英文病例报告的写作技巧

病历英语作文最简单三个步骤Writing a Medical Case Report in English: Three Simple Steps撰写病历英语作文的三个简单步骤Step 1: Collect and Organize Your InformationFirstly, gather all the necessary data related to the patient"s medical history, including the chief complaint, history of present illness, past medical history, family history, and any relevant examination anize this information in a logical sequence to ensure a coherent narrative.第一步：收集和组织信息首先，收集与患者病史相关的所有必要数据，包括主诉、现病史、既往史、家族史以及任何相关的体检发现。

将这些信息按逻辑顺序组织起来，确保叙述连贯。

Step 2: Use Clear and Concise LanguageWhen drafting the medical case report, it is crucial to employ clear and concise language.Avoid using complex medical jargon that might confuse the reader.Instead, aim for simplicity while maintaining accuracy.Remember to use appropriate medical terms and describe symptoms and findings in a precise manner.第二步：使用清晰简洁的语言在撰写病历报告时，使用清晰简洁的语言至关重要。

case report写作顺序
Case Report写作顺序
Case Report是医学文献中常见的一种写作形式，其主要目的是通过报告真实世界中的病例，展示某种疾病的临床特征、诊断、治疗方法和结局。

Case Report的写作顺序一般包括以下几个步骤：
1. 引言：简要介绍该病例的基本信息，包括患者年龄、性别、症状、体征、临床诊断等。

2. 病例描述：详细描述该病例的临床表现，包括症状、体征、检查结果等。

3. 诊断方法：阐述该病例的诊断方法和依据。

4. 治疗方法：描述该病例的治疗方法和过程，包括药物治疗、手术治疗、放射治疗等。

5. 治疗结果：描述该病例的治疗结果，包括治愈、好转、无效等。

6. 结论：总结该病例的特点和教训，提出建议和展望。

在撰写Case Report时，需要注意以下几点：
1. 病例描述要详细，尽量客观、准确、完整。

2. 诊断方法和治疗方法的描述要具体，要有依据。

3. 结论要简明扼要，要有针对性。

4. 语言要简洁明了，尽量避免使用过于复杂的句子和词汇。

医学专业CaseReport格式与写作技巧对于医学专业的留学⽣来说，可能还没有资源、没有数据、不会统计、英语很差，那么如何完成⼀篇专业的学术论⽂甚⾄发表呢？Case report（病例报道）就是⼀个很好的选择。

作为⼀名学⽣，你可能没有时间做⼤样本的回顾，没有课题⽀持，没有经费可⽤，没有⼈⼿帮忙。

但只要选择⼀个特殊的、有研究价值的病例进⾏深⼊研究，这篇Case就能完成。

⽽病例，在中国并不算是严格保密的材料，只要费点⼼思就能得到。

下⾯我们来谈谈Case Report格式，以及如何写作。

⼀个完整的Case Report包括以下⼏个部分：1. Abstract2. Introduction3. Case presentation4. Discussion5.References让我们以⼀个例⼦来说明。

这是⼀例关于肺腺癌患者中EGFR基因和EML-ALK基因共同突变的Case。

EGFR基因和EML-ALK基因是互斥的，极少共同突变，这个病例的特殊性，成为它可以发表的亮点。

1、abstract六句话：第⼀句：关于肺癌；第⼆句：关于EGFR；第三句：EGFR基因与肺癌；第四句：关于EML4-ALK；第五句：EML4-ALK与肺癌；第六句：EGFR与EML4-ALK关系2、introduction写两个部分：第⼀部分：逻辑上与摘要相同，只是展开⼀些讲，每⼀点⽤2-3句话，重点部分⽤4-6句话（本例就是：EGFR与EML4-ALK互斥，很少同时在同⼀患者肿瘤组织中发现。

同时陈述⽀持这⼀观点的⼏个重要⽂献和数据）。

第⼆部分：套话。

我们在这⾥报道EGFR与EML4-ALK同时positive的⼀例肺腺癌患者。

3、case presentation这部分是⽂章的主体，最关键。

但却是全⽂最好写的部分。

为什么？因为你只需要陈述这个病例的全部情况就可以，⼥，45岁，因为XX⼊院，实验室检查发现……，⼿术发现……，病理提⽰……，免疫组化提⽰……⽽且，很多话是可以“拿来”的，好⽐⼀个填空⼀样，只是个别数值需要修改下就好。

英文病例写作范文阅读带翻译病例写作是医生日常的工作，英文的病例该如何写呢，接下来店铺为大家整理英文病例写作范文，希望对你有帮助哦!英文病例写作范文篇一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，向颈与双臂放射，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)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。

医学英语模拟写作技巧医学英语模拟写作技巧医学英语写作是医学专业学习的重要环节之一。

医学英语的写作要求准确、简洁、明确，字句要恰当、得体。

下面将介绍几种医学英语模拟写作技巧，帮助医学专业学习者提高医学英语写作的能力。

1. 学会分析文献结构。

阅读和分析各种医学文献是医学英语写作的重要一步。

了解文献的结构能帮助你更好地理解文献内容，并提供一个模板，以便写作时参考。

一般来说，医学文献包括摘要、引言、方法、结果和讨论等部分。

针对不同部分的写作要求，你可以更好地组织你的思路和表达。

2. 精简语句，让写作更简明。

在医学英语写作中，简洁明了是非常重要的。

因为医学英语写作需要传达准确的信息，不需要花哨的修辞和冗长的句子。

因此，学习合理运用简单句和并列句，要避免使用复杂句和被动语态。

另外，采用适当的缩写、术语和常见医学缩写，也可以使你的写作更简明。

3. 注重准确性，避免歧义。

医学英语写作要求准确性，因为医学信息是非常敏感的，任何错误或歧义可能导致严重的后果。

因此，你应该确保用词准确，特别是关键的医学术语和词汇。

另外，注意文法错误和标点符号的使用，以避免产生误解或误导。

4. 使用科学推理，提高写作论证能力。

医学英语写作需要有科学理由和充分的论证。

你应该使用科学推理的方法来支持你的观点。

在讨论部分，你可以结合实验证据和已发表的研究，提供相关的数据和引用。

此外，合理运用科学词汇和专业概念，也可以增强你的写作论证能力。

5. 实践写作，持续提高。

医学英语写作需要不断的实践和持续的提高。

你可以通过模拟写作来锻炼自己的医学英语写作能力。

例如，可以模拟写作摘要、病历报告、研究论文等，不断地总结经验和改进。

此外，你还可以参加医学英语写作培训班或课程，通过与他人交流和学习，提高自己的写作技巧。

总之，医学英语写作是医学专业学习的重要一环。

通过学习和实践，你可以掌握一定的医学英语写作技巧。

准备好字典和参考资料，学会分析文献结构，精简语句，注重准确性，使用科学推理，并不断实践和提高，你将可以写出高质量的医学英语作品。

Case History 病史In-Patient Case History 住院病历Items of Case History1. General Data, Biographical Data 一般项目2. Chief Complaints (C. C.) 主诉3. Present Illness (P. I.) 现病史4. Past (Medical) History (P. H.) 既往病史5. Personal History (Per. H.)/ Social History 个人史/社会史6. Family History (F. H.) 家族史7. Medications 曾用药物8. Allergies 过敏史9. System Review, Review of Systems 系统回顾10. Physical Examination (P. E.) 体格检查/查体11. Laboratory Data 实验室与其他检查/检查资料12. Impression (Imp.) (Diagnosis) 诊断13. Hospital Course 住院治疗情况记录14. Discharge Instructions/ Recommendations出院医嘱15. Discharge Medications 出院后用药General Data, Biographical Data 一般项目Reliability (病历可靠性):Reliable(可靠)/ Not Entirely(不完全可靠)/Not Clearly Defined (不够准确)/Confused and Uncertain (混乱不清)/ Unobtainable (无法获得)Supplier/ Complainer of History (供史者/病史陈述者):Patient/ Husband/ Wife/ Father/ Mother/ Colleague/ NeighborChief Complaints (C. C.) 主诉: 病例重要部分之一，通常包括患者年龄、简要的相关的既往史、患者的就诊原因及目前症状持续的时间等。

如何撰写和发表病例报告病例报告（case report）是对一例或数例病案诊断处理的描述和分析，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、病例报告可以为未来的患者诊治提供一丝线索，能从临床上帮到医生很多。

作为一种记录临床观察的方法之一，病例报告能及时提供有价值的信息，特别是关于罕见疾病的信息。

它们向医务专业人员展示了同行在类似情况下是如何行动的，从而通过分享最佳做法来帮助决策过程。

它们不仅对知识库做出了重大贡献，而且还有助于为研究人员自己的出版履历加分。

然而，写出一个好的病例报告需要的不仅仅是一个吸引人的病例。

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。

那么，病例报告应该怎么写呢？今天和大家分享一些撰写和发表具有高影响力的病例报告的技巧。

如何撰写临床病例报告？万变不离其宗。

病例报告一般包括四大部分：摘要、前言、病例介绍、讨论。

DO应该这么做1.把案例报道当做故事来讲写病例报告的最好方法是讲故事。

可以按时间顺序排列事件，具体说明你的诊断考虑因素，阐明你的临床决策过程的论据，让你的读者可以跟随病例的每一个发展，并了解为什么你在治疗期间进行了特定的测试或作出一些决定的原因。

2.注意细节清楚描述导致鉴别诊断的相关症状和体征，无论是正面的还是负面的信息，以便为读者提供你做出决定的背景。

你也可以在你的病例报告中写出包括血液检测结果的实际值、处方药的详细剂量或其他应根据情况结果考虑的变量。

3.关联的情况下尽量使用图片俗话说得好，一张图片胜过千言万语，尤其是对于能够通过图像清晰有效地说明检查结果的病例报告而言。

但是，如果没有正当理由，请避免使用图片-只有当他们具备关联时才这样做。

例如，一个新鉴定的致病微生物的宏观和微观图像是必不可少的，而你在文中其他地方已经清楚地解释了模型的图片可能是过度的。

英文病例书写学习整理有关英文病例的写作，提供大家查考：一、主要调查项目：1.主诉chief complaint：weakness, malaise, chills, fever, sleep, pain, headache, appetite, weight, stomach and bowels, nausea and vomiting, diarrhea, urine, genitalia, neuropsychiatric disorders, respiration, shortness of breath, bleeding or discharge, etc. 2.现症历present illness：onset(date, mode), duration before present entry, exciting cause and environmental influences, prodromal symptoms, general symptoms, course or progress( location, duration, severity, continuity, intermission, radiation, treatment), aggravating and alleviating factors, loss of weight, appetite and strength, sleep, bowel movement, frequency of urination, menstruation, etc.3.既往历past history：1)former places of residence, previous stage of health( 健壮的robust，纤弱的delicate), experience with similar disease, immunity to infectious disease 2)previous illness：麻疹measles, 腮腺炎mumps, 水痘chicken-pox, 百日咳pertussis, 流行性感冒influenza, 猩红热scarlet fever, 白喉diphtheria，伤寒typhoid fever, 支气管炎bronchitis, 肺炎pneumonia，脑炎encephalitis,脑膜炎meningitis，破伤风tetanus,小儿麻痹poliomyelitis,赤痢dysentery，霍乱cholera, 胸膜炎pleurisy,天花small-pox，疟疾malaria,结核病tuberculosis，黄疸病jaundice，过敏性反应allergy,etc 3)venereal disease：specific symptoms, signs, and the disease by name, treatment. 4)Accidents( date, any disability, sequelae), operation and hospitalization (date , procedure, name of hospital , physician, complications, bleeding tendency)4.家族历familyhistory：family tendency, presence of hereditary disorders, cancer, tuberculosis, mental disorder and nervous affection, rheumatism, diabetes, hypertension, cerebral vascular accident, hemophilia, syphilis, tumor, epilespsy, allergy, contact with diseased individuals, relationship of patient’s childhood and adult life, age, health condition, and cause of death of parents, grandparents, self , spouse, siblings , or relatives. 5.个人历personal history：1)Social history：fears, metal status, education, financial condition, number of dependents, family harmony or fractious , hygienic condition at home 2)Marital history：duration of marriage, 1st or 2nd marriage, age and death of spouse and children , cause and age at time of death, number of children , pregnancies, 流产次数miscarriages, 死产数stillbirths 3)occupational history：duration of employment, pastwork, exact nature of work, exposure to occupational hazards, whether work is satisfactory or not. 4)Habits：alcohol, tobacco, narcotic, coffee, tea, appetite, food habits, regularity of meals, rapidity of eating , bowel movements, sleep, exercise, interests, etc. 6.系统检查system review：1)General：nutrition, fever, night sweats, tremor, weight gain or loss, weakness, allergy. 2)Skin：荨麻疹hives, rash, eczema 3)Head：trauma, headache, loss of hair 4)Eyes：vision, pain glasses diplopia. 5)Ears：pain, discharge, deafness, tinnitus.6)Nose：obstruction, discharge, epistaxis, rhinitis. 7)Mouth：teeth, lips, gums, tongue, disturbance in taste.8)Throat.：sore throat, tonsillitis, 脓性扁桃腺炎quinsy, dysphagia 9)Neck：adenitis, goiter , rigidity 10)Cardiorespiratory：palpitation, tachycardia, blood pressure, chest pain, dyspnea, cough , hemoptysis ,seasonal cold, expectoration.11)Gastrointestinal：appetite, nausea, vomiting, distress(before or after meals), melena, colic, jaundice, fullness, hernia, hemorrhoid, constipation, diarrhea, frequency of bowel movement , heartburn, idiosyncrasies, relation of symptoms to eating, type and quantity of food 12)Genito-urinary：dysuria, urinary frequency, dribbling , hematuria, pyuria, nocturia and volume, enuresis, incontinence, sores about external genitalia, symptoms suggestive of syphilis(mucous patches, falling hair), urethral discharge, exposure to venereal infection, obstetric history, catamenia(age of onset, date of last period, cycle and amount, periodicity , dysmenorrheal, menopause) leucorrhea, associated headache 13)Neuromuscular：神经过敏nervousness, emotional stress, weakness, muscle or joint pains, convulsion, numbness,neuralgia, anesthesia, muscular atrophies or dysatrophies, deformities. 二、病历与时态1．现症历(present illness)：1)A.现在式：表示一般的真理、职业、人格、习惯和现在的事实、动作或状态。

英文病历撰写手记病历是医生记录患者病情和诊疗过程的重要文档。

对于医生来说，准确、清晰地撰写英文病历至关重要。

本手记将介绍英文病历的撰写方法和注意事项。

1. 病历组成部分1.2 现病史（Present Illness）现病史应详细记录患者的主要症状、起病时间、发展情况以及辅助检查结果等。

应使用客观、中立的语言描述。

例如：Patient presents with fever, cough, and shortness of breath for the past week. Chest X-ray shows infiltrates in both lungs.1.3 既往史（Past Medical History）既往史包括患者过去的疾病、手术、药物过敏等情况。

应尽量提供详细信息，如果无则注明“无”。

例如：Patient has a history of hypertension and diabetes. No known drug allergies.1.4 家族史（Family History）家族史包括患者家庭成员的疾病情况，特别是与患者当前问题相关的疾病。

例如：Patient's mother has a history of breast cancer.1.5 个人史（Social History）个人史包括患者的生活方式、吸烟、饮酒、嗜好、职业等信息。

例如：Patient is a non-smoker and consumes alcohol occasionally.1.6 体格检查（Physical Examination）体格检查应记录医生对患者进行的全面检查，包括体温、脉搏、呼吸、血压等指标。

应详细描述发现的异常情况。

例如：Vital signs: temperature 37.5°C, heart rate 82 bpm, respiratory rate 18 breaths per minute, blood pressure 120/80 mmHg. Chest auscultation reveals decreased breath sounds in the lower left lung field.1.7 辅助检查（Laboratory and Diagnostic Tests）1.8 诊断（Diagnosis）1.9 治疗（Treatment）治疗部分应详细记录医生针对患者病情制定的治疗计划，包括药物治疗、手术、物理疗法等。

How to write patient's case history如何写英文病历PATIENT 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 hi story 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 contri butes 60% to 80% of the information needed for accurate 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发混淆，致使重要资料的遗漏和查房效率的低下。

学校规定，实习期间的完全病历中必须有⼀定⽐例的英⽂病历。

虽然平时对英语还算感兴趣，但对于连⼀个中⽂病历都是刚开始写的实习⽣来说，写好甚⾄仅仅是写出来⼀份英⽂病历都不是容易的事情，战战兢兢地写过⼏份之后，深感写英⽂病历实乃⼀项⾮常重要但常常被⼈忽视或当作形式主义完成的东西。

本⽂并⾮英⽂病历教学帖，只是就写英⽂病历中的⼀些注意事项谈⼀谈⾃⼰的体会，希望能抛砖引⽟吧。

记得开始写第⼀份时，甚⾄连"现病史"、"⽉经史"、"初步诊断"这些基本项⽬中以前没有注意的名称都不知道如何写，快速翻阅了⼀通诊断学之后，OK，从identification到impression的项⽬名称基本会写了，菜鸟迈出了第⼀步。

别急，我说的是"基本"会写了，其实认真起来还有很多细节值得琢磨，case record， admission note之间有没有区别，⽤哪个⽐较正规？"性别"是***还是gender？"国籍"、"民族"英⽂都是nationality，两个怎么区分？当然我们可以把问题暂时留到以后，现在要解决的是没有的问题，知道了⼀份病历中各个项⽬的写法，就像建房⼦有了基本的框架，虽然你还不知道要往⾥⾯放些什么家具，但起码你知道哪是卧室哪是厨房东西往哪搁了。

病历的第⼀部分identification⽐较简单，只要把基本的⼏⼗百把个单词记住了就可以应付，我能想起来的注意事项主要有这么⼏个，都很简单，让⽜⼈们见笑了。

［医学教育搜集整理］ l.姓名的写法，单名两个字的拼⾳⾸字母均⼤写，中间空格，双名姓和名的第⼀个字同单名，名第⼆个字⾸字母⼩写并紧挨名的第⼀字，如"⾼鹏程"写作"Gao Pengcheng"，⽽"Pengcheng Gao"的假洋⿁⼦写法现在很少看到了采⽤，在和外国⼈的交流中感觉他们对国⼈的first name即为family name这⼀⽂化差异都普遍了解，⼤可不必随⽼外的⽤法别扭地把姓放在后⾯。

