smoker and does not drink alcohol. She works as a teacher and lives with her husband and two children.Review of Systems:- General: Fatigue- Respiratory: Cough, shortness of breath- Cardiovascular: No chest pain or palpitations- Gastrointestinal: No nausea, vomiting, or diarrhea - Neurological: No headaches or dizzinessPhysical Examination:- Vital Signs:- Blood Pressure: 120/80 mmHg- Heart Rate: 80 bpm- Respiratory Rate: 20 breaths per minute- Temperature: 98.6°F- General: Patient appears fatigued- Respiratory: Decreased breath sounds and wheezing heard on auscultation- Cardiovascular: Regular rate and rhythm, no murmurs - Gastrointestinal: Soft and non-tender abdomenDiagnostic Tests:- Chest X-ray: Atelectasis in the left lower lobe- Pulmonary Function Tests: Decreased FEV1/FVC ratio consistent with obstructive lung diseaseAssessment:- Acute exacerbation of asthma with atelectasis in the left lower lobePlan:- Start oral prednisone for asthma exacerbation- Continue albuterol inhaler every 4-6 hours as needed - Incentive spirometry to improve lung function- Follow-up in 1 week for re-evaluation中文病历卡作文：患者姓名：简·史密斯年龄：45岁性别：女职业：教师入院日期：2021年8月15日主诉：患者自述持续咳嗽、气促和疲劳已有两周之久。
英语简要病历报告作文
英语简要病历报告作文Title: Patient Medical Report: A Case of Respiratory Infection。
Date: April 16, 2024。
Patient Information:Name: [Patient Name]Age: [Age]Gender: [Gender]Date of Admission: [Date]Admitting Physician: Dr. [Physician Name]Chief Complaint:The patient presents with symptoms of cough, fever, shortness of breath, and fatigue.History of Present Illness:The patient, [Patient Name], a [Age]-year-old [Gender], presented to the emergency department with complaints of cough, fever, shortness of breath, and fatigue for the past five days. The cough was productive, with yellowish-green sputum. The fever was intermittent and associated with chills. The patient also reported experiencing mild chest pain exacerbated by coughing.Past Medical History:The patient has a past medical history significant for asthma, for which they use an inhaler as needed. There are no known allergies to medications.Medications:The patient takes [Medication Name] for asthma asneeded.Social History:The patient is a non-smoker and denies any history of alcohol or illicit drug use. They work as a [Occupation] and have no recent travel history.Family History:There is no significant family history of respiratory illnesses.Physical Examination:On physical examination, the patient was febrile with a temperature of [Temperature], tachycardic with a heart rate of [Heart Rate], and tachypneic with a respiratory rate of [Respiratory Rate]. Oxygen saturation was [Oxygen Saturation]% on room air. Lung auscultation revealed coarse crackles in the lower lung fields bilaterally. There was no evidence of cyanosis, clubbing, or peripheral edema. 。
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 History1. 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/ NeighborChief 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。
医学英语病历书写范文
医学英语病历书写范文Here is a 1,000 word essay on the topic of "Sample Medical English Patient Record":The importance of accurate and comprehensive patient record-keeping cannot be overstated in the medical field. Properly documenting a patient's history, symptoms, diagnosis, and treatment plan is crucial for providing high-quality, coordinated care. This is especially true when dealing with complex or chronic conditions that require ongoing monitoring and management.When writing a patient record, the primary goal should be to create a clear, concise, and easily understandable document that can be effectively utilized by the entire healthcare team. This means organizing the information in a logical, structured format and using standardized medical terminology and abbreviations appropriately.The first section of the patient record is typically the chief complaint, which succinctly describes the primary reason for the patient's visit. This should