英文病例范本
Note for Jane Doe on 4/8/03 - Chart 2646
Chief Complaint (1/1): This 19 year old female presents today complaining of acne from continually washing area, frequent phone use so the receiver rubs on face and oral contraceptive use.
Location: She indicates the problem location is the chin, right temple and left temple locally. Severity: Severity of condition is worsening.
Menses: Onset : 13 years old. Interval: 22-27 days. Duration: 4-6 days. Flow: light. Complications: none.
Allergies: Patient admits allergies to penicillin resulting in difficulty breathing.
Medication History: Patient is currently taking Alesse-28, 20 mcg-0.10 mg tablet usage started on 08/07/2001
medication was prescribed by Obstetrician-Gynecologist A.
Past Medical History: Female Reproductive Hx: (+) birth control pill use, Childhood Illnesses: (+) chickenpox, (+) measles.
Past Surgical History: No previous surgeries.
Family History: Patient admits a family history of anxiety, stress disorder associated with mother. Social History: Patient admits caffeine use She consumes 3-5 servings per day, Patient admits alcohol use Drinking is described as social, Patient admits good diet habits, Patient admits exercising regularly, Patient denies STD history.
Review of Systems: Integumentary: (+) periodic reddening of face, (+) acne problems, Allergic / Immunologic: (-) allergic or immunologic symptoms, Constitutional Symptoms: (-) constitutional symptoms such as fever, headache, nausea, dizziness.
Physical Exam:
Patient is a 19 year old female who appears pleasant, in no apparent distress, her given age, well developed, well nourished and with good attention to hygiene and body habitus.
Skin: Examination of scalp shows no abnormalities. Hair growth and distribution is normal. Inspection of skin outside of affected area reveals no abnormalities. Palpation of skin shows no abnormalities.
Inspection of eccrine and apocrine glands shows no evidence of hyperidrosis, chromidrosis or bromhidrosis. Face shows keratotic papule.
Impression: Acne vulgaris.
Plan: Recommended treatment is antibiotic therapy.
Jane received extensive counseling about acne. She understands acne treatment is usually long-term. Return to clinic in 4 week(s).
Patient Instructions:
Patient received literature regarding acne vulgaris.
Discussed with the patient the prescription for Tetracycline and handed out information re garding the side effects and the proper method of ingestion.
Prescriptions:
Tetracycline Dosage: 250 mg capsule Sig: BID Dispense: 60 Refills: 0 Allow Generic: Yes
_______________________ A. Dermatologist, MD
Sample Prescription
Charting Plus? - Electronic Medical Records https://www.360docs.net/doc/a42895024.html,
Dr. Dermatology, MD
DEA#:
_____________________________________________________________
Name: Jane Doe Date: 4/8/03
Addr: 1231 8th Street, Suite 222
West Des Moines , IA 50265
_____________________________________________________________
Tetracycline
250 mg capsule
BID
X_____________________________________ X_____________________________________ Substitution Permitted Dispense as written
Refills: 0
Disp: 60
Allow Generic: Yes
Sample Referral Letter
Charting Plus? - Electronic Medical Records https://www.360docs.net/doc/a42895024.html,
4/8/03
A. General Practitioner, MD
1231 8th Street, Suite 222
West Des Moines, IA 50265
Dear Dr. General Practitioner:
Jane Doe was seen in my office for follow -up after your initial referral. Thank you again for allowing me to participate in the care of your patients. In an attempt to provide your patients with quality patient care through improved communication, the following represents my notes from their last office visit:https://www.360docs.net/doc/a42895024.html,
Impression: Acne vulgaris.
Plan: Recommended treatment is antibiotic therapy.
Jane received extensive counseling about acne. She understands acne treatment is usually long-term. Return to clinic in 4 week(s).
Patient Instructions:
Patient received literature regarding acne vulgaris.
Discussed with the patient the prescription for Tetracycline and handed out information regarding the side effects and the proper method of ingestion.
Prescriptions:
Tetracycline Dosage: 250 mg capsule Sig: BID Dispense: 60 Refills: 0 Allow Generic: Yes If I may be of any further assistance in the care of your patient, please let me know. Sincerely,
A. Dermatologist, MD
Sample Patient Instructions for Acne Chartin g Plus? - Electronic Medical Records https://www.360docs.net/doc/a42895024.html,
Patient Instructions for Jane Doe on 04/11/2002
ACNE VULGARIS
What is it?
Acne vulgaris, commonly referred to as just acne, is a chronic inflammation of the skin that occurs most often during adolescence but can occur off and on throughout life. The skin eruptions most often appear on the face, chest, back and upper arms and are more common in males than females.
Signs and symptoms:
* Blackheads the size of a pinhead.
* Whiteheads similar to blackheads.
* Pustules - lesions filled with pus.
* Redness and inflamed skin.
* Cysts - large, firm swollen lesions in severe acne.
* Abscess - infected lesion that is swollen, tender, inflamed, filled with pus, also seen in severe acne.
