文档库 最新最全的文档下载
当前位置:文档库 › 外科英文病例模板

外科英文病例模板

外科英文病例模板
外科英文病例模板

CASE

Medical Number: 682786 General information

Name:Ding Zier

Age: Forty seven

Sex: Female

Race:Han

Occupation:farmer Nationality:China

Marital status: Married Address:jianli county,Jingzhou City,Hubei Province

Date of admission:April 17, 2013 Date of record: April 17, 2013 Complainer of history: the patient herself

Reliability: Reliable

Chief complaint: Intermittent low back pain for 10 years Present illness: Ten years ago, the patient suddenly felt pain in the lower back,with hematuria , but no urinary frequency, urgency, dysuria, fever and other symptoms.After the Left kidney stones removal surgery,Patients with low back pain relief.Five years ago, patients felt intermittent low back pain with urinary frequency, urgency again, no dysuria, hematuria, fever and other symptoms, the patient didn’t treat it.2013-02-24 reviewed the ultrasound found that "Left kidney stones" .For the sake of further treatment, then come to our hospital, outpatient revenue to "Left kidney stones" to our department.

Since the onset, the patients private prosecution spiritedness, appetite, sleep somewhat less, slightly more urination, defecation is normal, no significant changes in physical weight. Past history

Operative history:10 years ago,did kidney stones removal surgery.

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 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

She was born in Jianli County and almost always lived in Jianli county. She did not go to school. Her living conditions were in general. No bad personal habits and customs.

Menstrual history: The first time when she was 16. Lasting 5 to 6 days every times and its cycle is about 33 days.

Obstetrical history:Pregnacy 4 times, 4 nature production, no abortion.

Contraceptive history: Not clear.

Family history: Her parents are still alive.

Physical examination

T 36.3℃, P 72/min, R 18/min, BP 116/76mmHg. 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. Respiratory movement was bilaterally symmetric with the frequency of 18/min. No pleural friction fremitus. Resonance was heard during percussion. No abnormal breath sound was heard. No wheezes. No rales. Border of the heart was normal. Heart sounds were strong and no splitting. Rate 72/min. Cardiac

rhythm was not regular. No pathological murmurs. Abdomen was flat and soft. No bulge or depression. No abdominal wall varices. Gastralintestinal type or peristalses were not seen. Tenderness was obvious around the navel and in upper abdominal. There was rebound tenderness on renal region. Liver and spleen was untouched. No masses. Shifting dullness is negative. No vascular murmurs. No edema. Physiological reflexes were existent without any pathological ones.

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:Respiratory movement was bilaterally symmetric with the frequency of 18/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 76/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 were tenderness and rebound tenderness on 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

February 24, 2013 Jianli County People's Hospitalultrasound showed :multiple stones in the left kidney, liver calcification.

Professional Examination

The ureter walking area:normal

Meatal:normal

External vaginal orifice:normal

Clitoris:normal Anus:normal

History summary

1.P atient was a farmer, female, 47 years old.

2.I ntermittent low back pain for 10 years.

3.N o special past history but10 years ago,did kidney stones removal surgery.

4.P hysical examination showed that there were tenderness and rebound tenderness on renal region,no abnormity in lung, heart and abdominal.

5. investigation information: February 24, 2013 Jianli County People's Hospitalultrasound showed :multiple stones in the left kidney, liver calcification.

Impression:Left kidney stones

Signature: Chen Zhiqiang

英文病例报告的写作技巧

Writing Skills of Case Report in English 在医学刊物上发表的病例报告实际上是开始从事医学写作的最好的方法之一。病例报告的撰写,首先要做好题目的选择,肯定要选择与自己专业有关的临床工作,并能提出你认为是很感兴趣的,在概念上、临床上以及理论上存在的棘手问题。通常文字不超过3000字(包括参考文献和附录在内)。绝大多数的病例报告所采用的书写格式,类似于临床研究报告,应该包括:引言、病例叙述、讨论和结论。本文所采用的文章是从2004年英国LANCET杂志中摘录。 1、引言 引言部分要简短明了,应介绍与报告相关的主要临床和概念上的难题,说明病例的重要性,报道的原因,若可能的话,应引证一些最新的综述资料,并能简明地概括出所涉及到的资料内容。在时态上,由于陈述的是客观事实,故运用一般现在时。如: 2、病例叙述 病例叙述的宗旨就是让读者了解病例,明确全部相关结果。病例的叙述通常要

