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）
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PC(presenting complaint)（主诉）
4-hour crushing retrosternal chest pain（胸骨后压榨性疼痛４小时）
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HPC(history of presenting complaint)（现病史）
Onset: 4 hours of “crushing tight” retrosternal chest pain, radiating to neck and both arms, gradual onset over 5-10 minutes.（起病特征：胸骨后压榨性疼痛４小时，向颈与双臂放，5-10分钟内渐起病）
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）
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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。）
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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。
4/12 symptoms worse, exercise tolerance 200 yards on flat, limited by chest pain
4月12日，症状加重，受胸痛限制，仅耐受平地行走200码
No rest pain, no orthopnoea, no PND
无静息时疼痛，无端坐呼吸、无阵发性夜间呼吸困难
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Risk factors危险因素
Hypertension-no高血压：无
Smoking-20 cigarettes per day for 16 years吸烟：16年来每天20支
Diabetes-no糖尿病：无
Cholesterol-never checked胆固醇：未查
Ischemic heart disease-angina, previous MI缺血性心脏病：心绞痛、有心肌梗死病史
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PMH(past medical history)过去史
1963: appendectomy 1963年：阑尾切除手术
1972: duodenal ulcer, no symptoms since1972年：十二指肠溃疡，之后无症状
1986: myocardial infarction, full recovery / No subsequent investigation1986年：
心肌梗死，完全恢复，无随访
1989: gout quiescent on treatment1989年：痛风治疗期间症状静止
No diabetes, hypertension, rheumatic heart disease, tuberculosis, epilepsy, asthma, jaundice, cerebrovascular disease.无糖尿病、高血压、风湿性心脏病、结核病、癫痫、哮喘、黄疸、脑血管疾病
S/E(systems inquiry)系统回顾
General 一般情况
Fatigue lately, appetite unchanged, weight stable, no sweats or pruritus, sleeping well
最近有疲劳感，食欲无改变，体重稳定，无出汗或骚痒，睡眠佳。
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RS呼吸系统
Dyspnea on exertion, particularly uphill, but not limiting; no cough sputum/wheeze
劳累时呼吸困难，上坡尤其如此，但无呼吸限制，无咳嗽咳痰、哮喘。
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GIT gastrointestinal tract胃肠道
No current indigestion现无消化不良。
No symptoms lile previous duodenal ulcer过去无十二指肠溃疡症状。
No vomiting/dysphagia/abdominal pain无呕吐、吞咽困难、腹部疼痛。
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GUS genitourinary system生殖泌尿道
No urinary systems无泌尿道症状。
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NS神经系统
No headache/syncope无头痛、晕厥。
No dizziness/limb weakness/sensory loss无眩晕、肢体麻木、感觉丧失。
No disturberd bision/hearing/smell/speech无视觉、听力、味觉、嗅觉、语言障碍。?
MS运动系统
No painful gout for 5 years无痛性痛风5年。
No joint pain/stiffness/swelling无关节痛、僵硬、肿胀。
No disability无伤残。
?更多内容请参考医学知识网：，增长医学知识。
Skin皮肤
No rash/pruritus/bruising无皮疹、瘙痒、青肿。
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Drug history药物史
Atenolol 100 mg once daily（Atenolol 100mg每天1次）
GTN as required需要服用硝酸甘油。
Not taking aspirin无服用过阿斯匹林。
Allergies: penicillin-skin rash过敏反应：青霉素――皮疹。
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FH(family history)家族史
Father died of “heart attack” at age 53.
父亲53岁死于“心脏病”。
Mother died of old age at 76.
母亲于76岁去世。
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SH(social history)社会史
Lives with wife who fit and well.妻子健在，与其共同生活。
Own house私宅。
Completely independent生活全部自理。
Smoking 20 cigs/day for many years多年每天抽烟20支。Alcohol: 24 units per week饮酒：每周24个单位。
Sexual history: not appropriate性生活：未评价。
Overseas travel: not appropriate海外旅游：未评价。
Pets: not appropriate宠物：未评价。
Occupation: heavy goods vehicle driver职业：大型货车卡车司机。?
