大病例中英文对照
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)：56 years 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)：2013-08-05 13:04:22 职 业(Occupation): 病史陈述者(Complainer of History):
主诉(Chief Complaint)： headache and fever for 10 days. 现病史(History of the Present Illness)： 10 days 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 fever with body temperature fluctuations between 38.5°C to 38.8°C. Moreover, the patient was also experiencing dizziness, nausea, occasional vomiting of stomach contents. There is no blurred vision, tinnitus, earache, syncope, numbness, limbs twitch, or incontinence. He first went to the local Fuding hospital where they performed a lumbar puncture on him. The CSF WBC was 356X10^6/L, monocytes 85%; cerebrospinal fluid biochemistry: chlorine 119 mmol/L, glucose 1.74 mmol/L, protein 1.79 mmol/L. the MRI showed “bilateral centrum ovale multiple lacunar lesions, atherosclerotic changes in white matter, chronic sinusitis”. The patient was then diagnosed as “viral meningitis” and was prescribed “acyclovir”. He was also given “mannitol, glycerol & fructose injection” to decrease the intracranial pressure. Furthermore, PPI was given to decrease the stomach pain and rehydration treatment was done but, there was no significant improvement in the symptoms. The patient then came to the emergency room of our hospital where he was diagnosed as having “intracranial infection” and was admitted to the hospital. Upon admission, the patient’s mind was clear, the spirit was good, he had a poor appetite, his sleep was good, he had soft yellow stool and there was no significant change in weight. 29 years ago, the patient had a renal history of tuberculosis.
住院病历（二） (Medical Records for Admission)
既往史(Past Medical history)： General health status: normal Co-morbid conditions: Hypertension: Absent Cardiac disease: Absent Diabetes mellitus: Absent Kidney disease: Absent
History of infectious diseases:
Tuberculosis: Absent Hepatitis: Absent Others: 29 years ago, he had a renal history of tuberculosis.
History of preventive inoculation: Inoculation plan completed.
Allergic History: History of blood transfusion: Negative
1.Drug: Negative History of scars/wounds: Negative
2.Food: Negative History of surgical operations: Negative
3.Others: Negative History of long-term drug use: Negative
History of drug abuse: Negative 系统回顾(Review of Systems)： • HEENT: No hearing loss, tinnitus, dizziness, tooth ache, gingival bleeding, throat ache, hoarseness. • Respiratory : no chronic cough, sputum, expectorant, chest pain, asthma, dyspnea. • Cardiovascular: No increase in blood pressure, palpitation, shortness of breath, cyanosis, precardial pain, orthopnea, dizziness, lower limb edema. • GI: No hematemesis, swallowing difficulty, abdominal pain or distention, diarrhea, occult blood, constipation, jaundice, rash or itching. • Genitourinary system: No urinary frequency, urgency, dysuria, hematuria, pyuria, nocturia or frothy urine. • Hemapoietic: No ecchymose, purpura, lymphadenopathy, splenomegaly, epistaxis or gingival bleeding • Endocrine :no polydipsia, polyphagia, polyuria,change in sexual function or personality or visual field defect. • Musculoskeletal: No dysarthria, joint abnormality, spine abnormality, muscle atrophy or weakness in limbs. • Neurology: no headache, loss of memory, aphasia, paralysis, tic. • Mental state: no hallucination, delusional, disorientation, mood disorder
个人史(Personal history)： Place of birth: Residence: Epidemic area: None Travel history: Negative Drinking history: Yes 500ml/day for 30years and stopped 2 years ago Smoking history: Yes 20cigarettes/day for 30 years and stopped for 2 months Toxin, dust, radioactive or industrial exposure: Negative
婚姻、月经及生育史(Marital、Menstrual and
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]。
糜烂性胃炎病历模板范文
糜烂性胃炎病历模板范文（中英文实用版）English:Case History: Chronic GastritisPatient Information:- Name: [Patient"s Name]- Age: [Patient"s Age]- Gender: [Patient"s Gender]- Date of Admission: [Date]- Date of Discharge: [Date]Medical History:- Chief Complaint: [Chief Complaint]- History of Present Illness: [History of Present Illness] - Past Medical History: [Past Medical History]- Family History: [Family History]Physical Examination:- Vital Signs: [Vital Signs]- General Appearance: [General Appearance]- Abdomen: [Abdomen]- Extremities: [Extremities]Laboratory Tests:- Complete Blood Count (CBC): [CBC Results]- liver function tests: [Liver Function Test Results]- Stool Analysis: [Stool Analysis Results]Imaging Studies:- Upper Endoscopy: [Endoscopy Findings]- Ultrasound of Abdomen: [Ultrasound Findings] Diagnosis:- Chronic Gastritis- [Any Associated Conditions]Treatment Plan:- Medical Therapy: [Medications Prescribed]- Surgical Therapy: [Surgical Procedures]- Dietary and Lifestyle Recommendations: [Recommendations] Discharge Instructions:- Follow-up Appointments: [Appointments]- Medication Instructions: [Instructions]- Dietary and Lifestyle Advice: [Advice]中文：病历模板：慢性胃炎患者信息：- 姓名：[患者姓名]- 年龄：[患者年龄]- 性别：[患者性别]- 入院日期：[日期]- 出院日期：[日期]病史：- 主要症状：[主要症状]- 现病史：[现病史]- 既往病史：[既往病史]- 家族史：[家族史]体格检查：- 生命体征：[生命体征]- 一般情况：[一般情况]- 腹部：[腹部]- 四肢：[四肢]实验室检查：- 血常规：[血常规结果]- 肝功能检查：[肝功能检查结果]- 粪便分析：[粪便分析结果]影像学检查：- 上消化道内镜检查：[内镜检查发现] - 腹部超声检查：[超声检查发现]诊断：- 慢性胃炎- [任何相关疾病]治疗计划：- 药物治疗：[开的药物]- 手术治疗：[手术程序]- 饮食和生活方式建议：[建议] 出院指导：- 随访预约：[预约]- 药物说明：[说明]- 饮食和生活方式建议：[建议]。
