英文病历书写
英文病历书写疼痛
英文病历书写：疼痛(1)当上楼梯时，突然痛了起来，并且持续不止。
The pain came on suddenly while walking up the stairs and it was persistent.疼痛的发生感觉疼痛 feel (have; suffer from) a pain; pain is felt in ; feel painful头痛 have a headache; be troubled with a headache; feel a pain in one's head患剧烈头痛 have a nasty (bad) headache时常头痛 be subject (a martyr) to headaches有撞击似的两侧性头痛 have bilateral pounding headaches头痛逐渐地变为频发(较不严重) headaches gradually become more frequent (less severe)ex1:咀嚼时，有偶发的、暂时的、不可言状的疼痛或敏感。
There is occasional， transient， nondescript pain， or sensibility during mastication.ex2:该齿对于压迫作痛，且有钝麻如咬的疼痛。
The tooth became sore to pressure and there is a dull gnawing pain.发生时间ex1:Epigastric pain comes immediately after meal.ex2:Colic pain came on and off since yesterday.ex3:This pain has been relentlessly postprandial， regardless of the character of her meals.ex4:The joint pains were present mainly at night， with relief during the day.ex5:The mild frontal headaches were usually present upon awakening，but not severe enough to require analgesics.ex6:The pain usually commenced within 30 minutes after meals and lasted 1 to 3 hours.发生原因ex1:He described the pain as dull and aching， occurring approximately once a week， unrelated to food intake， and radiating to his back.(2)起初疼痛无变化，但数小时时变成发作性的'痛。
英文病历书写范例
英文病历书写范例（内科）Medical Records for AdmissonMedical Number: 701721General informationName: Liu SideAge: EightySex: MaleRace: HanNationality: ChinaAddress: NO.35, Dandong Road, Jiefang Rvenue, Hankou, Hubei.Tel: 857307523Occupation: RetiredMarital status: MarriedDate of admission: Aug 6th, 2001Date of record: 11Am, Aug 6th, 2001Complainer of history:patient’s son and wifeReliability: ReliableChief complaint: Upper bellyache ten days, haematemesis, hemafecia and unconsciousness for fo ur hours.Present illness:The patient felt upper bellyache about ten days ago. He didn’t pay attention to it and thought heha date something wrong. At 6 o’cloc k this morning he fainted and rejected lots of blood and gore. T hen 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 historyThe 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 s evere infectious disease. Allergic history: He was not allergic to penicillin or sulfamide. Respirator y system: No history of respiratory disease. Circulatory system: No history of precordial pain. Ali mentary 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 sys tem: No history of headache or dizziness. Personal historyHe was born in Wuhan on Nov 19th, 1921 and almost always lived in Wuhan. His living condition s were good. No bad personal habits and customs.Menstrual history: He is a male patient. Obstetrical history: NoContraceptive history: Not clear.Family history: His parents have both deads. Physical examinationT 36.5℃, P 130/min, R 23/min, BP 100/60mmHg. He is well developed and moderately nourished.Active position. His consciousness was not clear. His face was cadaverous and the skin was not sta ined yellow. No cyanosis. No pigmentation. No skin eruption. Spider angioma was not seen. No pi tting edema. Superficial lymph nodes were not found enlarged. HeadCranium: Hair was black and white, well distributed. No deformities. No scars. No masses. No ten derness.Ear: Bilateral auricles were symmetric and of no masses. No discharges were found in external au ditory canals. No tenderness in mastoid area. Auditory acuity was normal.Nose: No abnormal discharges were found in vetibulum nasi. Septum nasi was in midline. No nare s flaring. No tenderness in nasal sinuses. Eye: Bilateral eyelids were not swelling. No ptosis. No e ntropion. Conjunctiva was not congestive. Sclera was anicteric. Eyeballs were not projected or dep ressed. Movement was normal. Bilateral pupils were round and equal in size. Direct and indirect p upillary reactions to light were existent.Mouth: Oral mucous membrane was not smooth, and there were ulcer can be seen. Tongue was in midline. Pharynx was congestive. Tonsils were not enlarged.Neck: Symmetric and of no deformities. No masses. Thyroid was not enlarged. Trachea was in mi dline. ChestChestwall: Veins could not be seen easily. No subcutaneous emphysema. Intercostal space was nei ther narrowed nor widened. No tenderness.Thorax: Symmetric bilaterally. No deformities. Breast: Symmetric bilaterally.Lungs: Respiratory movement was bilaterally symmetric with the frequency of 23/min. thoracic e xpansion and tactile fremitus were symmetric bilaterally. No pleural friction fremitus. Resonance was heard during percussion. No abnormal breath sound was heard. No wheezes. No rales. Heart: No bulge and no abnormal impulse or thrills in precordial area. The point of maximum imp ulse was in 5th left intercostal