Causes:
Oil glands in the skin become plugged for reasons unknown but during adolescence, sex -hormone changes play some role. When oil backs up in the plugged gland, a bacteria normally present on skin causes an infection. Acne is NOT caused by foods, uncleanliness or masturbation. Cleaning the skin can decrease its severity but sexual activity has no effect on it. A family history of acne can indicate if an individual will get acne and how severe it might be. Currently, acne can′t be prevented.
Acne can be brought on or made worse by:
* Hot or cold temperatures.
* Emotional stress.
* Oily skin.
* Endocrine (hormone) disorder.
* Drugs such as cortisones, male hormones, or oral contraceptives.
* Some cosmetics.
* Food sensitivities. Again, foods do not cause acne but some certain ones may make it worse. To discover any food sensitivities, eliminate suspicious foods from your diet and then start eating them again one at a time. If acne worsens 2-3 days after consumption, then avoid this food. Acne usually improves in summer so some foods may be tolerated in summer that can′t be eaten in winter.
Treatment:
* Most cases of acne respond well to treatment and will likely disappear once adolescence is over. Even with adequate treatment, acne will tend to flare up from time to time and sometimes permanent facial scars or pitting of the skin may occur.
* If your skin is oily, gently clean face with a fresh, clean wash cloth using unscented soap for 3-5 minutes; an antibacterial soap may work better. A pre viously used wet washcloth will harbor bacteria. Don′t aggressively scrub tender lesions as this may spread infection; be gentle. Rinse the soap off for a good 1-2 minutes. Dry face carefully with a clean towel and use an astringent such as rubbing alcohol that will remove the skin oil.
Other tips that may help acne:
* Shampoo hair at least twice a week. Keep hair off of face even while sleeping as hair can spread oil and bacteria. If you have dandruff, use a dandruff shampoo. Avoid cream hair rinses.
* Wash sweat and skin oil off as soon as possible after sweating and exercising.
* Use thinner, water-based cosmetics instead of the heavier oil-based ones.
* Avoid skin moisturizers unless recommended by your doctor.
* Do not squeeze, pick, rub or scratch your skin or the acne lesions. This may damage the skin
causing scarring and delay healing of acne. Only a doctor should remove blackheads.
* Keep from resting face on hands while reading, studying or watching TV.
* Try to avoid pressing the phone receiver on you chin while talking on the phone.
* Ultraviolet light may be a treatment recommended by your doctor but this is by no means a license to sunbathe! Don′t use the sun to treat acne.
* Dermabrasion may be another option to treat acne scars. This is a type of cosmetic surgery to help remove unsightly scars.
Medications that may be prescribed to help acne include:
* Oral or topical antibiotics.
* Cortisone injections into acne lesions.
* Oral contraceptives.
* Tretinoin, which may increase sun sensitivity and excessive dryness, is not recommended during pregnancy.
* Accutane (isotretinoin) is a powerful drug to treat acne but causes birth defects. A woman taking this drug must be on two types of birth control and have negative pregnancy tests. This drug also increases sun sensitivity. Other more serious side effects can occur and your doctor will discuss those with you if Accutane is to be prescribed.
TETRACYCLINE
Your doctor has prescribed Tetracycline for your condition. Tetracycline is a very safe antibiotic. It is not related to penicillin and an allergy to it is unusual. There are several potential side effects:
1. Tetracycline can cause nausea or heartburn.
2. Tetracycline can cause vaginitis.
3. Tetracycline can cause excessive sun burn.
CAUTIONS:
1. Do not take Tetracycline with milk or milk products (ice cream, cheese, yogurt, etc.). This will cancel out the Tetracycline. Separate the Tetracycline from these products by one and one -half hours before and after each capsule. Do have a small amount of non milk-containing food in your stomach first to prevent nausea.
2. Do not take Tetracycline if you are pregnant.
3. Do not take Tetracycline if you are taking birth control pills unless specifically instructed to do so.
4. If at the beach or skiing in the sun, use an effective sunblock (SPF-15 or greater) to prevent burning.
If problems or questions arise, call the office for assistance. Side effects can occur and your doctor will discuss those with you if Accutane is to be prescribed.