按照时间先后顺序排列,这一部分所涉及到的资料内容包括以下:①病人现有的体症和症状,主诉和病痛。②医学史及相关家史(如糖尿病、心脏病等)。③社会史,诸如吸烟、饮酒和吸食毒品等。④服用过的药物。⑤体检和化验的突出结果。⑥鉴别诊断或考虑诊断。⑦最后诊断。⑧治疗和治疗后结果。通常仅需要提供检查和化验的阳性结果。不过有个别杂志需要提供全面详尽的检验和程序结果。列出化验的正常值范围和不正常的检验结果。在时态的运用上,由于陈述病人过去健康状况和治疗情况,故采用一般过去时。

3、讨论 讨论部分就是要解释病例叙述中不明确的一些情况,并提供对结果的解释。例如,报道肝酶升高,但未发现显著的肝功能异常,给读者讲明为何肝酶升高。在讨论部分的时态运用上,由于提供的是自己现在的推断和观点,故采用一般现在时。如:

普外科完整病例

For personal use only in study and research; not for commercial use 蓝山县中心医院 病历记录 姓名:彭至富第( 1 )页住院号:1102264 入院记录(一) 姓名:彭至富出生地:湖南蓝山 性别:男民族:汉族 年龄:65 岁职业:农民 婚姻:已婚住址:总市 入院时间:2011 年8 月8 日10:30 记录日期:2011 年8 月8 日11:40 病史陈述者:患者及家属入院方式:车送入院主诉:发作性右上腹疼痛12 年,寒战、高热伴皮肤黄染 1 天。 现病史:患者自诉于12 年前无明显诱因开始出现右上腹疼痛,为阵发性的 绞痛,疼痛可呈右肩部放射,伴恶心、呕吐,尤以进食油腻后易发生。曾于当地 医院(具体不详)就诊,经B 超检查为“胆囊结石”,予以相关对症排石处理(具 体诊疗计划和用药情况不详)后,症状好转。近半年来腹痛发作频繁,伴寒战, 发热(自测体温最高可大39.3 °C)及可疑黄疸。一直于家中自服抗生素(具体 药名不详)处理,症状似有所减缓。昨日夜间上腹部疼痛再次发作,同时伴寒战、 高热,晨起发现皮肤巩膜黄染,自觉难忍,遂平车急诊入院。急查,BP82/60mmhg, 血常规:HB156g/L 、WBC29.8X109/L. 直接胆红素25.0 μmol/L, 疑诊为“感染性 休克”收入我科进一步治疗。自起病以来,无意识障碍等不适,食纳精神差,大 小便一般。 既往史:否认心脏、肝肾疾患史,无“结核”、“肝炎”、“伤寒”等传染 病病史,无重大外伤史、手术史及输血史,否认药食过敏史,预防接种史不详。 系统回顾 呼吸系统:无慢性咳嗽,咯血史,无呼吸困难,发绀史,无肺结核接触史。 循环系统:无心悸,胸闷,胸痛史,无浮肿,昏厥史。消化系统:无反酸 嗳气,无慢性腹痛腹泻,余见现病史。 泌尿生殖系统:无尿频,尿急,尿痛史,无腰背酸胀史。造血系统: 无头昏,乏力史,无皮下出血,鼻炄史,无肝、脾、淋巴结肿大史。 内分泌系统及代谢:无烦渴,多饮,多食,多尿史,无食欲异常史。

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: ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________

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/887990945.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)