O/E(on examination)体检结果
General 一般情况
Unwell, sweaty, clammy, no cyanosis/jaundice
一般情况不佳，出汗、皮肤湿冷，无青紫、黄疸。
temperature: 37.5℃
体温37.5℃。
cigarette-stained fingers
烟熏手指。
no arcus / xanthomas / xanthelasma
无老人弓环、黄瘤、黄斑瘤。
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CVS心血管系统
Pluse 104 bpm regular, normal character
脉搏每分钟104次，规则，心音正常。
BP110/70 mmHg (right), 112/74 mmHg (left)
血压110/70 mmHg右，112/74 mmHg左。
JVP(jugular venous pulse) normal
颈静脉博动正常。
No precordial scars /chest deformities
无心前区疤痕、胸廓畸形。
Apex beat displaced to anterior axillary’s line 6th intercostals space
心尖博动向腋前线第6肋间移位。
No parasternal heave /thrills
无胸骨旁隆起、震颤。
Auscultation: heart sounds normal, but soft pan systolic murmur at apex radiating to axilla 听诊：心音正常，但心尖问及收缩前柔和杂音，向腋窝放。
PSM at apex and ejection systolic murmur in aortic area with no radiation
心尖问及收缩前柔和杂音，以及主动脉区喷性收缩期杂音，无放。
ESM in aortic area
收缩期血杂音。
Peripheral pulses: absent right popliteal to dorsails pedis
周围脉搏：右腘窝至足背动脉博动阙如。
No sacral or ankle edema
无骶部与踝部水肿。
RS呼吸系统
Trachea central 气管居中。
Respiratory rate15/ min, no respiratory distress呼吸频率15次/分，无呼吸窘迫。
Expansion symmetrical and normal胸廓扩张对称正常。
Vocal fremitus normal 语音震颤正常。
Percussion note normal叩击音正常。
Breath sounds vesicular throughout, no added sounds全肺闻及水泡音，无额外音。Abdomen腹部
No scars/ veins distension无疤痕、静脉怒张。
Palpation: soft, but tender LIF(left iliac fossa)扪诊：腹部柔软，但有触痛（左髂前窝）。Percussion note normal叩击音正常。
Auscultation: bowel sounds normal听诊：肠鸣音正常。
Genitalia not examined生殖器未检查。
Rectal examination: not performed肛门检查：未检查。
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NS神经系统
Higher function normal高级神经功能正常。
Cranial nerves颅神经
ⅰ: normal第一对颅神经：正常。
ⅱ:PERRLA(pupils equal in reaction to light and accomodation)/ normal fundi and visual fields 第二对颅神经：瞳孔对光调节反应等大，正常眼底与视野。
ⅲ,ⅳ,Ⅵ: no diplopia / nystagmus第三、四、九颅神经：无复视和眼球震颤。
ⅴ-Ⅻ: normal第五至十二对颅神经正常。
upper and lower limbs: power, tone, coordination, sensation all normal
Joints and skin： Normal关节与皮肤：正常。
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Summary
47-year-old male smoker with a family history and previous history of ischaemic heart disease, presents with s 4-month history of increasing exertional chest pain and a 4-hour history of persistent, severe pain at rest, which is unrelieved by GTN and associated with nausea, vomiting, and sweating. On examination, he has a resting tachycardia and evidence of left ventricular dilatation with a displaced apex beat and possible secondary mitral regurgitation. The most likely diagnosis is acute myocardial infarction.
47岁男性，有吸烟史与缺血性心脏病的家族史与过去病史，近4个月胸骨后压痛渐重，今静息时出现持续严重疼痛4小时，硝酸甘油未能缓解，并伴有恶心、呕吐与大汗。体检发现有静息时心动过速与左心室扩大依据，心尖搏动偏移，可能有二尖瓣返流。可能性最大的诊断是急性心肌梗死。
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Problem list问题总结
1.?????? chest pain-myocardial infarction?胸痛是否由心肌梗死引起？
2.??????? known ischaemic heart disease- myocardial infarction, post-infarct angina已知缺血性心脏病是否引起心肌梗死、梗死后心绞痛？
3.?????? Clinical left ventricular enlargement with secondary mitral regurgitation?
临床上有否左心室扩大伴二尖瓣返流？
4.?????? Previous duodenal ulcer but quiescent for years-no contraindications to thrombolysis?
十二指肠溃疡但静息多年，对溶栓疗法是否有禁忌症？
5.?????? Gout – can be precipitated by diuretics prescribed for cardiac failure
痛风――治疗心衰的速尿可促发痛风
6.?????? HGV driver – should he still be driving?