be a brief, one to two sentence summary stated in the patient's own words, such as "severe chest pain" or "persistent cough and difficulty breathing."Next, the history of present illness (HPI) provides more detailed information about the current health issue. This section should cover the timeline of symptom onset and progression, any aggravating or alleviating factors, associated signs and symptoms, and previous treatments tried. The HPI allows the clinician to develop a comprehensive understanding of the patient's condition.The past medical history section documents the patient's broader health background, including any chronic diseases, prior hospitalizations or surgeries, and relevant family health history. Capturing this contextual information is vital, as it can greatly inform the diagnostic process and guide appropriate management.The review of systems (ROS) involves systematically inquiring about and documenting pertinent positive and negative findings across all major body systems. This thorough assessment helps identify any additional medical issues that may be relevant, even if not directly related to the chief complaint.The physical examination portion of the record details the clinician's observations and measurements from the hands-on assessment. This can include vital signs, general appearance, specific findings from each body system examination, and any diagnostic test results. Clear, objective language should be used to describe the relevant physicalexam elements.Based on the information gathered in the previous sections, the assessment and plan section provides the clinician's medical decision-making. This includes the patient's working diagnosis or problem list, the rationale supporting this conclusion, and the proposed treatment strategy. The plan may involve medication prescriptions, referrals to specialists, recommended lifestyle modifications, and plans for ongoing monitoring and follow-up.Throughout the patient record, it is critical to use standardized medical terminology and abbreviations correctly. This ensures accurate communication and reduces the risk of ambiguity or misinterpretation. Additionally, all entries should be dated, timed, and signed by the responsible clinician.Proper documentation not only supports effective patient care, but also has important legal and financial implications. Patient records may be used as evidence in malpractice cases, to justify insurance claims, or to demonstrate compliance with regulatory requirements. Clinicians must be diligent in creating thorough, high-quality records that fully capture the patient encounter.Beyond these general principles, the specific formatting and required elements of a patient record can vary somewhat based on thehealthcare setting, clinical specialty, and organizational policies. For example, emergency department visit notes may have a different structure than those for outpatient primary care appointments.Regardless of the particular template used, the overarching goals remain the same - to document the patient's story in a clear, comprehensive, and legally-defensible manner. By mastering the art of effective medical record-keeping, clinicians can strengthen interprofessional communication, enhance continuity of care, and ultimately improve patient outcomes.。
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）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。