space inside of the mid clavicular line and not diffuse. No pericardi al friction sound. Border of the heart was normal. Heart sounds were strong and no splitting. Rate 150/min. Cardiac rhythm was not regular. No pathological murmurs.Abdomen: Flat and soft. No bulge or depression. No abdominal wall varicosis. Gastralintestinal ty pe or peristalses were not seen. Tenderness was obvious around the navel and in upper abdoman. T here was not rebound tenderness on abdomen or renal region. Liver and spleen was untouched. No masses. Fluidthrill negative. Shifting dullness negative. Borhorygmus not heard. No vascular mur murs. Extremities: No articular swelling. Free movements of all limbs.Neural system: Physiological reflexes were existent without any pathological ones. Genitourinary system: Not examed. Rectum: not exanedInvestigationBlood-Rt: Hb 69g/L RBC 2.70T/L WBC 1. 1G/L PLT 120G/L History summary1. Patient was male, 80 years old2. Upper bellyache ten days, haematemesis, hemafecia and unconsciousness for four hours.3. No special past history.4. Physical examination: T 37.5℃, P 130/min, R 23/min, BP 100/60mmHg Superficial lymph node s were not found enlarged. No abdominal wall varicosis. Gastralintestinal type or peristalses were not seen. Tenderness was obvious around the navel and in upper abdoman. There was not rebound tenderness on abdomen or renal region. Liver and spleen was untouched. No masses. Fluidthrill ne gative. Shifting dullness negative. Borhorygmus not heard. No vascular murmurs. No other positive signs. 5. investigation information:Blood-Rt: Hb 69g/L RBC 2.80T/L WBC 1.1G/L PLT 120G/LImpression: upper gastrointestine hemorrhage Exsanguine shock出院小结（DISCHARGE SUMMARY）， ===============Department of GastroenterologyChanghai Hospital，No.174 Changhai Road Shanghai, China Phone: 86-21-25074725-803 DISCHARGE SUMMARYDA TE OF ADMISSION: October 7th, 2005 DA TE OF DISCHARGE: October 12th, 2005 ATTE NDING PHYSICIAN: Yu Bai, MD PA TIENT AGE: 18ADMITTING DIAGNOSIS:V omiting for unknown reason: acute gastroenteritis?BRIEF HISTORYA 18-year-old female with a complaint of nausea and vomiting for nearly one month who was see n at Department of Gastroenterology in Changhai Hospital, found to have acute gastroenteritis and non-atrophic gastritis. The patient was subsequently recovered and discharged soon after medicati on.REVIEW OF SYSTEMShe has had no headache, fever, chills, diarrhea, chest pain, palpitations, dyspnea, cough, hemopty sis, dysuria, hematuria or ankle edema.PAST MEDICAL HISTORYShe has had no previous surgery, accidents or childhood illness.SOCIAL HISTORY: She has no history of excessive alcohol or tobacco use.FAMIL Y HISTORYShe has no family history of cardiovascular, respiratary and gastrointestinal diseases. PHYSICAL EXAMINA TIONTemperature is 37, pulse 80, respirations 16, blood pressure 112/70. General: Plump girl in no app arent distress. HEENT: She has no scalp lesions. Her pupils are equally round and reactive to light and accommodation. Extraocular movements are intact. Sclerae are anicteric. Oropharynx is clear. There is no thyromegaly. There is no cervical or supraclvicular lymphadenopathy. Cardiovascular: Regular rate andrhythm, normal S1, S2. Chest: Clear to auscultation bilateral. Abdomen: Bowel sounds present, no hepatosplenomagaly. Extremities: There is no cyanosis, clubbing or edema. Neurologic: Cranial n erves II-XII are intact. Motor examination is 5/5 in the bilateral upper and lower extremities. Sens ory, cerebellar and gait are normal.LABORATORY DATAWhite blood cells count 5.9, hemoglobin 111g/L, hematocrit 35.4. Sodium 142, potassium 4.3, chl oride 106, CO2 25, BUN 2.6mmol/L, creatinine 57μmol/L, glucose 4.1mmol/L, Albumin 36g/L. Endoscopic ExamChronic non-atrophic gastritisHOSPITAL COURSEThe patient was admitted and placed on fluid rehydration and mineral supplement. The patient im proved, showing gradual resolution of nausea and vomiting. The patient was discharged in stable c ondition.DISCHARGE DIAGNOSIS Acute gastroenteritisChronic non-atrophic gastritisPROGNOSISGood. No medications needed after discharge. But if this patient can not get used to Chinese food, she had better return to UK as soon as possible to prevent the relapse of acute gastroenteritis. The patient is to follow up with Dr. Bai in one week. ___________________________ Yu Bai, MD D: 12/10/2005。
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. 。
病历书写(英文)
What is history record
▪ The clinical record documents the patient's history and physical findings. It shows how clinicians assess the patient, what plans they make on the patient's behave, what actions they take, and how the patient responds to their efforts .