是否适合继续从事重型货车司机驾驶职业？
大病历书写模板
住院病历 姓名：舒达光性别：女年龄：59岁 职业：农民民族：汉婚姻：已婚 籍贯：上海住址：浦东新区机场镇滨四村2队 入院日期：2015年8月1日11：00：00记录日期：2015年8月1日11：10：00 病史陈述者：曙晓光可靠程度：可靠 主诉：口干多饮多尿20日 现病史：20日前患者无明显诱因下出现口干多饮，饮水量2-2.5L/日，渴喜冷饮，伴多尿，日间8-10次，夜尿3-4次，小溲色黄，无明显纳强消瘦，无乏力，无恶心呕吐腹痛，无视物模糊，无泡沫尿，无肢体麻木疼痛，无夜间静息痛，无间歇性跛行等不适。症情持续无好转，今至我院门诊就诊查得随机指血糖22mmol/L，尿常规：尿葡萄糖++++，尿酮体-，尿白细胞-，尿蛋白质-，今为求进一步诊治，由门诊拟“糖尿病（未分型）”收治入院。 刻下：口干多饮，多尿，纳可，寐安，大便调。 既往史：否认高血压病、冠心病、脑梗塞等其他内科慢性疾病史。否认肝炎、结核等传染病史。否认手术外伤史。预防接种史不详。 系统回顾 呼吸系统：否认咳嗽、咳痰、咯血、呼吸困难、发热、胸痛、盗汗等病史。 循环系统：否认心悸、活动后气促、下肢水肿、心前区痛、血压升高、晕厥等病史。 消化系统：否认食欲减退、反酸、嗳气、恶心、呕吐、腹胀、腹痛、便秘、腹泻、呕血、黑便、便血、黄疸等病史。 泌尿生殖系统：否认腰痛、尿频、尿急、尿痛、排尿困难、血尿、尿量异常、夜尿增多、水肿、阴部瘙痒、阴部溃烂等病史。 造血系统：否认乏力、头晕、眼花、牙龈出血、鼻出血、皮下出血、骨痛等病史。 神经系统：否认头晕、头痛、晕厥、眩晕、记忆力减退、视力障碍、失眠、意识障碍、颤动、抽出、瘫痪、感觉异常。
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: ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________
最全最佳中医病历书写模板
入院记录 职业：农 住址：XX 县XX 镇琵琶沟村 病史叙述者：患者本人及家属 可靠程度：可靠 入院时间：2011-12-28 12 : 10 记录时间：2011-12-28 14:03 发病节气：小寒 主诉：反复头昏6年余，加重伴恶心、呕吐1天。 现病史：患者于入院前6年，无明显诱因出现头昏，为持续性头昏，以中下 午时明显，感疲倦，无晕厥、昏迷等症状。以上症状出现以来患者求治于石阡县 人民医院，测量血压180mmH ，诊断为高血压病，给予开具降压药口服具体药物 患者叙述不详，后患者头昏症状缓解。于入院前 3年患者头昏症状再次出现，并 有所加重。患者求治于石阡县人民医院行头颅 CT 平扫诊断为：“脑梗塞”，并住 院治疗（具体治疗情况不详）。之后患者又求治于安顺市人民医院行头颅 CT 检查 均诊断为：脑梗塞。以上3年来呈反复发作。于入院前1天患者再次出现头昏， 头昏较前有所加重，呈持续性头昏，伴头顶部胀痛。并感恶心、伴呕吐 2次，均 为胃液，未见明显喷射性呕吐。今为求系统治疗故特求治于我院，于门诊测量血 压为：“170/ 100mmHg 以“高血压病3级极高危组”收入我科。 入院症见：头昏，无视物旋转，偶尔有头胀，咳嗽，头昏明显时感恶心、伴 呕吐，四肢肌力 尚可，行走自如。纳眠一般，二便调。 既往史：患脑梗塞3年。否认“肝炎、结核、伤寒”等传染病病史，否认手 术外伤史，无药 物及食物过敏史，预防接种史不详。 个人史：出生于原籍未到外地久居，无近期疫区涉足史，平素生活规律，无 烟酒不良嗜好， 无其他特殊不良嗜好。 婚姻史：适龄非近亲结婚，配偶及子女均体健。 月经史：13岁^3-59_ 49岁（无明显阴道流血）。 家族史：否认家族内类似疾病及遗传病病史。 中医四诊：神清、神可，面色如常，形态自如，气息如常，舌淡红，苔白腻, 脉弦滑 体格检查 T : 36.2 C, P : 64 次/分， R : 21 次/分， Bp : 170/90mmHg 姓名：XXX 性别：女 年龄：72岁 民族：仡佬族 婚 姻：已婚 籍贯： 贵州XX XXX
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） Onset: 4 hours of “crushing tight” retrosternal chest pain, radiating to neck and both arms, gradual onset over 5-10 minutes.（起病特征：胸骨后压榨性疼痛４小时，向颈与双臂放 https://www.360docs.net/doc/6f14789536.html,，5-10分钟内渐起病） 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）
英文病历样本