英语作文疾病报告怎么写Title: Report on Disease Outbreak。

Introduction:In recent days, there has been a concerning surge in the incidence of a particular ailment within our community. This report aims to provide a comprehensive overview of the disease, its symptoms, potential causes, and proposed measures for containment and mitigation.1. Disease Overview:The disease in question, tentatively named "X-20," manifests primarily with symptoms such as high fever, persistent cough, fatigue, and difficulty in breathing. Patients afflicted with X-20 have reported varying degrees of severity, ranging from mild discomfort to severe respiratory distress requiring medical intervention.2. Epidemiological Investigation:Initial epidemiological investigations suggest that X-20 exhibits characteristics consistent with a viral respiratory infection. However, the exact pathogen responsible for the outbreak has yet to be conclusively identified. Surveillance efforts are underway to track the spread of the disease and identify potential sources of transmission within the community.3. Clinical Presentation:Individuals affected by X-20 typically experience an incubation period of 2-14 days following exposure to the virus. During this time, asymptomatic carriers may unknowingly transmit the infection to others. Upon onset, symptoms may progress rapidly, prompting affected individuals to seek medical attention.4. Public Health Response:In response to the escalating threat posed by X-20,public health authorities have initiated a series of proactive measures to contain the spread of the disease. These include:Implementing rigorous surveillance protocols to monitor suspected cases and trace contacts of confirmed patients.Enhancing diagnostic capabilities to facilitate early detection and isolation of infected individuals.Advising the public to practice stringent hygiene measures, such as frequent handwashing and respiratory etiquette, to reduce the risk of transmission.Collaborating with healthcare facilities to ensure adequate resources and personnel are available to manage the influx of patients presenting with symptoms of X-20.5. Challenges and Recommendations:Despite concerted efforts to mitigate the impact of the outbreak, several challenges persist, including limitedaccess to testing, shortages of personal protective equipment, and misinformation fueling public panic. To address these challenges effectively, it is imperative that:Resources be allocated towards expanding testing capacity and ensuring timely access to accurate diagnostic tools.Healthcare workers receive adequate training andsupport to safely care for patients while minimizing their own risk of exposure.Public health messaging be transparent, consistent, and culturally sensitive to counteract the spread of misinformation and promote adherence to preventive measures.Conclusion:In conclusion, the outbreak of X-20 presents asignificant public health challenge that demands a coordinated and multi-faceted response. By leveraging the collective efforts of healthcare professionals,policymakers, and the public, we can effectively contain the spread of the disease and safeguard the health and well-being of our community.。

病历英语作文写作的三步走策略In the medical field, a patient's medical record is a crucial document that provides a detailed overview of their health status, diagnosis, and treatment plan. When it comes to writing a medical record in English, simplicity and clarity are essential. Here's a three-step approach to writing a basic medical record in English:**Step 1: Gathering Information** The first step is to gather all the necessary information about the patient's health condition. This includes details such as thepatient's name, age, gender, and contact information. Additionally, it's important to record the patient's chief complaint, which is the main reason for their visit to the doctor. Other relevant information may include thepatient's past medical history, family history, and any allergies or medications they are currently taking.**Step 2: Writing the Medical Record** Once you have gathered all the necessary information, it's time to start writing the medical record. Begin by introducing thepatient and providing a brief overview of their condition. Then, focus on the chief complaint and provide a detaileddescription of the patient's symptoms, including their duration, severity, and any associated factors.Next, outline the doctor's diagnosis and explain the reasoning behind it. Include any relevant tests or procedures that were performed to confirm the diagnosis. Finally, describe the treatment plan, including any prescribed medications, recommended lifestyle changes, or follow-up appointments.**Step 3: Review and Editing** After writing the medical record, it's crucial to review and edit it for clarity and accuracy. Check for any grammatical errors or typos that may have crept in. Ensure that all information is complete and accurate, and that it flows smoothly from one section to the next. It's also important to ensure that the medical terminology is used correctly and that the language is easy to understand for non-medical readers.**中文内容****病历英语作文的三步走策略**在医学领域，病历是患者健康状况、诊断以及治疗计划的重要文件。

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:4、结论结论部分就是根据病情的讨论,最后得出自己独到的见解,并且提出自己的意见和观点来,并且结论部分必须结构简洁明了,文理通顺。

简明确切地论述文献的重要内容。

英文病例汇报实用句型1. 一般情况（完全套话）Mr./Ms. **(family name), a **(age) year-old **(profession), was admitted on **(admission date).2. 病史He complains that...He complains of one-month history of palpitation and short of breathness after exertion.He complained about epigastric pain which has lasted for 3 months.He noticed a hardened lump on the left neck 3 months ago.Pancytopenia was found a month ago.He presented with dyspnea since 10 days ago.His chief complaint was ...既往诊疗~~~~~~~~He was confirmed as / definitely diagnosed as ...(确诊为)To make a definite diagnosis, bone marrow aspiration was performed.He was suspected as...(疑似)The discomfort tended to worsening, which urged him to seek for medical care.He has been given 3 cycles of DA regimen for chemotherapy andcomplete remission was achieved only after the first cycle.He was given the thyroidectomy of the left lobe in local hospital.He was treated with antibiotics (details unknown), which didn't take effect as expected.The general condition is good at present.He was pain free now and hemodynamically stable.3. 查体Nothing noteworthy was found in the physical examination.There was nothing remarkable in the p hysical examination except for…The physical examination was otherwise normal except that…（上点小菜~~~血液科常见体征）皮肤粘膜generalized pallor，scattered petechiae，oral mucosal hematoma 淋巴结enlarged lymph nodes头部yellow eyes (yellow-stained sclera)胸部tenderness in sternum，coarse breath sound, cardiac murmur,arrhythmia腹部enlargement of liver，splenomegaly4．辅助检查The laboratory findings suggested/indicated/demonstrated/showed that…Bone marrow film was performed, which confirmed the diagnosis of ALL.The results of blood routine showed that WBC count was 4,000 /cm3, while NEU count 2,500/cm3, hemoglobin 100 g/L, PLT count 100,000 /cm3. (/cm3 is pronounced as per cubic millimeter)Chest CT scan supported the diagnosis of NHL.（专业文档是经验性极强的领域，无法思考和涵盖全面，素材和资料部分来自网络，供参考。