英文大病历
Complete Medical HistoryName: Zhanghou Sex: maleProfession :peasant Age:31 yearsNative place: Tian Jin Address:chitu village chitu town dongli district tianjin Marital state: married Nationality: HanDate of admission: February 28 2003 Date of history taking :February 28 2003Narrator: the patient Reliability of the history: reliableThe HistoryChief Complaint: lumbago for 2 years with weakness ,numbness in lower limbs, more severe 2 months.Present Illness:2 years ago ,after working ,the patient always felt lumbago, sometimes referred pain at the hip and lower extremities,mainly at the dorsal the left lower limb was more severe. At the same time he felt weak and numb at lower limbs, also more severe in the left side. No muscle atrophy, no abnormal of stool and urine. No temperature abnormal or color changes in the local skin. No nails damaged. Then the patient went to the hospital in his town, and had a X-ray examination, shown hypertrophy in the lumbar vertebrae., given some drugs for pain-control. After having some drugs and more rest, the symptoms lightened. But 2 months ago ,without significant causes,the symptoms became more severe. The lumbago often made him sleepless at nights. And he can only walk 500meters without a break. his left lower limb felt numb and weak.Having the drugs and rest both can not ease the symptoms. So he came to our hospital for advanced diagnosis and treatment. Since the disease, no changes in consciousness,body temperature, appetite, body weight .and normal of stool and urine.Past history: the patient had a history of high intensive working for about 10 years. No history of chronic diseases like hypertension, CAD and mellitus diabetics. No history of hepatitis or AIDS , tuberculosis .No history of trauma and operation. No history of hypersensitivity of any drug or food.Review of Systems:Respiratory system: no history of chronic cough , expectoration, hemoptysis , chest pain , or short of breath.Circulation system: no history of dyspnea or edema at the lower limbs. No history of palpitation or chest pain. No dizziness, headache, No history of hypertension. Digestive system: no history of anorexia, abdominal distention, regurgitation. No nausea and vomiting. No history of constipation , diarrhea ,melena and so on. Urogenital system: no history of swollen eyelids or lumbago. No frequent micturition, urgency of micturition or urodynia. No dysuria ,hematuria or retention and incontinence of urine .no history of acute or chronic nephritis.Hemopoeltic system: No pallid countenance ,weakness,dizziness , daze ,tinnitus. No history of bleeding and repeated infections. No history of enlargement of liver and spleen.Metabolic and Endocrine system:no abnormal cold or hot feeling, hidosis ,headache weakness,impaired vision,polyphagia ,polyuria distributed change of temper and intelligence.Nervous system: No headache ,projectile vomiting . no syncope ,spasm ,impaired vision, abnormal sensation or motion. No change of personality .no mania ,depression or hallucination.Motor system: lumbago and limitation of movement for 2 years. weakness and numbness at lower limbs, the left more severe. No spasm, atrophy or palalysis. No joint red swollen, hot ,pain or limitation of motion. No trauma or fracture. Personal history: born in her native place and living in Tianjin. No history of exposure to habits of drinking or smoking.Marital History:. Married at 24 years old and having a child. the child and his wife both health.Family history: denying the family history of any heredity diseases ,or MD, CAD, hypertension ect.Physical ExaminationTemperature: °C pulse rate: 72/min respiratory rate: 18/min blood pressure:130/80mmHgGeneral appearance : normal development and medium in nourished ,no abnormal consciousness, good corporation in examination. Free position.Skin and mucous membrane : No pallid , cyanosis, and jaundice . no abnormal pigmentation and depigmentation . no erythma annulare, petechia and spiderangioma. Normal elasticity of skin, no edema.Superficial lymph nodes: no enlargement of the superficial lymph nodes.Head and its organs:Skull:no deformity, tenderness or mass. Evenly distributed hair with black color and shine.Eyes: no drop out of eyebrow and no madarosis ,no swollen or prolapse of eyelids. No pallor, granules ,follicles pectechiae of conjunctivae . transparent of cornea ,no nebula ,keratoleukoma, malacia, ulcer or vascularization. No exophthalmos or motions of the eye balls in any direction. Equal and round pupils at both sides with diameter 4mm, normal and active direct and indirect light reflexs,normal accommodation and convergence reflexes. Vision , visual field and eyegroud not examined.Ears:no deformity .no abnormal secretion from external canals. No red, tenderness, swollen in the mastoid. Rough tested normal hearing.Nose: no deformity. No deviation of septum nasi. No ala flutter. No edema ,abnormal secretion ,and congestion of the membrane . good ventilation. No tenderness in any paranasal sinuses.Buccal cavity: no pallid or cyanosis of lips ,also no dryness ,herpes simplex. No congestion ,petechia or ulcer in the buccal membrane . 