_______________________________A. Dermatologist, MD
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: ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________
住院病历中英文对照
随着中外交流的加强，专业英语对医院也是越来越重要！花了点时间整理了下“住院病历的英汉对照”的格式，发上来和大家分享，希望对能用到的人有所帮助！ 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 姓名年龄性别婚否籍贯民族 Occupation Date of admission Informant History 职业入院日期病史叙述者病史 Chief complaint 主诉 History of present illness 现病史 Past history 既往史： Previous health status: well ordinary bad Infectious diseases 平素健康状况：良好一般较差传染病史 Immunizations Allergies: N Y clinical manifestation 预防接种史过敏史无有临床表现 allergen: Trauma: Surgery: 过敏原外伤史手术史 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
全英文病例报告表模板
CASE REPORT FORM TEMPLATE Version: 6.0 (8 November 2012) PROTOCOL: [INSERT PROTOCOL NUMBER] [INSERT PROTOCOL TITLE] Participant Study Number: Study group:
BASELINE DATA General Instructions for Completion of the Case Report Forms (CRF) Completion of CRFs ? A CRF must be completed for each study participant who is successfully enrolled (received at least one dose of study drug) ?For reasons of confidentiality, the name and initials of the study participant should not appear on the CRF. General ?Please print all entries in BLOCK CAPITAL LETTERS using a black ballpoint pen. ?All text and explanatory comments should be brief. ?Answer every question explicitly; do not use ditto marks. ?Do not leave any question unanswered. If the answer t o a question is unknown, write “NK” (Not Known). If a requested test has not been done, write “ND” (Not Done). If a question is not applicable, write “NA” (Not Applicable). ?Where a choice is requested, cross (X) the appropriate response. Dates and Times ?All date entries must appear in the format DD-MMM-YYYY e.g. 05-May-2009. The month abbreviations are as follows: January = Jan May = May September = Sep February = Feb June = Jun October = Oct March = Mar July = Jul November = Nov April = Apr August = Aug December = Dec In the absence of a precise date for an event or therapy that precedes the participant’s inclusion into the study, a partial date may be recorded by recording “NK” in the fields that are unknown e.g. where the day and month are not clear, the following may be entered into the CRF: N K N K 2 0 0 9 DD MMM YYYY ?All time entries must appear in 24-hour format e.g. 13:00. Entries representing midnight should be recorded as 00:00 with the date of the new day that is starting at that time. Correction of Errors ?Do not overwrite erroneous entries, or use correction fluid or erasers. ?Draw a straight line through the entire erroneous entry without obliterating it. ?Clearly enter the correct value next to the original (erroneous) entry. ?Date and initial the correction. Protocol Number: Page 1 of 15
英语病历
1 病历case histroy 一般事项date of admission /marital status /present address /correspondence / occupatio n 主诉chief complaints 现病史present illness / history of present illness 既往史past medical history 家族史family history 个人病史personal history / social history 曾用药物medications 过敏史allergies 系统回顾system review / review of system 体检physical examination 一般资料physical data 生理指标physical signs 一般状况或全身状况general appearance 头眼与耳鼻喉head ,eyes,ear,nose,throat ,略作heent. 胸部与心肺CHEST,heart,and lungs 腹部abodoms 四肢extremities 神经系统nervous system,Neurological,略作CNC或Neuro, 骨骼肌系统Musculoskeletal 泌尿生殖系统Genitourinary 化验室资料laboratory data/ studies /diagnosis 血液检查blood test 化学7项指标chem.-7 心脑电图electrocardiogram / electroencephalogram , 略作EKG/EEG X线检查与x光片X-ray examination, x-ray slides, 计算机X线断层扫描与核磁共振扫描资料computerized x-ray tomography and nuclear mag netic resonance spectroscopy dta. CT AND NMR 其他检查资料other lab data 印象与诊断impression and diagnosis 住院治疗情况hospital course 出院医嘱discharge instructions / recommendations 出院后用药discharge medications 2 看病时用英文 1) 一般病情: He feels headache, nausea and vomiting. (他覺得頭痛、噁心和想吐。) He is under the weather. (他不舒服，生病了。) He began to feel unusually tired. (他感到反常的疲倦。) He feels light-headed. (他覺得頭暈。) She has been shut-in for a few days. (她生病在家幾天了。) Her head is pounding. (她頭痛。) His symptoms include loss of appetite, weight loss, excessive fatigue, fever and chills. (他的症狀包括沒有食慾、體重減輕、非常疲倦、發燒和發冷。) He feels exhausted or fatigued most of the time. (他大部份時間都覺得非常疲倦。)
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 Side Age: Eighty Sex: Male Race:Han Nationality:China Address: NO.35, Dandong Road, Jiefang Rvenue, Hankou, Hubei. Tel: 857307523 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 2. 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 history The 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 severe infectious disease. Allergic history: He was not allergic to penicillin or
英文病历
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 姓名年龄性别婚否籍贯民族 Occupation Date of admission Informant History 职业入院日期病史叙述者病史 Chief complaint 主诉 History of present illness 现病史 Past history 既往史： Previous health status: well ordinary bad Infectious diseases 平素健康状况：良好一般较差传染病史 Immunizations Allergies: N Y clinical manifestation 预防接种史过敏史无有临床表现 allergen: Trauma: Surgery: 过敏原外伤史手术史 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 食欲减退反酸嗳气恶心呕吐 abdominal distention abdominal pain constipation diarrhea 腹胀腹痛便秘腹泻 hematemesis melena hematochezia jaundice 呕血黑便便血黄疸 Urinary system:
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/a42895024.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.
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.
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,.
英文--肝硬化完整大病历
Complete Medical History General information Name: Du Donghe Sex: male Profession : retired worker Age:53 years Native place: Tian Jin Address:shenghe Department pujijian Road hebei district tianjin Marital state: married Nationality: Han Date of admission: July 16th 2012 Date of history taking :July 16th 2012 Narrator: the patient's daughter Reliability of the history: reliable The History Chief 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 or diarrhea . So the patient
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
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: