骨科英文病历

CASE

Medical Number: 682786 General information

Name:Guo **

Age:Thirty four

Sex: Male

Race:Han

Nationality:China

Marital status: Married

Native place:Tianjin

Address: Tianjin Municipality Jinghai county Da feng dui town zhen dafengdui village Occupation: freelance work

Date of admission: Jan 11st, 2001 Date of record: 11Am, Jan 11st, 2001 Complainer of history: the patient herself

Reliability: Reliable

Tel: 82422500

Chief complaint: Trauma result to the arms and legs feeling,activities obstacles about 6 hours

Present illness: six hours ago, the patient had a traffic accident,suddenly felt pain in his neck ,the feeling of his arms and legs lost,he can’t move .At the same time , he have unconscious barriers, no dizziness, no headache, no chest distress ,no dyspnea ,no nausea and vomiting ,no abdominal pain ,no diarrhea . He was sent to the emergency department of the hospital ,MRI of the neck shows C4/5 intervertebral disc broken and extruded ,Cervical spinal cord was compression, and high signal change at the same spinal cord,so he was sent the bone spine because of Cervical spinal cord injury with tetraplegia

Since onset, his appetite is good, both his spiritedness and sleep are normal. His defecation and urination are normal, too.His weight is not significantly change

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.

Review of systems:

Respiratory system: no history of Sore throat, chronic cough, sputum, hemoptysis , wheezing , dyspnea , chest pain

Circulatory system: no history of Palpitation, dyspnea on exertion, hemoptysis , syncope, edema of lower limbs, precordial pain ,hypertention

Alimentary system:no history of anorexia , sour regurgitation , belching ,nausea, vomitting

Genitourinary system:No history of lumbago, frequent micturition, urgent micturition, urodynia , dysuria hematuria nocturia polyuria oliguria facial edema

Hematopoietic system:No history of fatigue, dizziness, blurred vision, gingival bleeding, subcutaneous hemorrhage ,ostealgia ,epistaxis Metabolic and endocrine system:No history of excessive appetite, anorexia, sweats, cold intolerance, polydipsia, tremor hands, change of character, obvious obesity, emaciation, hirsutism hair, losing pigmentation, chang of sexual function, amenorrhea

Musculoskeletal system: No floating arthralgia,no arthraliga ,no swelling of joints, no deformiteies of jionts ,no myalgia ,no atrophy of muscle. Neural system:No history of headache ,dizziness, vertigo, syncope, degeneration of memory, visual disturbance, insomnia, disturbance of consciousness, tremor, spasm, paralysis, paresthesia

Personal history

He was born in Tianjin, and almost always lived inTianjin. His living conditions were good. No bad personal habits and customs,no history of smoking,no history of drinking

Obstetrical history: get married at 24 years old,have two children,they are

healthy

Family history: Deny family genetic history

Physical examination

Vital signs:T 36.5℃, P 68/min, R 16/min, BP 129/90mmHg.

General condition:He is well developed and moderately nourished. Passive position. The skin was not stained yellow. No cyanosis. No pigmentation. No skin eruption. Spider angioma was not seen. No pitting edema. Lymphnodes: Superficial lymph nodes were not enlarged or pressing pain. 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.

Mouth: Oral mucous membrane was smooth, and of no ulcer or erosion. Tongue was in midline. Pharynx was not congestive. Tonsils were not enlarged.

Neck: Symmetric and of no deformities. No masses. Thyroid was not enlarged. Trachea was in midline.

Chest

Chestwall: 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:

Inspection: Respiratory movement was bilaterally symmetric with the frequency of 20/min. Intercostal space was not wide or narrow Palpation: Thoracic expansion and tactile fremitus were symmetric bilaterally. No pleural friction fremitus.

percussion: Resonance was heard. No abnormal breath sound was heard. Lower borders was in the sixth intercostal space on Collarbone midline, the eighth intercostal space on midaxillary line ,the tenth intercostal space on scapular line.Space range of mobility:right 7.9cm,left 7.8cm Dusculation: breath regular, No wheezes. No rales.

Heart:

Inspection: 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.