那年，开始接触ＮＥＪＭ、ＪＡＭＡ、Ｌａｎｃｅｔ、ＢＭＪ，心绪来潮，我应该学下医学英语于是，便开始从课本后面的英文单词开始，但效果并不是特别理想，记了忘，记了忘．．．于是便开始转换学习方法，任何学习最终都是为应用，当然不排除部分学习。

索性拿起英文病例读起，说实话，当时只可以看懂３０－４０％。

于是又只好从最基本英文病历书写开始，记得那时候很兴奋，做梦都会梦见和老外讨论病历，而且心里还一直想着医学词汇的表达。

不用两周，我就掌握了英文病历的基本书写，尤其是一些常用表达和症状的描述。

就这样，可以在同学们面前显摆下了，可以读的懂ＮＥＪＭ、ＪＡＭＡ、Ｌａｎｃｅｔ、ＢＭＪ了。

当期末考试，传染病学考试最后一个大题为英文时，同学们都还唏嘘不已，唯我心中喜悦啊。

其实英文病历的入门很简单，后面则需要自己的造化了。

下附相关郭航远学习资料：目录第一章病人身份第二章主诉第三章现病史第四章过去史、系统回统和个人史第五章月经、婚姻、生育史和家族史第六章体检（一般项目）第七章体检（头颈部）第八章体检（胸腹部）第九章体检（神经、骨骼和肌肉）第十章体检（泌尿生殖道与其他）第十一章标准化病人体检项目第十二章实验室检查第十三章辅助检查第十四章诊断（疾病名称）第十五章常用医嘱术语第十六章常用药物及中草药第十七章住院文书格式第十八章附录附1、常用解剖术语附2、医学英语常用前后缀附3、医学英语的特征附4、医学英语常用短语附5、英语问诊常用句子附6、医学英语缩写一览表附7、医院日常用品和设备附8、医学院和医院相关名称第一章病人身份[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 age2、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 colleague] 患者的同事·[Patient`s neighbor] 患者的邻居·[Patient`s Kin (Mother; Son; daughter;brother;Sister)] 患者的亲属(父亲、母亲、儿子、女儿、兄弟、姐妹)·[Taxman] 出租车司机·[Traffic police] 交通警察10、日期的表示方法·2002年10月1日[10-1-2002(10/1/2002; Oct.1,2002; Oct.lst,2002)](美国)·2002年10月1日[1-10-2002(1/10/2002; 1 Oct.,2002; 1st of Oct., 2002)] (英国)11、住院类别的表示方法·[Emergent (Emergency call)] 急诊·[Urgent] 危重·[Elective (General)] 一般（普通）12、入院时病情的表示方法·[Stable] 稳定·[Unstable] 不稳定·[Relative stable] 相对稳定·[Critical (Imminent)] 危重·[Fair (General)] 一般第二章主诉[Chief Complaint]1、主诉的表示方法：症状+时间（Symptom Time）·症状+for+时间如：[Chest pain for 2 hours] 胸痛2小时·症状+of+时间如：[Nausea and vomiting of three days` duration] 恶心呕吐3天·症状+时间+in duration如：[Headache 1 month in duration] 头痛1月·时间+of+症状如：[Two-day history of fever] 发热2天2、常见症状·[Fever] 发热·[Pain] 疼痛·[Edema] 水肿·[Mucocutaneous hemorrhage (bleeding)] 皮肤粘膜出血·[Dyspnea (Difficuly in breathing;Respiratory difficulty;short of breath)] 呼吸困难·[Cough and expectoration (Sputum;Phlegm)] 咳嗽和咯痰·[Hemoptysis] 咯血·[Cyanosis] 紫绀·[Palpitation] 心悸·[Chest discomfort] 胸闷·[Nausea (Retch;Dry Vomiting)and Vomiting] 恶心和呕吐·[Hematemesis (Vomiting of blood)] 呕血·[Hematochezia (Hemafecia)] 便血·[Diarrhea] 腹泻·[Constipation (Obstipation)] 便秘·[Vertigo (Giddiness; Dizziness)] 眩晕·[Jaundice (Icterus)] 黄疸·[Convulsion] 惊厥·[Disturbance of consciousness] 意识障碍·[Hematuria] 血尿·[Frequent micturition,urgent micturition and dysuria] 尿频，尿急和尿痛·[Incontinence of urine] 尿失禁·[Retention of urine] 尿潴留（1）发热的表示方法·[Infective (Septic)fever] 感染性发热·[Non-infective (Aseptic)fever] 非感染性发热·[Dehydration (Inanition)fever] 脱水热·[Drug fever] 药物热·[Functional hypothermia] 功能性低热·[Absorption fever] 吸收热·[Central fever] 中枢性发热·[Fever type] 热型▲[Continuous fever] 稽留热▲[Remittent fever]驰张热▲[Intermittent fever] 间歇热▲ [Undulant fever] 波状热▲ [Recurrent fever]回归热▲[Periodic fever] 周期热▲ [Irregular fever]不规则热▲[Ephemeral