32 teeth, no caries. No bleeding or congestion ,lead line in gums. Thin and slight yellow fur coated on the tongue ,with normal in motion. No redness and congestion in pharynx ,no deviation of uvulae. No edema in tonsils.Neck: symmetry . no enlargement of external jugular vein, no abnormal pulsation of carotid arteries or veins. No rigidity .no enlargement of thyroid glands ,and the trachea in the centeral position. No murmur. Negative of hepatojugular reflux. Chest: symmetry. No deformity. No barrel chest ,pigeon chest or funnel chest. No tenderness over the chest .the thoracic respiration present. R 18/min, symmetry in both sides. Symmetry and no abnormality of the 2 breasts.Lungs:Inspections: no bulges or recession of the intercostals spaces during respiration. Respiratory movement equal in both sides and regular . no dyspnea or three concave sign.Palpation: symmetry respiratory movement in the two sides, no increase or decrease of vocal fremitus. No pleural friction fremitus . no subcutaneous crepitation.Percussion: resonance in all over the lung fields . 5 cm in width of apexes ,and the lower margin of lung at 6th,8th,10th on midclavicular ,midaxillary,midcapular line respectively. The movement of the lower margin of the lungs: 6 cm..Auscultation: clear of vesicular breathing sounds all over the lung fields. No moist rales or rhonchis .normal of vocal resonance. No pleural friction sound.Heart:Inspection: no precordial bulging. Apical impulse in the 5th ICS 1cm inside of left midclavicular line with an area of 2 cm in diameter.Palpation: apical impulse and its area as that in inspection. Regular ,normal intensity. No pericardial friction rubs or thrill.Percussion: relative cardiac dullness shown as follows:The distance between the left midclvicular line and the midsternal line is 8cm. Auscultation: HR 72/min with regular rhythm, heart sounds clear and intensive . no murmurs at any auscultation area of the valvula. No pericardical friction sound. Radial arteries: pulse rate 85/min, with regular rhythm, equal in both sides, normal intensity .Perivascular signs: no capillary pulsation, water hammer pulse ,pistol-shot sounds and Duroziez’s murmur . no pulse deficit, and pulse alternant.Abdomen:Inspection: symmetry. No bulge abdomen ,abdominal distention .normal abdominal respiration. No visible gastrointestinal waves. No varicosity , scar ,petechia at the abdominalSkin.Palpation: soft, no tenderness and rebounding tenderness, no tightened abdominal wall. No palpable mass.Liver: not palpable.Gallbladder: not palpable. Negative of murphy’s sign.Kidneys: not palpable. No tenderness in the any site of kidneys or ureters. Spleen: not palpable.Appendix: no tenderness at the Mcburney’s site.Percussion: tympany in all over the abdomen, no shifting dullness. No percussive pain of liver and spleen. The upper margin of liver at the 5th ICS in the right midcalvicular lineAuscultation: normal borhorygmus, 4/min, no murmur of vessels. No friction rubs . Anus and rectum: not examined.Spine: no lordosis, kyphosis, or scoliosis. tenderness and punching tenderness at the level of L3-L5. Limitation of movement, especially anteflextion. No changes in the local skin.Extremities: symmetry, no deformity . free motion .no joint .redness ,swollen ,tenderness or hotness . no edema in the lower extremities. myodynamia of left lower limb in 4th grade and right lower limb in 5-th grade. Details in the special condition.Nerve system:numbness in lower limbs ,more severe in left side. Normal other place. Biceps,triceps ,radioperiosteal , and abdominal wall reflexes knee jerk and Achilles jerk activer. babinski’s (+_)oppenheim’s,chaddock’s,gordon’s negative. No patellar or ankle clonus.Laboratory findings:Blood routine: WBC *10ª ,N , L ,Hb 141g/l .RBC *1012/l ,plt 238*10ª/l.X-ray: hypertrophy of lumbar vertebrae.MRI : the results not gotten.Special condition: no lordosis, kyphosis, or scoliosis of spine. tenderness and punching tenderness at the level of L3-L5. Limitation of movement, especially anteflextion. No changes in the local skins. extrmities symmetry, no deformity . free motion .no joint .redness ,swollen ,tenderness or hotness . no edema in the lower tension of left lower limb in 4th grade and right lower limb in 5-th grade. Sensation in left lower limb decreased. Biceps,triceps ,radioperiosteal , and abdominal wall reflexes knee jerk and Achilles jerk activer. babinski’s (+_)oppenheim’s,chaddock’s,gordon’s negative. No patellar or ankle sign(+).SummaryThe patient named Zhanghou ,male ,is 31 years old,admission with the chief complaint of lumbago for 2 years with weakness and numbness in the lower limbs, more svere for 2 years ago ,after working ,the patient always felt lumbago, sometimes referred pain at the hip and lower extremities,mainly at the dorsal the left lower limb was more severe. At the same time he felt weak and numb at lower limbs, also more severe in the left side. No muscle atrophy, no abnormal of stool and urine. No temperature abnormal or color changes in the local skin. No nails damaged. Then the patient went to the hospital in his town, and had a X-ray examination, shown hypertrophy in the lumbar vertebrae., given some drugs forpain-control. After having some drugs and more rest, the symptoms lightened. But 2 months ago ,without significant causes,the symptoms became more severe. The lumbago often made him sleepless at nights. And he can only walk 500 meters without a break. his left lower limb felt numb and the drugs and rest both can not ease