Palpation : apex impulse was normal .no thrill, no percardial friction rubs Percussion: relative cardiac outline was not enlarge

Right(cm) intercostal space left(cm)

2.6 二 2.9

3.0 三

4.5

3.6 四 5.6

五8.2

The distance between clavicle middle lin and the midline was 9.0cm Ausculation: No pericardial friction sound. Heart sounds were strong and no splitting. Rate 80/min. Cardiac rhythm was regular. No pathological murmurs.No Pericardial friction rubs

Peripheral vessals: normal pistal shot of big arteries,no Duroziez’s sign ,no water hammer pulse, no capillary pulsation, no paradoxical pulse, no pulsus alternans

Abdomen:

Inspection: Flat and symmetry. No bulge or depression .No gastral pattern

and intestinal pattern. No venous distention of abdoman . No purple striae . No surgical scars or hernia

Palpation: soft. There was not tenderness and rebound tenderness on abdomen or renal region. Liver was not reached. Spleen was not enlarged. No masses. Gallbladder can’t be touched,Murphy was negative. percussion: borders of liver dull was existence.Upper borders of liver on right midclavicular line the fifth intercostal space,which was 9.8cm far from the down edge of the liver. Shifting dullness negative. ausculation : Borhorygmus 5/min, which was not increased or decreased. No vascular murmurs.No gurgling or peritoneal fricatives

Genitalia ,rectum and Anus: normal

Specialized examination: Spine was normal and have no lateral anterior posterior protruding deformities. Cervical Spinous process had tenderness pain.No articular swelling or deformity. No movements of all limbs.Physiological reflexes were not existent ,and the same to pathological ones.

Laboratory findings

MRI of the neck showed C4/5 intervertebral disc broken and extruded , Cervical spinal cord was compression, and high signal change at the same spinal cord. (2014-8-2)

Abstract

1.Patient was a freelance work ,male, 34years old.

2.Trauma result to the arms and legs feeling,activities obstacles about 6 hours.

3.No special past history.

4.MRI of the neck showed C4/5 intervertebral disc broken and extruded , Cervical spinal cord was compression, and high signal change at the same spinal cord.

Impression: Cervical spinal cord injury with tetraplegia

Signature:

住院病历英文翻译

最全的医学英语之NO.1 2014-03-05保研助手 最全的医学英语之NO.1 1、抗生素医嘱[Antibiotic order] Prophylaxis 预防性用药 Duration of oder用药时间 Procedure 操作，手术 Empiric theraphy经验性治疗 Suspected site and organism 怀疑感染的部位和致病菌Cultures ordered 做培养 Documented infection 明确感染 Site and organism 部位和致病菌 Explanation required 解释理由 Antibiotic allergies 何种抗生素过敏 No known allergy 无已知的过敏 Drug+dose+Route+frequency药名+剂量+途径+次数

2、医嘱首页[Admission / transfer] Admit / transfer to 收入或转入 Resident 住院医师 Attending 主治医师 Condition 病情 Diagnosis 诊断 Diet 饮食 Acitivity活动 Vital signs 生命体征 I / O 记进出量 Allergies 过敏 3、住院病历[case history] Identification 病人一般情况 Name 姓名 Sex 性别 Age 年龄 Marriage 婚姻 Person to notify and phone No. 联系人及电话Race 民族 I.D.No. 身份证 Admission date 入院日期 Source of history 病史提供者 Reliability of history 可靠程度

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

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。)

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.wendangku.net/doc/6d6346598.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--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 th th 2012 Date of history taking :July 162012 Date of admission: July 16Narrator: 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