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1 病历case histroy一般事项date of admission /marital status /present address /correspondence / occupatio n主诉chief complaints现病史present illness / history of present illness既往史past medical history家族史family history个人病史personal history / social history曾用药物medications过敏史allergies系统回顾system review / review of system体检physical examination一般资料physical data 生理指标physical signs一般状况或全身状况general appearance头眼与耳鼻喉head ,eyes,ear,nose,throat ,略作heent.胸部与心肺CHEST,heart,and lungs腹部abodoms四肢extremities神经系统nervous system,Neurological,略作CNC或Neuro,骨骼肌系统Musculoskeletal泌尿生殖系统Genitourinary化验室资料laboratory data/ studies /diagnosis血液检查blood test化学7项指标chem.-7心脑电图electrocardiogram / electroencephalogram , 略作EKG/EEGX线检查与x光片X-ray examination, x-ray slides,计算机X线断层扫描与核磁共振扫描资料computerized x-ray tomography and nuclear mag netic resonance spectroscopy dta. CT AND NMR其他检查资料other lab data印象与诊断impression and diagnosis住院治疗情况hospital course出院医嘱discharge instructions / recommendations出院后用药discharge medications2 看病时用英文1) 一般病情:He feels headache, nausea and vomiting. (他覺得頭痛、噁心和想吐。
)He is under the weather. (他不舒服，生病了。
)He began to feel unusually tired. (他感到反常的疲倦。
)He feels light-headed. (他覺得頭暈。
)She has been shut-in for a few days. (她生病在家幾天了。
)Her head is pounding. (她頭痛。
)His symptoms include loss of appetite, weight loss, excessive fatigue, fever and chills. (他的症狀包括沒有食慾、體重減輕、非常疲倦、發燒和發冷。
)He feels exhausted or fatigued most of the time. (他大部份時間都覺得非常疲倦。
)He has been lacking in energy for some time. (他感到虛弱有段時間了。
) { 枫下论坛 .net /forum }He feels drowsy, dizzy and nauseated. (他覺得昏昏欲睡，頭暈目眩和想吐。
)He feels as though everything around him is spinning. (他感到周圍的東西都在打轉。
) He has noticed some loss of hearing. (他發覺聽力差些。
)She has some pains and itching around her eyes. (她眼睛四周又痛又癢。
)(2) 傷風感冒：He has been coughing up rusty or greenish-yellow phlegm. (他咳嗽帶有綠黃色的痰。
) His eyes feel itchy and he has been sneezing. (他眼睛發癢，而且一直在打噴嚏。
)He has a fever, aching muscles and hacking cough. (他有發燒，筋骨痠痛和常常咳嗽。
) (h acking = constant)He coughed with sputum and feeling of malaise. (他咳嗽有濃痰，而且覺得很虛弱。
) (mal aise = debility)He gets a cold with a deep hacking cough. (他傷風咳嗽。
)He has a headache, aching bones and joints. (他頭痛，骨頭、關節也痛。
)He has a persistent cough. (他不停地在咳。
) 或He has bouts of uncontrollable coughing. (他一陣陣的咳嗽，難以控制。
)He has hoarse and has lost his voice sometimes. (他聲音嘶啞，有時失聲。
)He has a sore throat and a stuffy nose. (他嗓子疼痛而且鼻子不通。
)His breathing is harsh and wheezy. (他呼吸時，有氣喘似的呼哧呼哧作響。
)He has a stabbing pain that comes on suddenly in one or both temples. (有時突然間太陽穴刺痛。
)He has a runny nose, sneezing or a scratchy throat. (他流鼻水，打噴嚏和喉嚨沙啞。
) (3) 女性疾病：She has noticed one lump in her breast. (她發覺乳房有個腫塊。
)There is a hard, swollen lump on her right breast. (她右乳房有腫塊。
)Her left breast is painful and swollen. (她左乳房疼痛且腫大。
)She has heavy bleeding with her periods. (她月經來的很多。
)Her vaginal discharge is white or greenish-yellow and unpleasant smelling. (她陰道分泌物帶白色或綠黃色，而且氣味不好。
)She has noticed occasional spotting of blood between periods. (在月經來的前後，她有時也發覺有滴滴達達的流血。
)She has some bleeding after intercourse. (性交後有出血。
)She feels some vaginal itching. (她感到陰部發癢。
)She has painful periods and abnormal vaginal discharge. (她月經來時疼痛，而且陰道有不正常的分泌物。
)(4) 手腳毛病：His both hands and feet ache all over. (他兩手兩腳都很痠痛。
)He has pain on the sole of his feet. (他腳底很痛。
)There is a wart-like lump on the sole of right foot. (我右腳底有個像肉疣般的硬塊。
) His ankles look puffy and they pit when he presses them with his finger. (他的足踝好像腫了，用手按，就有小坑痕。
) (pit = small dent form)(句裡的they 和them 都是指ankles)The pain in his left foot is accompanied by redness and swelling. (左腳痠痛，並有紅腫。
)The joints near his fingernails and knuckles look swollen. (指頭和指節旁邊的關節，似乎有腫大。
)He has numbness and tingling in his hands and fingers. (他的手和指頭感到麻木和刺痛。
) His legs become painful following strenuous exercise. (激烈運動後，他的腿就痛。
)His knee is misshapen or unable to move. (他的膝蓋有點畸形，也不能動。
)There are some swellings in his armpit. (他的腋窩腫大。
)He is troubled with painful muscles and joints. (他的筋骨和關節都痛。
)She is troubled by the pains in the back and shoulders. (她的後背和肩膀都痛。
)His knee has been bothering him for some time. (他的膝蓋不舒服，已有一段時間了。
) (5) 睡眠不好：He is sleeping poorly.（他睡不好）He has difficulty in sleeping, inability to concentrate.（他不易入睡，也難集中精神。
）It is usually hard for her to fall asleep when she goes to bed at night.（她晚上就寢，很難入睡。
）He wakes during the night or early morning and finds it difficult to fall asleep again.（他晚間或清早醒來後，再也不能入睡。
）He has nightmares occasionally.（他有時做噩夢。