the symptoms. So he came to our hospital for advanced diagnosis and treatment. Since the disease, no changes in consciousness,body temperature, appetite, body weight .and normal of stool and urine.PE: T:°C , Bp 130/80mmHg,normal development, moderately nourished, clear counsciousness. Good corporation in physical examination. Normal in skull ,neck,lungs ,heart and abdomen no lordosis, kyphosis, or scoliosis of spine. tenderness and punching tenderness at the level of L3-L5. Limitation of movement, especially anteflextion. No changes in the local skins. extrmities symmetry, no deformity . free motion .no joint .redness ,swollen ,tenderness or hotness . no edema in the lower tension of left lower limb in 4th grade and right lower limb in 5-th grade. Sensation in left lower limb decreased. Biceps,triceps ,radioperiosteal , and abdominal wall reflexes knee jerk and Achilles jerk activer. babinski’s (+_)oppenheim’s,chaddock’s,gordon’s negati ve. No patellar or ankle sign(+).Blood routine: WBC *10ª ,N , L ,Hb l .RBC *1012/l ,plt 238*10ª/l.X-ray: hypertrophy of lumbar vertebrae.MRI : the results not gotten.Impression:Intern doctor :Bianbo。
护理病历英文版
护理病历英文版中英文护理病历患者姓名：陈东林性别：男年龄：82岁主诉：因“反复发作，胸闷10余年，加重半月”入院现病史：患者于2003年出现胸痛、胸闷，在同济医院就诊断为“冠心病不稳定型心绞痛陈旧型心肌梗塞”，并行支架植入术治疗，术后症状明显缓解。
近半月来出现胸痛、胸闷，持续约20-30分钟，服用发放丹参滴丸有时效果不佳，服用速效救心丸症状可缓解，活动时可诱发，无夜间渐发性呼吸困难，轻咳嗽，少量白色泡沫痰。
有时感到头昏，无发热盗汗。
门诊以“冠心病、心绞痛”收入院。
患者发病以来精神差，体力下降，睡眠可，饮食差，二便如常。
既往史：高血压病20年，冠心病10年，肝囊肿，左肾结石，前列腺增生，否认肝炎、结核或其它传染病史，按国家计划进行接种，喹诺酮类过敏史，否认外伤史，1988年脑脂肪手术。
查体：体温36.4℃，心率62次/分，呼吸18次/分，血压140/80mmHg，其它无特殊。
专科检查：血压140/80mmHg，神志清楚，心率62次/分，心音正常，心律齐，其他无特殊。
个人史：无特殊婚姻史：已婚初步诊断：1、冠心病心绞痛支架术后心功能不全2级2、高血压病3级极高危组3、前列腺增生护理评估：1、病史(1)患病及治疗经过1）患病经过：患者于2000年出现胸痛、胸闷，近半月来出现胸痛胸闷，持续约20-30分钟，活动时可诱发，无夜间渐发性呼吸困难，轻咳嗽，少量白色泡沫痰。
有时感到头昏，无发热盗汗。
2）诊治经过：在同济医院被诊断为“冠心病不稳定型心绞痛陈旧型心肌梗塞”，并行支架植入术治疗，术后症状明显缓解。
近半月来出现胸痛、胸闷，持续约20-30分钟，服用发放丹参滴丸有时效果不佳，服用速效救心丸症状可缓解。
3）目前状况：患者发病以来精神差，体力下降，睡眠可，饮食差，二便如常。
4）相关病史：高血压病20年，冠心病10年2、心理社会资料患者对疾病的性质、过程、预后及防治知识有一定程度的了解，但是了解不全面。
患者住院期间无焦虑、恐惧、抑郁、悲观等心理反应。
英文肝硬化完整大病历
Complete Medical History General informationName: Du Donghe Sex: maleProfession : retired worker Age:53 yearsNative place: Tian Jin Address:shenghe Department pujijian Road hebei district tianjinMarital state: married Nationality: HanDate of admission: July 16th 2012 Date of history taking :July 16th 2012 Narrator: the patient's daughter Reliability of the history: reliableThe HistoryChief Complaint: weakness for 1 year, more severe with edema in lower limbs for half a year、Present Illness:1 years ago ,without significant causes,the patient began to feel weakness、No headache, dizzy, palpitation, shortness, abdominal pain or diarrhea 、 The patient went to the hospital in his town, and checked his live function, shown the live is damaged,given liver-protecting treatment(the detail of drugs used is unclear)、But the symptom is not obviously lightened、And half a year ago ,the symptom became more severe,with edema in lower limbs , abdominal distension and bulge、No headache, dizzy, palpitation, shortness, tightness, abdominal pain ordiarrhea 、 So the patient went to the out-patient department of our hospital to check the HBV-DNA 5、 4 10E+4copies/ml,AFP13、91mg/ml,HBsAg(+),HBsAb(+)、HBsAb-IgG(+), PreS1(+)、He also had a MR scan of the upper abdomen,shown hepatic cirrhosis,splenomegaly,portal hypertention,gastric varix,umbilical vein repassing、So he was accepted in our section for advanced diagnosis and treatment、Since the disease, no changes in consciousness, appetite, body weight 、and normal of stool while less of urine、Past history: the patient became blind 50 years ago、And he has a history of hepatitis B for 26years、No history of chronic diseases like hypertension, CAD and mellitus diabetics、No tuberculosis 、No history of trauma, operation and blood transfusion、 He was allergic to penicillin and sulfa drugs、The history of vaccination is unclear、Review of Systems:Respiratory system: no history of chronic cough , expectoration, hemoptysis , chest pain , or short of breath、Circulation system: half a year age he had the edema at the lower limbs、no history of dyspnea,palpitation or chest pain、 No dizziness, headache、No history of hypertension、Digestive system: half a year age he began to have the abdominal distentionand bulge、no history of anorexia, , regurgitation反流、No nausea and vomiting、 No history of constipation , diarrhea ,melena 、Urogenital system: no history of swollen eyelids or lumbago腰疼、No frequent micturition, urgency of micturition or urodynia、No dysuria ,hematuria or retention and incontinence of urine 、no history of acute or chronic nephritis、Hemopoeltic system: 1 years ago the patient began to feel weakness and became more severe half a year ago、No pallid 苍白countenance面容 ,dizziness , daze头昏眼花 ,tinnitus耳鸣、 No history of bleeding and repeated infections、The MR scan shows splenomegaly、、Metabolic and Endocrine system:no abnormal cold or hot feeling, hidrosis多汗,headache ,impaired vision,polyphagia 食欲过盛,polyuria ect、normal distributed hair、no change of temper and intelligence、Nervous system: No headache ,projectile vomiting 、no syncope ,spasm ,impaired vision, abnormal sensation or motion、No change of personality 、no mania躁狂 ,depression or hallucination、Motor system: No spasm, atrophy or palalysis、No joint red swollen, hot ,pain or limitation of motion、 No trauma or fracture、Personal