神经外科完整病例

神经外科完整病例 文稿归稿存档编号:[KKUY-KKIO69-OTM243-OLUI129-G00I-FDQS58-

完整病历 姓名:李少华性别:女 年龄:47岁籍贯:湖南省衡阳县 职业:务农民族:汉族 婚姻:已婚住址:湖南省衡阳县三湖镇永安村乐志组 住院号:499369 科室:神经外科 床号:37床病史陈述者:患者本人 入院时间:2011年 07月19日03时30分 记录时间:2011年 07月19日21时30分 主诉:因硬物击伤头部9小时余入院。 现病史:患者家属诉患者07月18日晚6时左右被硬物击伤头部,当时患者感头痛,无昏迷,无呕吐及抽搐,头皮有裂伤并活动性出血,急送衡阳县人民医院诊治,给予清创缝合、破伤风等对症治疗,术后给予抗炎止血等治疗,行头颅CT示右侧颞顶硬膜外血肿,为求进一步治疗,逐来我院急诊科,以“脑血肿”转入我科。患者起病以来,持续头痛,无呕吐。 既往史:体质一般,高血压病史2年余,在家一直服药(具体不详),慢性支气管炎及胃病史近10年,否认“肝炎”等病史,否认“糖尿病”“心脏病”等病史,无输血史,无药物过敏史,预防接种史不详。 系统查询: 呼吸系统:稍有咳嗽、咳痰,有胸闷、无胸痛、盗汗及咯血。 循环系统:无胸前区疼痛,有头昏、头痛,无晕厥史。 消化系统:有反酸、嗳气,既往有腹痛病史,无腹泻、呕吐、黑便史。 泌尿系统:无苍白、尿频、尿急、尿痛、排尿困难及腰痛史。 血液系统:无头晕、眼花、耳鸣、鼻出血、牙龈出血、黄疸、淋巴结肿大、骨骼疼痛史。

完整病历(二) 代谢及内分泌系统:无多饮、多尿、多汗、怕热史,智力、性格、皮 肤、性欲无明显改变。 神经系统:无意识障碍、记忆力改变、视力障碍、抽搐、瘫痪、精神异 常等病史。 关节及运动系统:无关节疼痛、无局部红肿及运动障碍。 个人史:生于原籍,无外地久居史,否认血吸虫疫水接触史,无烟酒等 不良嗜好,否认重大精神创伤史。 月经史:12岁 3-4天/28-31天 2011年7月12日,既往月经规律,经 量正常,白带正常。 婚育史:适龄结婚,G2P2,均顺产,配偶及子女均体健。 家族史:否认家族遗传病史及特殊传染病史,家族中无特殊病史可询。 体格检查 T 36.8 ℃ P 86次/分 R 19次/分 BP 110/70 mmHg 一般情况:发育正常,营养中等,神志清楚,自动体位,检查合作。 皮肤:温度正常,湿润、弹性正常,无黄染,无出血点、蜘蛛痣及皮疹。 淋巴结:浅表淋巴结无肿大。 头部:头颅五官大小形态正常,可见绷带环行包扎头,敷料干燥,右侧顶结节见约6.0cm皮肤裂伤(已在外院清创缝合),余无压痛及肿 块,头发色黑,有光泽,分布均匀。 眼:眉毛无脱落,无倒睫,眼睑无下垂、水肿及内外翻,巩膜无黄染,角膜透明。瞳孔等大等圆,约2.5mm,对光反射灵敏。调节反射存 在。 耳:外耳道无流脓,听力正常,乳突无压痛。

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.