General information Name Age Sex Race Nationality Address Occupation Marital status Date of admission Date of record Complainer of history Reliability: Reliable Chief complaint The patient has a cough producing thick rusty sputum and a high fever that is accompanied by shaking chills. He has a right chest pain when breathing. History of present illness The patient has had a cold after swimming in the cold water recently. He had a cough with thick rusty sputum. He had shaking chills and felt a chest pain on the right side. He saw a doctor. A week after, he thought he was over it and didn’t pay attention to it, w ent swimming again. Now the condition is more serious. He has a high fever with 39℃that is accompanied by shaking chills. He has a bad cough with no-blood sputum. When he takes a deep breath, it even hurts. Past medical history The patient is health before. No history of infective disease. No allergy history of food and drugs. No operative history. No disease history in other system. Personal history He was born in XXX on XXXX and almost always lives in XXX. His living conditions were good. No bad personal habits and customs. Menstrual history: He is a male patient. Family history: His parents are both alive. Physical examination General: T P R BP W H. The patient is a well-developed, well-nourished adult male. HEENT: PERRL, EMOI, small oral aperture. Neck: JVP to angle of jaw, 2+ carotid pulses, full range of motion. Cardiac: RRR, normal S1,S2, distant heart sounds. Chest wall: No subcutaneous emphysema. No tenderness. Thorax: Symmetric bilaterally. Breast: Symmetric bilaterally. Lungs: Respiratory movement is bilaterally asymmetric with the frequency of 24/min. We can hear coarse breathing when listening to a portion of the chest with a stethoscope. There are moist rales on bilateral inferior lung. Heart: Border of the heart is normal. Heart sounds are strong and no splitting. Rate 150/min. No pathological murmurs. Abdomen: Flat and soft. No abdominal wall varicose. There is no rebound tenderness on abdomen or renal region. Liver and spleen are untouched. Skin: No pigmentation. No pitting edema. No skin eruption. Extremities: No articular swelling. All limbs can free move. Genitourinary system: Not examed. Rectum: Not examed. Neural system: Physiological reflexes are existent without pathological ones. Investigation Chest X-ray: Lamellar shadow can be seen in middle and inferior lobe of right lung. The right lung is seriously infected. The volume of useful lung is reduced because of the collection of fluid around the lung.