history: born in her native place and living in Tianjin、Nohistory of exposure to radioactive poison、No habits of drinking or smoking、Marital History:、 Married at 30 years old and having a son、 his son and wife are both healthy、Family history: his mother had the hepatitis B、denying other family history of heredity diseases ,or MD, CAD, hypertension ect、Physical Examination Temperature: 37、1C pulse rate: 101/min respiratory rate: 18/min blood pressure:130/80mmHgGeneral appearance : normal development and medium in nourished ,no abnormal consciousness, good corporation in examination、 Free position、Skin and mucous membrane : No pallid , cyanosis, and jaundice 、 no abnormal pigmentation and depigmentation 、no erythma annulare, petechia and spider angioma、 Normal elasticity of skin, no edema、Superficial lymph nodes: no enlargement of the superficial lymph nodes、Head and its organs:Skull:no deformity, tenderness or mass、Evenly distributed hair with black color and shine、Eyes: no drop out of eyebrow and no madarosis ,no swollen or prolapse of eyelids、No pallor, granules ,follicles pectechiae of conjunctivae 、transparent of cornea ,no nebula ,keratoleukoma, malacia, ulcer or vascularization、No exophthalmos 眼球突出or enophthalmos、free motions of the eye balls in any direction、 Equal and round pupils at both sides with diameter 4mm, No light reflexes, no accommodation and convergence reflexes、 Vision , visual field and eyegroud not examined、Ears:no deformity 、no abnormal secretion from external canals、 No red, tenderness, swollen in the mastoid、 Rough tested normal hearing、Nose: no deformity、No deviation of septum nasi、No ala flutter、No edema ,abnormal secretion ,and congestion of the membrane 、good ventilation、 No tenderness in any paranasal sinuses、Buccal cavity: no pallid or cyanosis of lips ,also no dryness ,herpes simplex、 No congestion ,petechia or ulcer in the buccal membrane 、 32 teeth, no caries、 No bleeding or congestion ,lead line in gums、 Tongue was in midline ,with normal in motion、No redness and congestion in pharynx ,no deviation of uvulae、 No edema in tonsils、Neck: symmetry 、no enlargement of external jugular vein, no abnormal pulsation of carotid arteries or veins、No rigidity 、no enlargement of thyroid glands ,and the trachea in the centeral position、No murmur、Negative of hepatojugular reflux、Chest: symmetry、 No deformity、 No barrel chest ,pigeon chest or funnelchest、 No tenderness over the chest 、the thoracic respiration present、 R 18/min, symmetry in both sides、Symmetry and no abnormality of the 2 breasts、Lungs:Inspections: no bulges or recession of the intercostals spaces during respiration、 Respiratory movement equal in both sides and regular 、 no dyspnea or three concave sign、Palpation: symmetry respiratory movement in the two sides, no increase or decrease of vocal fremitus、No pleural friction fremitus 、no subcutaneous crepitation、Percussion: resonance in all over the lung fields 、 5 cm in width of apexes ,and the lower margin of lung at 6th,8th,10th on midclavicular ,midaxillary,midcapular line respectively in both left and right side、 The movements of the lower margin of the lungs are 6 cm in both left and right side、Auscultation: rough of vesicular breathing sounds all over the lung fields、fine rales are heard in bilateral subpulmonic parts、no rhonchis 、normal of vocal resonance、 No pleural friction sound、Heart:Inspection: no precordial bulging、Apical impulse in the 5th ICS 1cminside of left midclavicular line with an area of 2 cm in diameter、Palpation: apical impulse and its area as that in inspection、Regular ,normal intensity、 No pericardial friction rubs or thrill、Percussion: relative cardiac dullness shown as follows:The distance between the left midclvicular line and the midsternal line is 8cm、Auscultation: HR 101/min with regular rhythm, heart sounds clear and intensive 、no murmurs at any auscultation area of the valvula、No pericardical friction sound、Radial arteries: pulse rate 101/min, with regular rhythm, equal in both sides, normal intensity 、Perivascular signs: no capillary pulsation, water hammer pulse ,pistol-shot sounds and Duroziez’s murmur 、 no pulse deficit, and pulse alternant、Abdomen:Inspection: symmetry、bulge abdomen、normal abdominal respiration、No visible gastrointestinal waves、No varicosity , scar ,petechia at the abdominal Skin、Palpation: tightened abdominal wall ,no tenderness and rebounding tenderness 、 No palpable mass、Liver: not palpable、Gallbladder: not palpable、 Negative of murphy’s sign、Kidneys: not palpable、No tenderness in the any site of kidneys or ureters、Spleen: not palpable、Appendix: no tenderness at the Mcburney’s site、Percussion: tympany in all over the abdomen, shifting dullness(+)、No percussive pain of liver and spleen、The upper margin of liver at the 5th ICS in the right midcalvicular lineAuscultation: normal borhorygmus, 4/min, no murmur of vessels、No friction rubs 、Anus and rectum: not examined、Spine: no lordosis, kyphosis, or scoliosis、No tenderness and punching tenderness 、 No Limitation of movement、 No changes in the local skin、Extremities: symmetry, no deformity 、 free motion 、muscle strength is normal、no joint redness ,swollen ,tenderness or hotness、Noacropachy,koilonychia,floating patella test(-)、bilateral dorsalis pedis arteries can be palpated、edema in the lower extremities(+++)、Nerve system: Biceps,triceps ,radioperiosteal , and abdominal wall reflexes normal、knee jerk and Achilles jerk are also normal、babinski’s ,oppenheim’s,chaddock’s,gordon’s negative、Hoffmann sign (-)、 Neck tetany (-) Kernig sign (-)、Brudzinski sign (-)、No patellar or ankle clonus、Laboratory findings: HBsAg(+),HBsAb(+)、HBsAb-IgG(+), PreS1(+)、HBV-DNA 5、4 10E+4copies/ml,AFP13、91mg/ml(2012、6、29,GH) MRI: hepatic cirrhosis,splenomegaly,portal hypertention,gastric varix,umbilical vein repassing、SummaryThe patient named Du Donghe ,male ,is 53years old,admission with the chief complaint of weakness for 1 year, more severe with edema in lower limbs for half a year in July 16th 2012 、1 years ago ,without significant causes,the patient began to feel weakness、He went to the hospital in his town, and checked his live function, shown the live is damaged, given liver-protecting treatment(the detail of drugs used is unclear)、But the symptom is not obviously lightened、 And half a year ago ,the symptom became more severe,with edema in lower limbs ,abdominal distension and bulge、So the patient went to the out-patient department of our hospital to check the HBV-DNA 5、 4 10E+4copies/ml,AFP13、91mg/ml,HBsAg(+),HBsAb(+)、HBsAb-IgG(+), PreS1(+)、He also had a MR scan of the upper abdomen,shown hepatic cirrhosis,splenomegaly,portal hypertention,gastric varix,umbilical vein repassing、So he was accepted in our section for advanced diagnosis and treatment、the patient became blind 50 years ago、And he has a history of hepatitis B for 26years、He was allergic to penicillin and sulfa drugs、He has no history of exposure to radioactive poison、and his mother had the hepatitis B、PE: T:37、1C,P: 101/min R: 18/min Bp 130/80mmHg,normal development, moderately nourished, clear counsciousness、Good corporation in physical examination、rough of vesicular breathing sounds all over the lung fields、fine rales are heard in bilateral subpulmonic parts、HR101bpm,with regular rhythm、no murmurs at any auscultation area of the valvula、bulge abdomen,tightened abdominal wall ,no tenderness and rebounding tenderness、Liver and Spleen are not palpable、shifting dullness(+),edema in the lower extremities(+++)Laboratory findings: HBsAg(+),HBsAb(+)、HBsAb-IgG(+), PreS1(+)、HBV-DNA 5、4 10E+4copies/ml,AFP13、91mg/ml(2012、6、29,GH)MRI: hepatic cirrhosis,splenomegaly,portal hypertention,gastric varix,umbilical vein repassing、Impression: 1、HBV cirrhosisPortal hypertensiongastric varix2、HypersplenismSignature:Jin Dan。
口腔科英文病历
口腔科英文病历第一篇：口腔科英文病历Oral and Maxillofacial Surgery Complete Medical History（Zhang te）Medical Number: 182786 General information Name: T ao lili Age: Forty eight Sex: Female Race: Han Occupation: worker Nationality: China Marital status: Married Address:NO.138,mawangduiRvenue,changsha, Hunan.Tel: 84722500Date of admission: Jun 20st, 2013 Date of record: 11Am, Jun20st, 2013 Complainer of history: the patient herself Reliability: ReliableChief 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.the 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.Hematopoietic system: No history of anemia andmucocutaneous 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 She was born in Wuhan on Nov 19th, 1957 and almost always lived in Wuhan.She graduated from senior high school.Her living conditions were good.No bad personal habits and customs.Menstrual history: The first time when she was sting 3 to 4 days every times and its cycle is about 30 days.Obstetrical history: Pregnacy 3 times, once nature production, abortion twice.Contraceptive history: Not clear.Family history: His parents have both died.Physical examinationT 36.4℃, P 80/min, R 20/min, BP 90/60mmHg.She is well developed and moderately nourished.Active position.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 enlarged.Head Cranium: Hair was black and 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.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.Neither nipples nor skin were retracted.Elasticity was fine.Lungs: Respiratory movement was bilaterally symmetric with the frequency of 20/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 80/min.Cardiac rhythm was regular.No pathological murmurs.Abdomen: Flat and soft.No bulge or depression.No abdominal wall varicosis.Gastralintestinal type or peristalses were not seen.There was not tenderness and rebound tenderness on abdomen or renal region.Liver was not reached.Spleen was not enlarged.No masses.Fluidthrill negative.Shifting dullness negative.Borhorygmus 5/min.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 exaned Investigation No.Professional ExaminationOral mucous membrane was smooth, and of no ulcer or erosion.T ongue was in midline.Pharynx was not congestive.Tonsils were not enlarged.Patients with poor oral hygiene has much dental calculus.There are a about 2*2*1.5cm mass on lower incisors(33-41)gingivae.It is tender but notbleed.It can not be moved and its surface is sm ooth.Corresponding superficial lymph nodes don’t enlarge.Impression: EpulisSignature: Zhang teHospital course record for the first time 2013-6-20 8:50一、Characteristics of cases：1.Clinical presentation:Patient was a worker , female, 48 years old.2.lower incisors gingivae mass found for more than 3 month.3.No special past history.4.Physical examination showed no abnormity in lung, heart and rmation about her oral can be seen above.5.Shorting of investigation information.6.Temperature is36.5℃, pulse 80, respirations 20, blood pressure 90/60.二、Examination to discuss diagnostic basis：1.lower incisors gingivae mass found for more than 3 month。