医学病历英文缩写

?aa.-of each[各] ?Ab.-antibody[抗体] ?abd.-abdomen[腹部] ?ABG-arterial blood gas[动脉血气] ?abn.-abnormal[异常] ?ABp-arterial blood pressure[动脉压] ?Abs.-absent[无] ?abstr.-abstract[摘要] ?a.c.-before meals[饭前] ?Ach.-actylcholine[乙酰胆碱] ?ACH.-adrenal cortical hormone[肾上腺皮质激素] ?ACT.-active coagulative time[活化凝血时间] ?ACTH.-adrenocorticotripic[促肾上腺皮质激素] ?ad.(add.)-adde[加] ?ad effect.-ad effectum [直到有效] ?ADH.-antidiuretic hormone[抗利尿激素] ?ad lib-at liesure[随意] ?adm.(admin)-adminstration[给药] ?ad us est.-for external use[外用] ?af.-atrial fibrillation[房颤] ?aF.-atrial flutter[房扑] ?A/G ratio.-albumin-globulin ratio[白-球蛋白比] ?AIDS.-acquired immune deficiency syndrome[爱滋病] ?al.-left ear[左耳] ?alb.-albumin[白蛋白] ?AM.-before noon[上午] ?amb.-ambulance[救护车] ?amp.(ampul)-ampoule[安瓿] ?ANA.-anesthesia[麻醉] ?anal.-analgesic[镇痛药] ?ap.-before dinner[饭前] ?appr.(approx.)-approximately [大约] ?AR.-aortic regurgitation[主闭] ?AS.-aortic stenosis[主狭] ?ASA.-aspirin[阿斯匹林] ?ASD.-atrial septal defect[房缺] ?AST.-aspartate transaminase[谷草转氨酶] ?atm.(atmos.)-atomsphere[大气压] ?ATS.-antitetanic serum[抗破伤风血清] ?av.-average[平均] ?Ba.-Barium[钡] ?BBT.-basal body temperature[基础体温] ?BCG.-bacille Calmette- Guerin[卡介苗] ?biblio.-biliography[参考文献]

住院病历中英文对照

1.POMR (Problem-Oriented Medical Records)表格式住院病历 2.Biographical data:一般项目： https://www.wendangku.net/doc/6d6346598.html, Age Sex Marital status Nativity Race 姓名年龄性别婚否籍贯民族 4.Occupation Date of admission Informant History 职业入院日期病史叙述者病史 5.Chief complaint主诉 6.History of present illness现病史 Past history既往史： 7.Previous health status: well ordinary bad Infectious diseases 平素健康状况：良好一般较差传染病史8.Immunizations Allergies: N Y clinical manifestation 预防接种史过敏史无有临床表现 9.allergen: Trauma: Surgery: 过敏原外伤史手术史 10.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) 11.Respiratory system:呼吸系统 12.Sore throat chronic cough sputum hemoptysis wheezing 咽痛慢性咳嗽咳痰咯血哮喘 13.dyspnea chest pain 呼吸困难胸痛 14.cadiovascular system: 循环系统 15.Palpitation dyspnea on exertion hemoptysis syncope 心悸活动后气促咯血晕厥 16.edema of lower limbs precordial pain hypertention3 m4 G: a6 ] h 下肢水肿心前区疼痛高血压 Digestive system: 消化系统 Anorexia sour regurgitation belching nausea vomitting; L. N) o# e w! A$ H* W 食欲减退反酸嗳气恶心呕吐abdominal distention abdominal pain constipation diarrhea 8 G1 d; G# P$ `( ] 腹胀腹痛便秘腹泻8 t) }/ q7 i' v# ]6 V hematemesis melena hematochezia jaundice% c2 h& ^) w% r/ G% s# i9 c- h 呕血黑便便血黄疸 Urinary system: 泌尿系统 Lumbago frequent micturition urgent micturition urodynia 腰痛尿频尿急尿痛7 D) {2 U/ K# ?5 L9 L V9 G dysuria hematuria nocturia polyuria oliguria facial edema 排尿困难血尿夜尿多尿少尿面部水肿Hematopoietic system 造血系统 Fatigue dizziness blurred vision gingival bleedig 乏力头昏牙龈出血" j9 w, N. P5 j m! C subcutaneous hemorrhage ostealgia epistaxis ' z$ {% i; V4 r7 {- S 皮下出血骨痛鼻衄0 b* ?5 ] ~ R* a# b( A" g e* H Metabolic and endocrine system: 代谢及内分泌系统 Excessive appetite anorexia sweats cold intolerance 食欲亢进食欲减退多汗畏寒" f8 X: \! j |4 A r6 z polydipsia tremor hands change of character obvious obesity 0 [: z) L! A& M/ {+ y$ l 多饮双手震颤性格改变显著肥胖* D* N. t& S& i# | p- _& ] - E. ^% k" v5 ]6 A* g emaciation hirsutism hair losing pigmentation 消瘦多毛毛发脱落色素沉着: N d4 x! B5 R chang of sexual function amenorrhea 性功能改变闭经. T' J. A; Y, Z# ]2 f Musculoskeletal system - \+ }/ L6 H8 e8 A9 H; {# G