普外科完整病例

病历记录 第( )页 入 院 记 录(一) 住址:腰陂镇东南村 主诉:发作性右上腹疼痛 12年,寒战、高热伴皮肤黄染 1 天。 现病史:患者自诉于 12 年前无明显诱因开始出现右上腹疼痛,为阵发性的 绞痛,疼痛可呈右肩部放射,伴恶心、呕吐,尤以进食油腻后易发生。曾于当 地医院(具体不详)就诊,经B 超检查为“胆囊结石”,予以相关对症排石处 理(具体诊疗计划和用药情况不详 ) 后,症状好转。近半年来腹痛发作频繁,伴 寒战,发热(自测体温最高可大39.3 ° C )及可疑黄疸。一直于家中自服抗生 素(具体药名不详)处理,症状似有所减缓。昨日夜间上腹部疼痛再次发作, 同时伴寒战、高热,晨起发现皮肤巩膜黄染,自觉难忍,遂平车急诊入院。急 查,BP82/60mmhg 血常规:HB156g/L WBC29.8X109/L 直接胆红素 25.0卩mol/L,疑诊为“感染性休克”收入我科进一步治疗。自起病以来,无意 识障碍等不适,食纳精神差,大小便一般。 既往史:否认心脏、肝肾疾患史,无“结核”、“肝炎”、“伤寒”等传 染病病史,无重大外伤史、手术史及输血史,否认药食过敏史,预防接种史不 详。 系统回顾 呼吸系统:无慢性咳嗽,咯血史,无呼吸困难,发绀史,无肺结核接触史。 循环系统:无心悸,胸闷,胸痛史,无浮肿,昏厥史。 消化系统:无反酸 嗳气,无慢性腹痛腹泻,余见现病史。 泌尿生殖系统:无尿频,尿急,尿痛史,无腰背酸胀史。 造血系统:无头 昏,乏力史,无皮下出血,鼻炄史,无肝、脾、淋巴结肿大史。 内分泌系统及代谢:无烦渴,多饮,多食,多尿史,无食欲异常史。 神经系统:无头痛,昏厥,瘫痪史,无抽搐,痉挛史 姓名:彭富忠 出生地:湖南茶陵 性别:男 民族:汉族 年龄: 55岁 职业:农民 10:30 入院时间: 2011年 3月 8日 记录日期: 2011年 3月 8日 11:40 病史陈述者:患者及家属 入院方式:车送入院 姓名:彭富忠 住院号:1102264 婚姻:已婚

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.

普外大病历2012

普外大病历2010-06-09 19:11 -----------普通外科病历、手术记录及麻醉记录书写要求 (一)普通外科病历书写要求 1.病史详见一般病历内容及书写要求,但在体格检查后部应加“外科情况”一项。如外科情况在腹部,则在腹部检查后面注明“见外科情况”。外科情况的记录,要求详细、准确、实在。如描记创口应记明部位、范围、大小、深浅、色泽、分泌物性状、肉芽组织、上皮及周围皮肤情形;描记肿块应记明部位、大小、形状、硬度、移动度与周围组织的关系;如为肿瘤,注意有无转移及引流淋巴结肿大等;描记腹膜炎时应记明视、触、叩、听、直肠指诊等各种物理检查所见,必要时绘图说明。须行紧急手术者,术前应详细病程记录,术后补写病历。 2.检验血、尿常规检查须在入院后24小时内完成,急症应及时完成,手术前的发热或病程中有特殊变化者,应随进检查。并按需要术前作出血时间、血凝时间及血型鉴定等。如有可疑,应作梅毒、艾滋病血清学检查。粪便于入院后检查1次,需要时间再复查。 脏器功能的测定及特殊检查等按需要进行。 创口分泌物、脓肿及囊肿穿刺液等,需要时送细菌涂片与培养(包括普通培养与厌氧培养)、抗菌药物敏感测定和涂片细胞学检查。

(二)手术记录书系写要求 1.手术记录凡行手术的病例均应书写手术记录。手术记录应由手术者或第一助手书写(应经手术者复核签名),内容包括患者姓名、住院号(或门诊号)、手术日期、手术前及手术后诊断、手术名称、手术者、助手及洗手护士姓名、麻醉方法、麻醉者姓名、手术经过等。对手术经过,应系统、详细地记载,如患者的体位、皮肤消毒、无菌巾(单)铺盖,切口部位,方向、长度、组织分层解剖,病变部位所见及其处理方法(必要时可绘图说明),切口缝合方法、缝线种类,引流物位置、数量,创口包扎方法,术中及毕业时患者情况,以及敷料、器械的清点,术中用药、输液、输血等治疗,麻醉效果等,均应逐项记录。病理标本应描述眼观所见情况,并注明已否送往病理检查。 2.手术后记录包括手术的主要情况、手术后病情的变化及主要处理措施。 (三)麻醉记录书写要求 1.凡施麻醉均须填写麻醉记录单。 2.麻醉记录单须由麻醉者于麻醉前按规定逐条填写,以便核对患者和掌握整个手术麻醉过程的病情变化。

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,.

