2、心内科常用英文病历模板

第二节心内科常用英文病历模板熟练地阅读和书写英文病历是一名临床医师需要具备的基本外语技能。

对英文病历的熟练掌握对于阅读英文文献和撰写英文论文都有很大的帮助。

本章主要介绍心内科常见疾病英文病历的格式和基本模板。

英文病历的书写格式大致与中文病历相似，主要包括以下部分：1.General information（一般情况）2.Chief complaint（主诉）3.Present illness（现病史）4.Past history（既往史）5.Personal history（个人史）6.Family history（家族史）7.Physical examination（体格检查）8.Investigation（辅助检查）9.History summary（病史特点）10.Impression（印象、初步诊断）11.Signature（签名）鉴于不同疾病的病历之间存在共性，本章按照病历的通用部分和心血管内科部分逐一进行介绍。

第一部分通用部分1. General information（一般情况）这一部分包括name（姓名），age（年龄），sex（性别），race（民族），nationality（国籍），address（地址和电话），occupation（职业），marital status（婚姻状况），date of admission（入院日期），date of record（记录日期），complainer of history（供史者）和reliability（可信度）等12项内容。

基本格式如下：Name:Liu SideAge: EightySex: MaleRace:HanNationality:China Address: NO.35, Dandong Road, Jiefang Rvenue, Hankou, Hubei. Tel: 857307523 Occupation: RetiredMarital status: Married Date of admission:Aug 6th, 2001Date of record: 11Am, Aug 6th, 2001Complainer of history: patient’s son and wife Reliability: Reliable2. 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 historyThe patient is healthy before.No history of infective diseases. No allergy history of food and drugs.Past historyOperative history: Never undergoing any operation. Infectious history: No history of severe infectious disease. Allergic history: He was not allergic to penicillin orsulfamide.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.3. Personal history（个人史）和Family history（家族史）这一部分包括患者的出生和居住情况、生活环境情况（疫水疫区接触史）、不良嗜好情况以及Obstetrical history（婚育史）、Menstrual history（月经史）、Contraceptive history（避孕史）等。

Family history（家族史）应包括直系亲属生存情况及家族性遗传病史。

基本格式示例如下：Personal historyHe 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: NoContraceptive history: Not clear.Family history: His parents have both deads.4. Physical examination（体格检查）体格检查部分内容比较繁多，应根据全身一般情况、头颈部、胸部、腹部、四肢的顺序逐一描述查体所见，其顺序和格式大致同中文病历。

（1）一般情况这一部分包括基本生命体征（体温、心率、呼吸、血压）、发育、营养、神志、体位、面容和表情、检查能否合作、全身皮肤黏膜、浅表淋巴结等情况。

示例：T 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 stained yellow. No cyanosis. No pigmentation. No skin eruption. Spider angioma was not seen. No pitting edema. Superficial lymph nodes were not found enlarged.（2）各系统体格检查按照从头部到四肢的顺序逐部位进行描述，与中文病历大致相同。

示例：HeadCranium:Hair was black and white, well distributed. No deformities. No scars. No masses. No tenderness.Ear: Bilateral auricles were symmetric and of no masses. No discharges were found in external auditory 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 nares flaring. No tenderness in nasal sinuses.Eye: Bilateral eyelids were not swelling. No ptosis. No entropion. Conjunctiva was not congestive. Sclera was anicteric. Eyeballs were not projected or depressed.Movement was normal. Bilateral pupils were round and equal in size. Direct and indirect pupillary 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 midline.ChestChestwall:Veins could not be seen easily. No subcutaneous emphysema. Intercostal space was neither 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 expansion 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 impulse was in 5th left intercostal space inside of the mid clavicular line and not diffuse. No pericardial 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 type orperistalses 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 negative. Shifting dullness negative. Borhorygmus not heard. No vascular murmurs. 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 examed5. Investigation（辅助检查）将重要的辅助检查结果一次记录即可。