怎样写英文病历

How to write patient's case history 怎样写英文病历 PA TIENT HISTORY 病史 A detailed patient history and physical exam form the foundation of patient uation and vital patient data that enables efficient, quality patient rounds. 一份详细的病史和体检是评估患者的基础，也可为组织高质量、高效率的查房提供重要的资料。 On the other hand, a poorly documented history and physical may leads to confusion, serious omission of vital data and inefficiency on patient rounds. In this age of modern technology with equipment such as CT, MRI and PET scanners, the history and physical exam seem to be slowly evolving into a relic of a past era! Both attending physicians as well as residents in training seem to rely more heavily on laboratory and imaging modalities than history to establish the diagnosis. “However no part of the patient uation is more essential to diagnosis than the patient history. The importance of skillful data collection is underscored by the widely accepted understanding that the medical history contributes 60% to 80% of the information needed for accura te diagnoses.” Thus to neglect the patient history denies the physician of a “vital” diagnostic tool. 另一方面，写得差的病史和体检可能会引起混淆，导致重要资料的遗漏和查房效率的低下。在这个具有现代化设备如CT、MRI、PET的年代里，病史和体格检查似乎已慢慢地成为一种历史遗物。无论是主治医生或住院医生都似乎越来越依赖于实验室和影像学检查而不是病史来明确诊断。然而对诊断来说，没有一种评估手段比病人的病史更重要。尽管普遍认为病史可提供准确诊断所需的60％一80％的信息，但有效地收集资料的技能仍被低估了。所以若忽略了患者的病史就意味着剥夺了医生的一种最重要的诊断工具。 The basic outline structure for the patient history and physical exam usually includes the following: Identification: patient name, age, gender, race, and occupation Chief Complaint: (in the patient’s words) HPI: (history of present illness) PMHx: (past medical history) Medications: should include current meds as well as medication allergies 病史和体格检查的基本框架内容通常包括以下内容： 身份证明：患者姓名，年龄，性别，种族和职业 主述：(用患者的话表达)

病历中中英文对照

病历中中英文对照 第一章病人身份[Identification] ? [Name] 姓名 ? [Sex] 性别? [Age] 年龄? [Occupation] 职业? [Date of birth] 出生日期? [Marriage （Marital status）] 婚姻? [Race] 民族? [Place of birth (Birth place)] 籍贯? [Identification No.(code of ID card No.)] 身份证号码? [Department of work and TEL. No. (Unit and Business phone No.)] 工作单位及电话? [Home address and phone No.] 家庭住址及电话? [Post code] 邮政编码? [Person to notify (Correspondent) and phone No.] 联系人及电话? [Source (Complainer;offerer;supplier;provider) of history] 病史陈术者?[Reliability of history] 病史可靠程试? [Medical security (Type of payment)] 医疗费用? [Type of admission (Patient condition)] 住院类别（入院时病情）? [Medical record No.] 病历号? [Clinic diagnosis] 门诊诊断 ? [Date of admission (admission date)] 入院日期 [Date of record] 记录日期 1、年龄的表示方法（以36岁为例） ?36 years old (y/o)?Age 36?36 year-old?The age of 36 ?36 years of age 2、性别的表示方法 ? [Male,♂] 男性? [Female,♀] 女性 3、职业的表示方法 ?工人[Worker] ?退休工作[Retired worker]?农民[Farmer (peasant)] ?干部[Leader (cadre)]?行政人员[administrative personnel (staff)]?职员[staff member] ?商人[Trader (Businessman)]?教师[Teacher] ?学生[Student] ?医生[Doctor]?药剂师[Pharmacist]?护士[Nurse] ?军人[Soldier] ?警察[Policeman]?工程师[Engineer] ?技术员[Technician] ?家政人员[Housekeeper]?家庭主妇[Housewife] ?营业员[Assistant] ?服务员[Attendant]?售票员[Conductor] 4、民族的表示方法 ?汉[Han] ?回[Hui] ?蒙[Meng] ?藏[Tibetan]?朝鲜[Korean]?美国人[American] ?日本人[Japanese] ?英国人[Britisher] 5、医疗费用的表示方法 ? [Self pay (Individual medical care)] 自费? [Government insruance (Public medical care)] 公费?[Insurance] 保险 ? [Local insurance] 本地医保? [Non-local in surance] 外地医保? [Labor protestion care] 劳保 6、婚姻状况的表示方法 ? [Married] 已婚? [Single (Unmarried)] 未婚? [Diverced] 离婚? [Widow] 寡妇? [Widower] 鳏夫7、病史可靠程度的表示方法 ? [Reliable] 可靠 ? [Unreliable] 不可靠 ? [Not entirely] 不完全可靠 ? [Unobtainable] 无法获得 8、住址的表示方法 ?[NO.3,Qing Chun Road East,Hangzhou, Zhejiang] 浙江省杭州市庆春东路3号 ?[XinDong Cun, Cheng Guan Town, Zhu Ji municipality, zhejiang province.] 浙江省诸暨市（县）城关镇新东村 9、病史陈述者的表示方法 ? [Patient himself (herself)] 患者本人? [Her husband] 患者的丈夫? [His wife] 患者的妻子? [Patient`s