普外科电子病历模板

住院病历 病史 主诉:发现左侧腹股沟区可复性包块10年余,不能回纳11小时。 现病史:10年前发现右侧腹股沟区有一包块,大小约1cm×1cm×0.5cm于站立时出现,平卧休息时可消失,1 0年来,未积极治疗,包块逐渐增大,大小约3cm×2.5cm×1cm,都可在平卧休息时消失。11小时前 发现右侧腹股沟区包块再次脱出,并不能自行送回,伴有局部胀痛不适,、恶性、呕吐(胃内容物) 1次,量少。今来我院,门诊以“左侧腹股沟疝并嵌顿”收入院,近来无咳嗽、咯痰,饮食、睡眠好, 大小便正常,体重无明显变化。 既往史:平素健康状况良好,有“风湿”病史10余年,最近2年未积极治疗,无肝炎,无结核,无伤寒等传染病史,预防接种史不详,无药物、食物过敏史。无输血史、无外伤、无中毒及无手术史。 个人史:出生在当地,无工作,无地方病地区居住情况,无冶游史,无烟酒嗜好。 婚育史:已婚,育二女,配偶已故。 妊娠2 次顺产2胎流产0胎早产0胎死产0胎。难产及病情: 月经史:初潮12岁,1~4/28天,绝经年龄50岁,经量一般,无痛经,经期规则。 家族史:父母已故(死因不祥),否认类似家族遗传病史。 体格检查 生命征:体温 36.8 ℃脉搏86 次/分呼吸 20 次/分血压140/101 mmHg 一般状况:发育正常,营养良好,正常面容,自如表情,自主体位,正常步态,神志清楚,语态清晰,检查合作。皮肤粘膜:色泽正常,未见皮疹,未见出血点,未见脱屑,未见紫癜。毛发分布正常,皮肤温、湿度正常,弹性正常,未见水肿,未见肝掌,未见蜘蛛痣。 淋巴结:全身浅表淋巴结未触及肿大。 头部:头颅大小正常,无畸形,未及压痛,未及包块,未及凹陷。眼睑正常,结膜未见水肿,巩膜无黄染,眼球未见异常,角膜未见异常,瞳孔等大等圆,对光反射灵敏。耳廓正常,无耳前瘘管,无外耳道分

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

外科完整病历范文完整

普外科大病历 姓名:恰马博住址:福贡县上帕镇木古甲村 性别:女工作单位:无 年龄:43岁入院日期:2013年10月21日11:20 婚否:已婚病史采集日期:2013年10月21日11:10 籍贯:怒江州福贡县病史记录日期:2013年10月21日14:50 民族:傈僳族病情叙述者:患者本人 主诉:左侧乳房无痛性肿块5月。 现病史:患者于今年1月初在洗澡时无意中发现左侧乳房有一“蚕豆”大小之肿块,当时无任何不适感,并未引起重视,至今年5月初,自觉肿块较前明显增大,约有“核桃”大小。曾在外院诊断为“左乳房包块性质待查”用中西医结合治疗效果不佳,肿块继续增大,遂来我院门诊就医,B超提示:“左乳房均质性肿块,有恶变可能”。为进一步诊治收住我科。自发病以来,患者无高热、午后低热,无胸痛及咳嗽,无乳头溢液及血性分泌物,无腹痛,腹泻及便秘,无明显消瘦,食欲及睡眠尚好,大、小便正常。体重无明显变化。既往史:平素体健;否认肝炎、血吸虫病、肺结核及其他传染病史;按时接种疫苗;无重要皮肤病史;无外伤及手术史;否认中毒及药物过敏史。 个人史生:于原籍,未去过外地,否认血吸虫疫水接触史。