病历书写全套模板1
入院记录 姓名 年龄 民族 出生地 病历陈述者性别 婚姻 职业 通讯地址可靠程度 入院时间记录日期 主诉：促使患者就诊的主要症状或体征及持续时间。高度概括，简明扼要，不超过20 个字。个别确实没有症状而是通过体检发现的检查结果可作为主诉。 现病史：本次疾病发生、演变、诊疗等方面的详细情况，按时间顺序书写。内容包括：发病时间、症状、演变及伴随症状的细节；与鉴别诊断有关的阳性及阴性资料；外单位（注明医疗机构，不写“当地”）诊疗经过及结果（治疗情况不写“具体治疗情况不详”） 既往史：（包括一般健康状况、疾病史、传染病史、预防接种史、手术外伤史、过敏（食 物及药物）史、输血史等。） 系统回顾： 呼吸系统：无反复咽痛、咳嗽、咳痰、咯血、呼吸困难、胸痛史。 循环系统：无心悸、胸闷、活动后气促、紫绀、下肢水肿、心前区痛、晕厥史。 消化系统：无腹痛、腹泻、便秘、呕血、黑便、黄疸史。 泌尿系统：无腰痛、尿频、尿急、尿痛、排尿困难、血尿、尿量异常、夜尿增多、 面部水肿史。 造血系统：无乏力、头昏、眼花、牙龈出、鼻衄、血皮下出血、骨痛史。 代谢及内分泌系统：无食欲亢进或食欲减退、多汗、畏寒、多饮、多尿、双手震 颤、性格改变、显著肥胖、明显消瘦、毛发脱落、色素沉着、肝掌及蜘蛛痣。 神经精神系统：无头痛、失眠或意识障碍，晕厥、痉挛、瘫痪、视力障碍、感觉 及运动功能障碍 性格改变、记忆力和智能障碍 肌肉骨骼系统：无关节肿痛、运动障碍、肢体麻木、痉挛、萎缩、瘫痪史。 个人史：出生并生长于原籍。否认疫区旅居史及疫水接触史，从事职业，否 认放射线及特殊毒物接触史。无烟酒等嗜好(若有烟酒史应写明多长时间，每日 用量，是否戒除)。无冶游史。包括出生地及经历地，重点了解疫源地和地方病 流行区；生活及饮食习惯，烟酒嗜好程度；过去及目前职业及其工作情况，有 无粉尘、毒物、放射性物质、传染病患者接触史；月经史16，3-4/30-32，48； 婚姻状况及生育情况；冶游史。与本次疾病有关的问题询问要到位，如肺癌病 人个人史要描述吸烟情况。） 婚姻史：24 岁结婚，爱人身体健康，夫妻关系和睦。育有 2 男 2 女。 月经史：14，（3～4）/（20～21），51。 家族史：父母体健。父已病故（死因不详），母患有“糖尿病”。家族中无类似病 史。否认有家族性疾病及遗传病史。（包括父母、兄弟、姐妹、子女健康状况； 家族成员疾病诊治情况；遗传性疾病史。与本次疾病有关的问题询问要到位， 如直肠、结肠肿瘤病人家族史要反应家庭成员结肠息肉患病情况。） 体格检查 检验及其他检查：暂缺。 入院诊断 2006-12-06，16：30 首次病程记录
英语 病例 模板
CASE Medical Number: 682786 General information Name:Wang Runzhen Age: Forty three Sex: Female Race:Han Occupation: Teacher Nationality:China Marital status: Married Address: NO.38, Hangkong Road, Jiefang Rvenue, Hankou, Hubei. Tel: 82422500 Date of admission:Jan 11st, 2001 Date of record: 11Am, Jan 11st, 2001 Complainer of history: the patient herself Reliability: Reliable Chief complaint: Right breast mass found for more than half a month. Present illness: Half a month ago, the patient suddenly felt pain in her right chest when she put up her hand. After touching it, she found a mass in her right breast, but no tendness, and the patient didn’t pay attention it. Then the pain became more and more serious, so the patient went to tumour hospital and received a pathology centesis. Her diagnosis was breast cancer. Then 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.
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,.
完整病历范文
内科 完整住院病历范文
内科教研室 完整住院病历(一) 姓名：潘××职业：个体户 性别：男住址： 年龄：36岁病史叙述者；病者本人 婚姻：已婚可靠程度：可靠 籍贯：广州入院日期：2007-9-3 民族：汉族记录日期：2007-9-3 主诉：持续发热4天，伴咳嗽、咳痰2天。
现病史：患者4天前起无明显诱因下出现发热，为低热，体温波动于37.2～37.8℃之间，持续无缓解，无伴畏寒、寒战，无明显出汗，无皮疹，无全身酸痛，无关节肿痛。遂到当地卫生所就诊，予以抗生素静滴，症状无好转。前日仍发热，并出现咳嗽、咳痰。咳嗽于夜间出现，阵发性，不剧烈，咳白色粘液样痰，量少，无臭味。后转为黄色粘痰，不易咳出，伴有轻度咽痛。不伴咯血、呼吸困难；无胸闷、胸痛；无恶心、呕吐；无腹胀、腹痛。于昨晚来我院急诊科就诊，查胸片示“右下肺炎”，予以“立健诺”、“达力新”等抗感染治疗，效果不明显。今日咳嗽加重再次来我院就诊，门诊以“右下肺炎”收入我科。自发病精神、体力尚可，睡眠、胃纳欠佳。有尿频、尿急，无尿痛，尿量正常，大便如常。体重无明显变化。 既往史：平素体健，前列腺炎病史数年；否认有肝炎、肺结核等传染病病史，否认有糖尿病、高血压病史，无手术、外伤史，否认食物及药物过敏史。预防接种史按计划进行。 系统回顾： 呼吸系统：详见现病史。 循环系统：无心悸、胸闷、胸痛史，无浮肿、晕厥史。 消化系统：无返酸、嗳气、呕吐、腹痛、腹泻、便秘、黄疸、呕血、便血及黑便史。 泌尿系统：有尿频、尿急、尿痛，无腰痛、无排尿困难、血尿、尿量异常及夜尿增多。否认肾毒性药物应用史，否认铅、汞化学毒物接触或中毒史。 造血系统：无头晕、乏力，无皮肤或粘膜瘀点、紫癜、血肿，无牙龈出血、鼻衄、骨痛史，无化学药品、工业毒物、放射性物质接触史。 内分泌系统及代谢：无畏寒、怕热、多汗，无食欲异常、性格改变、明显消瘦、双手震颤现象，无烦渴、多饮、多尿，无毛发增多或脱落、色素沉着、性功能改变。 神经精神系统：无头痛、失眠或嗜睡、意识丧失、抽搐、瘫痪、视力障碍、感觉及运动异常、性格改变、记忆力和智能减退。 肌肉骨骼系统：无关节肿痛、运动障碍、关节畸形、肢体麻木、痉挛、萎缩。 个人史：原籍出生并长大，无长期外地居留史，无血吸虫病疫区、疫水接触史，无“肝炎”“结核”等传染病人接触史；无吸烟、饮酒嗜好；否认工业毒物、粉尘及放射性物质接触史；否认有性病史及冶游史。
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
(完整版)门诊病历书写要求及内容
病历书写规范 病历是医务人员在医疗活动中形成的各种记录资料的总和，是医院医疗质量和管理水平的综合反应，病历作为医院珍贵的信息资料，为临床教学科研等工作提供依据，并具有法律效力。各级医院必须高度重视病历书，切实加强对病历书写工作的标准化和规范化管理。 一份病历的好坏直接反应医院的整体医疗质量和专业技术，更反应一个医生最基本的专业知识和医疗水平，为此今天我们大家一块共同学习一下病历的书写。 门诊病历书写要求及内容 一、门(急)诊病历内容包括门诊病历首页(门诊手册封面)、病历记录、化验单《检验报告》、医学影像检查资料等。 二、门(急)诊病历首页内容应当包括患者姓名、性别、出生年月、民族、婚姻状况、职业、工作单位、住址，药物过敏史等项目。 三、门(急)诊病历记录分为初诊病历记录和复诊病历记录。初诊病历书写内容应当包括就诊时间、科别、主诉、现病史、既往史、阳性体征、必要的阴性体征和辅助检查结果、诊断及治疗意见和医师签名等。 复诊病历记录书写内容应当包括就诊时间、科别、主诉、病史、必要的体格检查和辅助检查结果、诊断、治疗处理意见和医师签名等。 急诊病历书写就诊时间应当具体到分钟。 四、门(急)诊病历记录应当由接诊医师在患者就诊时及时完成。 五、抢救危重患者时，应当书写抢救记录。对收入急诊观察室