fever]短暂热▲[Double peaked fever]双峰热·[Fever of undetermined(unknown) origin, FUO] 不明原因发热·[Rigor (shivering;chill;shaking chill;ague)] 寒战·[Chilly Sensation (Fell chilly;cold fits;coldness)] 畏寒·[Ultra-hyperpyrexia] 超高热·[Hyperthermia (A high fever;hyperpyrexia;ardent fever)] 高热·[Moderate fever] 中度发热·[Hypothermia (Low-grade fever;slight fever;subfebrile temperature)] 低热·[Become feverish (Have a temperature)] 发热·[Crisis] 骤降·[Lysis] 渐降·[Typhoid fever] 伤寒热·[Rheumatic fever] 风湿热·[Cancerous fever] 癌性发热·[Fervescence period] 升热期·[Defervescence period] 退热期·[Persistent febrile period] 持续发热期（2）疼痛的表示方法·[Backache (Back pain)] 背痛·[Lumbago] 腰痛·[Headache] 头痛▲ [Vasomotor headache] 血管舒缩性头痛▲[Post-traumatic headache] 创伤后头痛▲[Migraine headache]偏头痛▲ [Cluster headache] 丛集性头痛·[Chest pain] 胸痛·[Precardial pain] 心前区痛·[Retrosternal pain] 胸骨后痛·[Abdominal pain (Stomachache)] 腹痛·[Acrodynia (pain in limbs)] 肢体痛·[Arthrodynia (Arthralgia)] 关节痛·[Dull pain] 钝痛·[Sharp pain] 锐痛·[Twinge pain] 刺痛·[Knife-like pain (Piercing pain)] 刀割（刺）样痛·[Aching pain] 酸痛·[Burning pain] 烧灼痛·[Colicky (Griping;cramp) pain] 绞痛·[Colic] 绞痛·[Bursting pain] 胀痛（撕裂痛）·[Hunger pain] 饥饿痛·[Tic pain] 抽搐痛·[Bearing-down pain] 坠痛·[Shock-like pain] 电击样痛·[Jumping pain] 反跳痛·[Tenderness pain] 触痛（压痛）·[Girdle-like pain] 束带样痛·[Wandering pain] 游走性痛·[Throbbing pain] 搏动性痛·[Radiating pain] 放射性痛·[Cramping pain] 痉挛性痛·[Boring pain] 钻痛·[Intense pain] 剧痛·[Writhing pain] 痛得打滚·[Dragging pain] 牵引痛·[Labor pain] 阵痛·[Cancerous pain] 癌性疼痛·[Referred pain] 牵涉痛·[Persistent pain (Unremitting pain)] 持续性痛·[Constant pain] 经常性痛·[Intermittent pain] 间歇性痛（3）水肿的表示方法·[Mucous edema (Myxedema)] 粘液性水肿·[Cardiac (Cardiogenic) edema] 心源性水肿·[Nephrotic (renal) edema] 肾源性水肿·[Hepatic edema] 肝源性水肿·[Alimentary (Nutritional) edema] 营养不良性水肿·[Angioneurotic edema] 血管神经性水肿·[Pitting] 凹陷性·[Nonpitting] 非凹陷性·[Localized (Local) edema] 局限性水肿·[Generalized edema (Anasarca)] 全身性水肿·[Hydrops] 积水·[Elephantiasic crus] 橡皮肿·[Cerebral(Brain) edema] 脑水肿·[Pulmonary edema (Hydropneumonia0] 肺水肿·[Hydrocephalus] 脑积水·[Edema of endoscrinopathy] 内分泌病性水肿·[Invisible (Recessive) edema] 隐性水肿·[Frank edema] 显性水肿·[Inflammatory edema] 炎性水肿·[Idiopathic edema] 特发性水肿·[Cyclical edema] 周期性水肿·[Ascites (Abdominal effusion;hydroperiotoneum)] 腹水·[Pleural effusion (Hydrothorax)] 胸水·[Pericardial effusion (Hydropericardium)] 心包积液·[Bronchoedema] 支气管水肿·[Slight (Mild)] 轻度·[Moderate] 中度·[Serious] 重度·[Transudate] 漏出液·[Exudate] 渗出液（4）呼吸困难的表示方法·[Cardiac dyspnea] 心原性呼吸困难·[Inspiratory] 吸气性·[Expiratory] 呼气性·[Mixed] 混合性·[Obstructive] 梗阻性·[Dyspnea at rest] 静息时呼吸困难·[Dyspnea on exertion] 活动时呼吸困难·[Dyspnea on lying down] 躺下时呼吸困难·[Paroxysmal