常见医学病案记录术语的中英对照
常见医学病案记录术语的中英对照病案记录术语的中英对照一、主诉 (Chief Complaint)主诉是指患者在就诊时主动告诉医生的症状或原因。
病案记录中通常以简洁的语言来描述患者最主要的不适或问题。
二、现病史 (Present Illness History)现病史是指患者目前所出现的症状、体征，以及这些症状、体征出现的时间、持续时间、频率、程度等详细情况的陈述。
通过现病史可以了解患者当前的健康状况。
三、既往史 (Past Medical History)既往史是指患者在当前就诊之前的生活史、病史、手术史、外伤史、过敏史等。
这些信息对于医生进行诊断、治疗和了解患者的健康状况至关重要。
四、过敏史 (Allergic History)过敏史是指患者对于某些药物、食物或其他物质出现过过敏反应的历史记录。
了解患者的过敏史可以有效避免使用会引起过敏反应的药物或接触过敏原。
五、家族史 (Family History)家族史是指患者的近亲属中是否有某些疾病的遗传倾向或者常见的遗传病史。
通过了解家族史可以评估患者的遗传风险，对医生的诊断和治疗方案的制定有重要影响。
六、体格检查 (Physical Examination)体格检查是指医生通过观察、触摸、听诊、叩诊等方式对患者进行全面的身体检查，以获得有关患者身体状况的客观数据。
七、辅助检查 (Auxiliary Examination)辅助检查是指医生为了进一步了解患者的病情和辅助诊断而进行的各种检查。
常见的辅助检查包括血常规、尿常规、心电图、超声检查等。
八、诊断 (Diagnosis)诊断是指医生根据收集到的病史、体格检查和辅助检查结果，对患者的疾病进行判断和确定。
在病案记录中会根据病情和病理进行具体的诊断说明。
九、治疗方案 (Treatment Plan)治疗方案是指医生根据诊断结果制定的针对患者疾病的治疗计划。
该计划会包括药物治疗、手术治疗、康复计划等。
十、进展观察 (Progress Observation)进展观察主要是记录患者治疗过程中的变化和效果。
病历常见英文缩写及中文释义对照表之欧阳歌谷创作
病历常见英文缩写及中文释义对照表欧阳歌谷（2021.02.01）AA 白蛋白（单位g/L）AA 再障AB实际碳酸氢盐ABG动脉血气ACEI血管紧张素转换酶抑制剂ACT激活凝血时间AD 阿尔海默茨病Af房颤AFP 甲胎蛋白定量（单位ng/ml）AG离子间隙AGN 急性肾炎a-HBD a-羟丁酸（单位U/L）AI 主闭AIHA 自身免疫性溶血性贫血AIH 自身免疫性肝炎AIN 急性间质性肾炎AKP 碱性磷酸酶（单位u/L）ALT 谷丙转氨酶（单位u/L）ALT 成人T细胞白血病AMI 急性心梗ANA 抗核抗体AP 心绞痛AP 急性胰腺炎DU十二指肠溃疡APB 房早APOA-1 载脂蛋白A1（单位mg%）APOB-100 载脂蛋白B100（单位mg%）APTT活化部分凝血活酶时间（单位秒）ARDS急性呼吸窘迫综合征ARF 急性肾功能不全AS 主狭ASD 房缺ASO抗链球菌溶血素“0”ASO 闭塞性动脉硬化AST谷草转氨酶（单位u/L）AT 房速ATP三磷酸腺苷A VB 房室传导阻滞A VNRT房室结折返性心动过速A VRT房室折返性心动过速BBabinski征指锥体束病损时大脑失去了对脑干和脊髓的抑制作用而出现的异常反射BB缓冲碱BBB 束支传导阻滞BE 碱剩余（单位mmol/L）BEE基础能量消耗BIL 胆红素Bicarbonate 碳酸盐BLO 潜血BP血压BS空腹血糖（单位mmol/L）BT出血时间BUN尿素氮（单位mmol/L）CC 反应蛋白（单位vg/ml）Ca 钙CAP 社区获得性肺炎CBC全血球计数CCU心血管监护室CEA 癌胚抗原（单位vg/ml）（辅助恶性肿瘤诊断）CF 心衰CGN 慢粒CGN 慢性肾炎CHD冠心病CHE胆碱酯酶CHF 充血性心衰CIN 慢性间质性肾炎CK 肌酸激酶（单位U/L）CK-MB 肌酸激酶同工酶（单位U/L）CL 氯化物（单位mmol/L）CLL 慢淋cm 厘米COPD 慢性阻塞性肺气肿CO2Cp 二氧化碳结合力（单位mmol/L）CPAP持续正压通气CPR心肺复苏Cr 肌酐（单位vmol/L）CRF 慢性肾功能不全CT 凝血时间（单位秒）CT断层扫描CVP中心静脉压C3补体C3（单位mg/ml）（降低见于急性肾炎）C4补体C4（单位mg/ml）（降低：见于免疫复合物引起的肾炎、系统性红斑狼疮、病毒性感染、狼疮性症候群、肝硬化、肝炎等）DD-BIL直接胆红素（单位vmol/L）DBP舒张压DCT双氢克尿噻DIC弥散性血管内凝血DKA 糖尿病酮症酸中毒DLE 盘状红斑狼疮DM舒张期杂音DM 糖尿病DN 糖尿病肾病DR 糖尿病视网膜病变ds-DNA 抗双连DNA抗体EEF射血分数ENT耳鼻喉科(五官科)ERCP 内镜逆行胰胆管造影术ESR 血沉（单位mm/h）E3VtM4格拉斯哥评分等级中的一种FFD 功能性消化不良FDP纤维蛋白原降解产物Fe 铁（单位mol/L）FUO不明原因发热F3 法三F4 法四GG 球蛋白（单位g/L）GD 甲亢GravesGERD 胃食管反流病g/L克/升GLASGOW-Ⅱ/gcs格拉斯哥昏迷评分GLU 葡萄糖/尿糖GNS葡萄糖生理氯化钠溶液GRA中性粒细胞（单位%）GU 胃溃疡HHAP 医院获得性肺炎Hb血红蛋白HbCO碳氧血红蛋白HBsAg乙肝表面抗原HGB血红蛋白浓度（单位g/L）HCO3碳酸盐（单位mmol/L）HCT 红细胞压积（单位%）HD 霍奇金病HDL 高密度脂蛋白（单位mg%）HE 肝性脑病HIE 新生儿缺血缺氧性脑病HIV人类免疫缺陷病毒HNKHC 高渗性非酮症糖尿病昏迷Hoffmann征上肢的锥体束征Holter24h动态心电图IIABP主动脉内气囊反搏术IBD 炎症性肠病I-BIL间接胆红素（单位vmol/L）IBS 肠易激综合症IDA 缺铁贫IDD 胰岛素依赖性糖尿病IgA免疫球蛋白A（单位/L）IgG免疫球蛋白G（单位/L）IgM免疫球蛋白M（单位/L）IGT 糖耐量减低IHD 缺血性心脏病IHSS特发性肥厚型主动脉瓣下狭窄IIM 特发性炎症性肌病INS胰岛素（单位IU/L）INR国际标准比率IPF 特发性肺纤维化ITP 过敏性紫殿IU国际单位IU/L 国际单位/升KK 钾（单位mmol/L）Kernig克尼格氏征，简称克氏征，是神经科常用的一种检查方法检查方法KET 酮体KPTT部分凝血活酶时间KUB腹部平片抗HBs乙肝表面抗体抗HBee抗体抗HBc核心抗体注:其中抗HBs、抗HBe为有益指标；抗HBc提示正在复制或既往已感染而现在已停止LL升Lac乳糖Large(+++)LD 低密度脂蛋白（单位mg%）LDH 乳酸脱氢酶（单位U/L）LEU 白细胞Ly% 淋巴细胞比值（单位%）Ly 淋巴细胞计数（单位109/L）LYM淋巴细胞（单位%）MMAS或POED 多发性骨纤维结构不良MCH 平均红细胞血红蛋白含量（单位pg）MCHC 平均红细胞血红蛋白浓度（单位g/L）MCV 平均红细胞体积（单位fL）MDS 骨髓增生异常综合症MG 重症肌无力mmHg（毫米汞柱）mmol/L（毫摩尔/升）MI 心梗MID单核细胞（单位%）MM 多发性骨髓瘤Moderate(++)MONO% 单核细胞比值（单位%）MPV平均血小板容积（单位fl）MVP 二间瓣脱垂NN%中性粒细胞比率Na 钠（单位mmol/L）nCa游离钙（单位mmol/L）Negative (-)NEUT% 中性粒细胞比例（单位%）NHL 非霍奇金NIT 亚硝酸盐NS生理氯化钠溶液NTG硝酸甘油OOB隐油OX2一种伤寒变形菌，具体名称不详OX19 斑疹伤寒OXk恙虫病PP 磷（单位mg/dl）PLT血小板计数（单位109/L）Pa02氧分压（单位mmHg）PaCO2二氧化碳分压（单位mmHg）PCO2二氧化碳分压PLTPH酸碱度PRO 蛋白质PT 凝血酶原时间测定（单位秒）Positive 阳性PY 蛋白定量（单位g/L）P(A-a)O2肺泡气-动脉血氧分压差P2肺动脉第二心音PaCO2动脉二氧化碳分压PAMPA氨甲苯酸PaO2动脉氧分压PCAP肺小动脉压PCWP肺毛细血管压PEEP呼气末正压pH酸碱度PPD结核菌素纯蛋白衍生物Prn必要时PT凝血酶原时间PAP 肺泡蛋白质沉积症PIE 间质肺气肿PTE 肺栓塞PCP 卡式肺囊虫肺炎PDA 动脉导管未闭PS 肺狭PAT 阵发性房性心动过速PNH 阵发性睡眠性血红蛋白尿PKU 苯丙酮尿症PD 帕金森氏病PEM 蛋白质－热能营养不良PID 盆腔炎Qqh每小时1次qid每天4次qn每晚1次qod隔日1次RRRBC 红细胞计数（单位1012/L）r-T3 反T3（单位ng/ml）r-GTr-谷氨酰胺转酞酶（单位u/L）RF类风湿因子RI胰岛素RR呼吸频率RBBB 右束支传导阻滞RAEB 难治性贫血伴原始细胞增多型RA 类风湿关节炎SSP02ScrSBESG 比重Small(+)S3第3心音S4第4心音SaO2血氧饱和度SB标准碳酸氢盐SBE亚急性细菌性心内膜炎SBP收缩压SGOT血清谷草转氨酶SGPT血清谷丙转氨酶SK链激酶SM收缩期杂音SSS 病态窦房结综合症SBE 亚急性感染性心内膜炎SAP 急性重症胰腺炎SSc系统性硬化病SLE 系统性红斑狼疮SCA 脊髓小脑共济失调TTTBIL/ T-BIL 总胆红素（单位vmol/L）TT凝血酶时间测定（单位秒）Trace(±)TTT 麝香草酚浊度实验（单位u）TBA胆汁酸（单位vmol/L）TP 总蛋白（单位g/L）T-CH总胆固醇（单位mg%）TG甘油三脂（单位mg%）TSH促甲状腺素（单位vIU/ml）T3三碘甲状腺原氨酸（单位ng/ml）T4甲状腺素（单位ng/ml）TPN全胃肠外营养T3三碘甲状原氨酸T4甲状腺素TAT抗蛇毒血清TIL短暂脑缺血发作tid每天3次t-PA组织型纤溶酶原激活物TPN全肠道外营养TSH促甲状腺激素TB 肺结核TIP 血栓性血小板减少性紫殿T2DM 2型糖尿病UU/L单位/升URO 尿胆原UA血尿酸（单位mmol/L）UK尿激酶UA 不稳定性心绞痛UC 溃疡性结肠炎V VLOL 极低密度脂蛋白（单位mg%）V/Q通气/灌注比VMA香草基杏仁酸VSD 室缺VDH 心脏瓣膜病W WBC白细胞计数（单位109/L）WD 肝豆状核变性其他µg/kg.min（微克/千克*分钟）µmol/L（微摩尔/升）。
直肠恶性肿瘤病历书写范文