▪ When creating a record, you do more than simply make a list of what the patient has told you and what you have found on examination. You must review your data, organize them, evaluate the importance and relevance of each item, and construct a clear, concise, yet comprehensive report.
folksay ▪ 5. Remember to have your signature
A. Outline of case record
▪ 1. Biographical data Biographical information of patient should include his full name, age (date of birth), sex, race, occupation, nationality, marital status and permanent home address. Also, the date of admission, the time at which you took the history, the source of history and estimate of reliability sho to make a good history record
英文病历书写
过饱的人 a heavy （great; hard） eater
食量 capacity for eating
ex1:他的食欲良好，但他平常的吃食习惯，由于口里伤处而中断。
His appetite was good, but the sore place in his mouth interrupted his usual eating habit.
没有发烧 be afebrile; have no fever
ex1:在发烧期间，他的平均体温是摄氏39度。
He ran a febrile course with an average temperature of 39°C.
ex2:他在患病期间尿量减少，并且发烧。
发烧
发烧 become feverish; have a temperature
发高烧 have a high fever
平常有微热，有几次升到38.4度 have low grade （slight） fever to 38.4°C on a few occasions
（2）他诉说非常口渴，但一点食欲也没有。
He complains of his thirst hard to release, while he has absolutely no appetite.
口渴
口渴 be （feel） thirsty form
ex2:他的胃口变得很大，食物热量增加2倍，但体重却减轻了10公斤。
His appetite became ravenous and his caloric intake doubled, yet he lost 10 kg.
英文病历书写——睡眠
英文病历书写
发觉（ 有点） 食欲不振 noted （ minimal） anorexia
食欲不定（ 无食欲障碍） one's appetite is variable （ undisturbed）
食欲反复无常 have a capricious appetite
食欲不佳 have a poor （feeble; weak; delicate） appetite
食欲增进 one's appetite improved
食欲有节制 （食欲旺盛，贪食不饱） have a moderate （good, enormous） appetite
无食欲障碍 one's appetite is undisturbed
食不过饱的人 a moderate （ spare; light） eater
不想吃 be disinclined to eat
取食不规则 eat irregularly
停吃 cease eating
促进食欲 improve （stimulate; sharpen; whet） the appetite
ex1:他无胃口，只吃了一点点东西。
体重以惊人的速度减少 lose weight with alarming speed
体重始终一样 weight remained stationary （steady）
体重不变 weight is stable （ unchanged）
体重维持不变 weight is well maintained
体重减轻
住院时体重 admission weight
最高（最低）体重 maximal （ minimal） weight
抑郁症英文病历书写模板
抑郁症英文病历书写模板
[医院名称]
[日期]
患者信息：
姓名：[患者姓名]
性别：[男/女]
年龄：[患者年龄]
联系电话：[患者联系电话]
主诉：
[患者的主要抱怨和症状描述]
现病史：
[患者目前的病情描述，包括起病时间、症状进展等]
既往史：
[患者的既往病史，包括过去的医学史、精神疾病史、手术史等]
家族史：
[患者家族中是否有精神疾病、抑郁症等相关疾病的家族史]
个人史：
[患者个人生活习惯、学习或工作情况、日常生活负担等]
体格检查：
- 一般情况：[患者的一般状态，如疲劳、食欲变化等]
- 精神状态：[患者的精神状态，如情绪低落、焦虑等]
- 神经系统检查：[对患者神经系统功能进行的检查结果]
辅助检查：
[患者曾进行的辅助检查，如血液化验、神经影像学检查等的结果]
诊断：
[医生对患者的初步诊断，如抑郁症、轻度抑郁发作等]
治疗计划：
- 药物治疗：[针对患者的症状和病情制定的药物治疗方案，包括药物名称、剂量和用法]
- 心理治疗：[计划进行的心理治疗方法，如认知行为疗法、支持性治疗等]
- 生活指导：[针对患者日常生活习惯、行为方式等方面的指导建议]
随访计划：
[医生制定的患者随访计划，包括下次随访时间和内容]
备注：
[医生对患者病情的特殊说明和其他需要备注的信息]
医生签名：
[医生姓名]
[医生职称/科室]
以上即为抑郁症的英文病历书写模板，供参考使用。
请根据实际病情和诊疗需求进行调整。
病历书写(英文)
• 3. History of present illness (HPI) The history of present ill ness should be a well-organized, sequentially developed elaboration of his chief complaint(s) on its various characteristics: ①date of onset, ②character of complaint, ③mode of onset, course and duration, ④location, ⑤ relationship to other symptoms, bodily function and activities, ⑥exacerbation and remissions, and ⑦effect of treatment.
4
How to make a good history record
• 1. Otems of history in the history • 3. Describe specifically any pertinent negative information • 4. Data not recorded are data lost • 5. Use short words instead of long and probably fancier ones
• HISTORY RECORD
1
What is history record
• The clinical record documents the patient's history and physical findings. It shows how clinicians assess the patient, what plans they make on the patient's behave, what actions they take, and how the patient responds to their efforts .