英文病历书写范例

英文病历书写范例（内科） Medical Records for Admisson Medical Number: 701721 General information 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 Chief complaint: Upper bellyache ten days, haematemesis, hemafecia and unconsciousness for four hours. Present illness: The patient felt upper bellyache about ten days ago. He didn’t pay attention to it and thought he had ate something wrong. At6 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 because of “upper gastrointestine hemorrhage and exsanguine 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. 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 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 and mucocutaneous bleeding. Endocrine system: No acromegaly. No excessive sweats. Kinetic system: No history of confinement of limbs. Neural system: No history of headache or dizziness. 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. Menstrual history: He is a male patient. Obstetrical history: No

骨科英文病历

CASE Medical Number: 682786 General information Name:Guo ** Age:Thirty four Sex: Male Race:Han Nationality:China Marital status: Married Native place:Tianjin Address: Tianjin Municipality Jinghai county Da feng dui town zhen dafengdui village Occupation: freelance work Date of admission: Jan 11st, 2001 Date of record: 11Am, Jan 11st, 2001 Complainer of history: the patient herself Reliability: Reliable Tel: 82422500 Chief complaint: Trauma result to the arms and legs feeling,activities obstacles about 6 hours Present illness: six hours ago, the patient had a traffic accident,suddenly felt pain in his neck ,the feeling of his arms and legs lost,he can’t move .At the same time , he have unconscious barriers, no dizziness, no headache, no chest distress ,no dyspnea ,no nausea and vomiting ,no abdominal pain ,no diarrhea . He was sent to the emergency department of the hospital ,MRI of the neck shows C4/5 intervertebral disc broken and extruded ,Cervical spinal cord was compression, and high signal change at the same spinal cord,so he was sent the bone spine because of Cervical spinal cord injury with tetraplegia Since onset, his appetite is good, both his spiritedness and sleep are normal. His defecation and urination are normal, too.His weight is not significantly change Past history Operative history: Never undergoing any operation. Infectious history: No history of severe infectious disease.

病历常见英文缩写及中文释义对照表

病历常见英文缩写及中文释义对照表 A A 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 V B 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

B Babinski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） C C 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）

临床病症病历英文单词

Case Records 表格式住院病历 Biographical data: 一般项目 Name Age Sex Marital status Native place Race 姓名年龄性别婚否籍贯 民族 Occupation Date of admission Informant 职业入院日期病史叙述者 History 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: allergen: 预防接种史过敏史无有临床表现过敏原 trauma history: surgery history: 外伤史手术史 Review of systems: (Tick if positive, cross out if negative. If positive, 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 dyspnea chest pain 咽痛慢性咳嗽咳痰咯血哮喘呼吸困难胸痛 Cardiovascular system: 循环系统 palpitation dyspnea on exertion hemoptysis syncope edema of lower limbs precordial pain hypertention 心悸活动后气促咯血晕厥下肢水肿心前区痛高血压 Digestive system: 消化系统 anorexia sour regurgitation belching nausea vomit abdominal distention abdominal pain 食欲减退反酸嗳气恶心呕吐腹胀腹痛 constipation diarrhea hematemesis melena hematochezia jaundice 便秘腹泻呕血黑便便血黄疸 Urinary system: 泌尿系统 lumbago frequent micturition urgent micturition urodynia dysuria hematuria nocturia 腰痛尿频尿急尿痛排尿困难血尿夜尿 polyuria oliguria facial edema 多尿少尿面部水肿 Hemopoietic system: 造血系统 fatigue dizziness blurred vision gingival bleeding subcutaneous hemorrhage ostealgia epistaxis 乏力头昏眼花牙龈出血皮下出血骨痛