无烟、酒嗜好。无食生鱼、生肉史。否认放射性物质接触史。否认肝炎、结核、麻风等传染病接触史。 月经史:13岁初潮,经期5到7天,周期28到30天,量中等无血块,无痛经,40岁绝经。家族史:父因胃癌于1968年病故。母因“脑溢血于1976年逝世。有二弟二妹,均健在。女儿健在。否认家庭遗传病史。家庭中无类似疾病患者。 系统回顾 五官器:头部无疮疖及伤史。双眼视力尚可,无耳痛,外耳道流脓史。无慢性鼻塞及流脓性分泌物史。近年来常有右牙痛,无咽痛史。 呼吸系:无气喘,呼吸困难,长期咳嗽,咯痰及咯血史。无午后低热、胸痛史。 循环系:无心悸、气急、发绀、夜间阵发性呼吸困难史。无心前区疼痛,高血压史。 消化系:无腹痛、腹胀、胀泻史、无喛气、反酸、呕吐史。无呕血、黑便及长期便秘史。血液系:无皮肤、粘膜出血、瘀点、瘀斑史。无贫血史。 泌尿生殖系:无尿频、尿急、血尿及排尿异常史。无颜面浮肿、腰酸、腰痛史。无阴道流血、痛经、白带过多、外阴瘙痒史。 神经精神系:无头痛、眩晕、昏厥、抽搐、意识障碍、精神错乱史。 运动系:无游走性关节痛及运动障碍史。无关节脱位及骨折史。 体格检查

普外科病历范文.

普外科 [病例摘要] XXX,女性,50岁。 主诉:进油腻食物后右上腹疼痛两天,加重12小时。 现病史:两天前因进油腻食物后出现右上腹疼痛,为持续性钝痛,伴有恶心。自服抗生素后无明显好转,12小时前右上腹疼痛逐渐加重,呈绞痛并向右肩及背部放散,同时出现寒战、发热,体温38。5,故急诊来院。病后无咳嗽、咯痰,大小便如常。 既往史:既往经常有“心口痛”病史,未经诊治。 个人史:无烟酒嗜好。 家族史:家庭其他成员无特殊疾病记载。 体格检查:体温38。5,脉搏98次/分,血压120/75MMHG,呼吸20次/分急性痛苦病容,发育正常,营养中等,皮肤巩膜无黄染。锁骨上淋巴结无肿大。气管居中,胸廓无畸形,双肺叩诊无异常,听诊无干湿啰音。心率98次/分,心界不大,节律齐,各瓣膜听诊区无杂音。腹部见外科情况。脊柱四肢无畸形。双膝腱反射存在,克尼格氏征阴性,巴彬斯基氏征阴性。外科情况:腹平坦,腹式呼吸存在,右上腹部压痛,可触及境界下清的包块,墨菲氏征阳性。肝脾触及,肝区轻度叩痛,肝上界位于右锁骨中线第5肋间,移动性浊音阴性,无振水音。肠鸣音无异常。肛门指诊未见异常。 辅助检查: 血常规:WBC18。0X10`9/L。腹部B超检查:肝脏正常大小,肝内外胆管无扩张。胆总管直径0。9CM。胆囊明显增大,13CMX7。5CM2,胆囊壁增厚,胆囊颈部可见1。5CM的强回声光团伴后方声影。 腹部X线检查:未见膈下游离气体,无液气面。

初步诊断:急性胆囊炎 [诊断依据] 右上腹突发剧烈疼痛,阵发性加剧,伴有右肩背部放散痛。寒战、发热,体温38。5。 右上腹触到肿大胆囊,墨菲氏征阳性。 B超显示胆囊明显增大13X7。5CM2,胆囊壁增厚,胆囊颈部可见1。5CM强回声光团,其后可见声影。 [鉴别诊断] 1.胃、十二指肠溃疡穿孔其特点为有多年上腹疼痛病史,发病有季节性。一般穿孔前 有上腹痛加重病史,并突然呈刀割样疼痛。 体检全腹压痛、反跳痛及肌紧张,腹膜刺激征较重,X透视下可见膈下游离气体,腹穿可抽出混浊性液体。 2.急性胰腺炎多有胆道疾病史或暴饮暴食病史,上腹疼痛剧烈并向腰背部放散。腹部 体检可有上腹压痛、肌紧张。B超检查可有胰腺形态的变化。血、尿淀粉酶升高,腹穿液淀粉酶测定也有助于诊断。 [进一步检查] 1.血、尿淀粉酶。 2.CT。 [治疗原则]

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

相关文档
相关文档 最新文档