的患者，应当书写留观期间的观察记录。 住院病历书写要求及内容 一、住院病历内容包括住院病案首页、住院志、体温单、医嘱单、化验单(检验报告)、医学影像检查资料、特殊检查(治疗)同意书、手术同意书、麻醉记录单、手术及手术护理记录单、病理资料、护理记录、出院记录(或死亡记录)、病程记录(含抢救记录)、疑难病例讨论记录、会诊意见、上级医师查房记录、死亡病例讨论记录等。 二、住院志是指患者入院后，由经治医师通过问诊、查体、辅助检查获得有关资料，并对这些资料归纳分析书写而成的记录。住院志的书写形式分为入院记录、再次或多次入院记录、24小时内入出院记录、24小时内入院死亡记录。 入院记录、再次或多次入院记录应当于患者人院后24小时内完成；24小时内入出院记录应当于患者出院后24小时内完成，24小时内入院死亡记录应当于患者死亡后24小时内完成。 三、人院记录的要求及内容： (一) 患者一般情况内容包括姓名、性别、年龄、民族、婚姻状况、出生地、职业、入院日期、记录日期、发病节气、病史陈述者。 (二) 主诉是指促使患者就诊的主要症状(或体征)及持续时间。 (三) 现病史是指患者本次疾病的发生、演变、诊疗等方面的详细情况，应当按时间顺序书写．并结合中医问诊要求，记录目前情况、伴随症状。内容包括发病情况、主要症状特点及其发展变化情况、伴随症状、发病后诊疗经过及结果、睡眠和饮食等一般情况的变化、以
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
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:
大病历书写标准模板医生必备
大病历书写标准模板医生必备 如何书写好病历是每个医院医生的职责，要真正写好就必须掌 握书写病历的要点。病历质量好坏体现医生的学术和品德，体现医院 的管理水平和医疗质量。姓名：_____ 性别：年龄：住院号：性别：工作单位：年龄：住址：民族：入院时间：（精确到分，格式： 2016-02-22 10:30）婚姻：______ 病历采写时间：____________ 籍贯：_____ 病史陈述者： ___________ 可靠程度：______ 联系电话：__________ 主诉：20字左右，症状及持续时间。现 病史：本次就诊主要疾病的首次发作情况，包括它的诱因，性质，阵发性或持续性，程度，与进食或体位的关系，是否影响活动，伴随症状等，采用何种措施，是否缓解等。有意义的阴性体征，用药（他人叙述的疾病或药物名称均应加引号），效果。（时间不能用英文缩写来代替，必须用文字表述。） 做过何种检查及结果。患者自发病以来，食欲、大小便、精神、体力、睡眠、体重改变。既往史：平素身体健康状况较好，无冠心病、高血压、糖尿病、肝炎、胆囊炎等病史，（若既往患病则要表述出年限，高血压、糖尿病等应写明极值。）无传染病史，否认结核接触史，无疫区、疫水接触史，无输血史，无外伤或手术史，预防接种史不详，无药物及食物过敏史。系统回顾：呼吸系统：无慢性咳嗽、咯痰、咯血史，无胸闷、呼吸困难，无发热、盗汗，无结核患者密切接触史。循环系统：无心悸、气促、发绀，无心前区疼痛，无高血压史，无晕厥、水肿病史，无动脉硬化，
无风湿热病史。消化系统：无腹痛、腹胀、反酸、暧气，无呕血、便 血，无食欲不振、恶心或呕吐史，大便正常。泌尿生殖系统：无尿频、尿急、尿痛，无腰痛及排尿困难，无眼睑浮肿，无血尿，尿潴留或尿失禁史。无肾毒性药物应用史。造血系统：无苍白乏力、眼花、耳鸣等，皮肤黏膜无瘀点、紫癜，无反复鼻出血或牙龈出血。内分泌系统及代谢：无畏寒、多汗、烦渴，无头痛或视力障碍，无食欲异常、烦渴、多尿等，毛发分布均匀，第二性征无改变，性格及智力无改变。神经精神系统: 无头痛、失眠、嗜睡，无喷射性呕吐、记忆力改变，无意识障碍、瘫痪、昏厥、痉挛，无视力障碍、感觉及运动异常，无性格改变，无狂躁、抑郁及幻觉等。肌肉骨骼系统：无关节肿痛，无运动障碍，无肢体麻木，无痉挛萎缩或瘫痪史。个人史：出生地及居住地，无疫区疫水接触史，无特殊化学品及放射线接触史，吸烟史，饮酒史，冶游史。月经史：行经天数初潮年龄月经周期末次月经时间/绝经年龄月经是否规律，月经量（中），（轻）度痛经，是否影响日常活动。婚姻史：已/未婚，结婚年龄，配偶健康状况（死亡应注明死因）。生育史：育子女几人，子女健康状况。家 族史：家族 中无肝炎传染病、代谢性疾病、血友病、肿瘤等病史，无家 族遗传倾向性疾病。体格检查T: P: R: BP: —般状况: 身高，体重，发育正常，营养良好，步入病室/平车入室，自 主体位，表情自如，语言流利，无慢性病容/面容痛苦，神志清楚，步态正常/蹒跚，体型正常，查体合作。皮肤黏膜：皮肤弹性正常，
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