直肠恶性肿瘤病历书写范文(中英文实用版)英文文档内容:Case History: Rectal Malignant TumorPatient Information:- Name: [Patient"s Name]- Age: [Patient"s Age]- Gender: [Patient"s Gender]- Date of Admission: [Date of Admission]- Date of Discharge: [Date of Discharge]Medical History:- Chief Complaint: [Chief Complaint]- History of Present Illness: [History of Present Illness] - Past Medical History: [Past Medical History]- Surgical History: [Surgical History]- Medications: [List of Medications]Physical Examination:- Vital Signs: [Vital Signs]- General Appearance: [General Appearance]- Abdomen: [Examination of Abdomen]- Anus and Rectum: [Examination of Anus and Rectum] Laboratory Investigations:- Complete Blood Count (CBC): [CBC Results]- Blood Chemistry: [Blood Chemistry Results]- Colonicoscopy: [Colonicoscopy Results]- Biopsy: [Biopsy Results]Diagnosis:- Rectal Malignant Tumor- Stage [Stage]Treatment Plan:- Initial Management: [Initial Management]- Surgical Procedure: [Surgical Procedure]- Adjuvant Therapy: [Adjuvant Therapy]- Follow-up Plan: [Follow-up Plan]Discharge Instructions:- Home Care: [Home Care Instructions]- Follow-up Appointments: [Follow-up Appointments]- Dietary Recommendations: [Dietary Recommendations]- Activity Level: [Activity Level Recommendations]Conclusion:This case history presents a comprehensive overview of a patient diagnosed with a rectal malignant tumor.The document includes essential patient information, detailed medical history, physical examination findings, and laboratory investigations.The treatment planoutlines the necessary interventions and follow-up care.The discharge instructions provide guidance for post-discharge management.中文文档内容：病例摘要：直肠恶性肿瘤患者信息：- 姓名：[患者姓名]- 年龄：[患者年龄]- 性别：[患者性别]- 入院日期：[入院日期]- 出院日期：[出院日期]病史：- 主诉：[主诉]- 现病史：[现病史]- 既往病史：[既往病史]- 手术史：[手术史]- 药物：[药物列表]体格检查：- 生命体征：[生命体征]- 一般情况：[一般情况]- 腹部：[腹部检查]- 肛门和直肠：[肛门和直肠检查]实验室检查：- 血常规：[血常规结果]- 生化检查：[生化检查结果]- 结肠镜检查：[结肠镜检查结果]- 活检：[活检结果]诊断：- 直肠恶性肿瘤- 分期：[分期]治疗计划：- 初始管理：[初始管理]- 手术方案：[手术方案]- 辅助治疗：[辅助治疗]- 随访计划：[随访计划]出院指导：- 家庭护理：[家庭护理指导]- 随访预约：[随访预约]- 饮食建议：[饮食建议]- 活动水平：[活动水平建议]结论：本病例摘要详细介绍了一位被诊断为直肠恶性肿瘤的患者的病历信息。
英文电子病历.
英文病历全攻略一、主要調查項目:1.主訴chief complaint:weakness, malaise, chills, fever, sleep, pain, headache, appetite, weight, stomach and bowels, nausea and vomiting, diarrhea, urine, genitalia, neuropsychiatric disorders, respiration, shortness of breath, bleeding or discharge, etc.2.現症歷present illness:onset(date, mode, duration before present entry, exciting cause and environmental influences, prodromal symptoms, general symptoms, course or progress( location, duration, severity, continuity, intermission, radiation, treatment, aggravating and alleviating factors, loss of weight, appetite and strength, sleep, bowel movement, frequency of urination, menstruation, etc.3.既往歷past history:1former places of residence, previous stage of health( 健壯的robust,纖弱的delicate, experience with similar disease, immunity to infectious disease2previous illness:麻疹measles, 腮腺炎mumps, 水痘chicken-pox, 百日咳pertussis, 流行性感冒influenza, 猩紅熱scarlet fever, 白喉diphtheria,傷寒typhoid fever, 支氣管炎bronchitis, 肺炎pneumonia,腦炎encephalitis,腦膜炎meningitis,破傷風tetanus,小兒麻痺poliomyelitis,赤痢dysentery,霍亂cholera, 胸膜炎pleurisy,天花small-pox,瘧疾malaria,結核病tuberculosis,黃疸病jaundice,過敏性反應allergy,etc3venereal disease:specific symptoms, signs, and the disease by name, treatment.4Accidents( date, any disability, sequelae, operation and hospitalization (date , procedure, name of hospital , physician, complications, bleeding tendency4.家族歷family history:family tendency, presence of hereditary disorders, cancer, tuberculosis, mental disorder and nervous affection, rheumatism, diabetes, hypertension, cerebral vascular accident, hemophilia, syphilis, tumor, epilespsy, allergy, contact withdiseased individuals, relationship of patient’s childhood and adult life, age, health condition, and cause of death of parents, grandparents, self , spouse, siblings , or relatives.5.個人歷personal history:1Social history:fears, metal status, education, financial condition, number of dependents, family harmony or fractious , hygienic condition at home2Marital history:duration of marriage, 1st or 2nd marriage, age and death of spouse and children , cause and age at time of death, number of children , pregnancies, 流產次數miscarriages, 死產數stillbirths3occupational history:duration of employment, past work, exact nature of work, exposure to occupational hazards, whether work is satisfactory or not.4Habits:alcohol, tobacco, narcotic, coffee, tea, appetite, food habits, regularity of meals, rapidity of eating , bowel movements, sleep, exercise, interests, etc.6.系統檢查system review:1General:nutrition, fever, night sweats, tremor, weight gain or loss, weakness, allergy.2Skin:蕁蔴疹hives, rash, eczema3Head:trauma, headache, loss of hair4Eyes:vision, pain glasses diplopia.5Ears:pain, discharge, deafness, tinnitus.6Nose:obstruction, discharge, epistaxis, rhinitis.7Mouth:teeth, lips, gums, tongue, disturbance in taste.8Throat.:sore throat, tonsillitis, 膿性扁桃腺炎quinsy, dysphagia9Neck:adenitis, goiter , rigidity10Cardiorespiratory:palpitation, tachycardia, blood pressure, chest pain, dyspnea, cough , hemoptysis , seasonal cold, expectoration.11Gastrointestinal:appetite, nausea, vomiting, distress(before or after meals, melena, colic, jaundice, fullness, hernia, hemorrhoid, constipation, diarrhea, frequency of bowel movement , heartburn, idiosyncrasies, relation of symptoms to eating, type and quantity of food12Genito-urinary:dysuria, urinary frequency, dribbling , hematuria, pyuria, nocturia and volume, enuresis, incontinence, sores about external genitalia, symptoms suggestive of syphilis(mucous patches, falling hair, urethral discharge, exposure to venereal infection, obstetric history, catamenia(age of onset, date of last period, cycle and amount, periodicity , dysmenorrheal, menopause leucorrhea, associated headache13Neuromuscular:神經過敏nervousness, emotional stress, weakness, muscle or joint pains, convulsion, numbness, neuralgia, anesthesia, muscular atrophies or dysatrophies, deformities.二、病歷與時態1.現症歷(present illness:1A.現在式:表示一般的真理、職業、人格、習慣和現在的事實、動作或狀態。