nocturnal dyspnea,PND] 夜间阵发性呼吸困难·[Orthopnea] 端坐呼吸·[Asthma] 哮喘·[Cardiac asthma] 心源性哮喘·[Bronchial asthma] 支气管性哮喘·[Hyperpnea] 呼吸深快·[Periodic breathing] 周期性呼吸·[Tachypnea (Rapid or fast breathing;accelerated breathing;short of breath)]气促·[Bradypnea (Slow breathing)] 呼吸缓慢·[Irregular breathing] 不规则呼吸（5）皮肤粘膜出血的表示方法·[Bleeding spots in the skin] 皮肤出血点·[Petechia] 瘀点·[Eccymosis] 瘀斑·[Purpura] 紫癜·[Splinter hemorrhage] 片状出血·[Oozing of the blood (Errhysis)] 渗血·[Blood blister (Hemophysallis)] 血疱·[Hemorrhinia (Nasal bleeding)] 鼻衄·[Ecchymoma] 皮下血肿（6）咳嗽与咯痰的表示方法·[Dry cough (Nonproductive cough;hacking cough)] 干咳·[Sharp cough] 剧咳·[Wet cough (Moist cough)] 湿咳·[Productive cough (Loose cough)] 排痰性咳·[Chronic cough] 慢性咳嗽·[Irritable cough] 刺激性咳嗽·[Paroxysmal cough] 发作性（阵发性）咳嗽·[Cough continually] 持续性咳嗽·[Spasmodic cough] 痉挛性咳嗽·[Whooping cough] 百日咳·[Winter cough] 冬季咳·[Wheezing cough] 喘咳·[Short cough] 短咳·[Distressed cough] 难咳·[Shallow cough] 浅咳·[Droplet] 飞沫·[Frothy sputum] 泡沫样痰·[Bloody sputum] 血痰·[Mucous (Mucoid) sputum] 粘液样痰·[Purulent sputum] 脓痰·[Mucopurulent sputum] 粘液脓性痰·[White (Yellow,green) sputum] 白（黄,绿）痰·[Fetid (Foul) sputum] 恶臭痰·[Iron-rust (Rusty) sputum] 铁锈色痰·[Chocolate coloured sputum] 巧克力色痰·[Thick sputum] 浓痰·[Thin sputum] 淡痰·[Viscous sputum] 粘痰·[Transparent sputum] 透明痰·[Much (Large amounts of) sputum] 大量痰·[Moderate amounts of sputum] 中等量痰·[Not much (Small amounts of ) sputum] 少量痰（7）内脏出血的表示方法·[Goldstein’s hemoptysis]戈耳斯坦氏咯血·[Massive hematemesis]大量呕血·[Epistasis (Nosebleed;Nasal bleeding; Hemorrhinia;rhinorrhagia)]鼻衄·[Hematuria] 血尿·[Initial hematuria] 初血尿·[Idiopathic hematuria] 特发性血尿·[Painless hematuria] 无痛性血尿·[Terminal hematuria] 终末性血尿·[Gross (Macroscopic) hematuria] 肉眼血尿·[Microscopic hematuria] 镜下血尿·[Hematuria in the whole process of urination] 全程血尿·[Gingival bleeding (Ulaemorrhagia;gum bleeding)] 牙龈出血·[Hematochezia] 便血·[Bloody stool] 血便·[Black stool (Melena)] 黑便·[Tarry stool] 柏油样便·[Bleeding following trauma] 外伤后出血·[Spontaneous bleeding] 自发性出血·[Bleeding Continuously] 持续出血·[Occult blood,OB] 隐血·[Hematobilia] 胆道出血·[Hemathorax] 血胸·[Hemarthrosis] 关节积血·[Hematocoelia] 腹腔积血·[Hematoma] 血肿·[Hemopericardium] 心包积血·[Cerebral hemorrhage] 脑出血·[Subarachnoid hemorrhage(SAH)] 蛛网膜下腔出血·[Excessive (Heavy) menstrual flow with passage of clots] 月经量多伴血块·[Mild (Moderate) menses] 月经量少（中等）·[Painless Vaginal bleeding] 无痛性阴道出血·[Postcoital bleeding] 性交后出血·[Pulsating bleeding] 搏动性出血·[Post-operation wound hemorrhage] 术后伤口出血·[Excessive bleeding after denal extraction] 拔牙后出血过多（8）紫绀的表示方法·[Congenital cyanosis] 先天性紫绀·[Enterogenous] 肠源性·[Central] 中枢性·[Peripheral] 周围性·[Mixed] 混合性·[Acrocyanosis] 指端紫绀（9）恶心与呕吐的表示方法·[Vomiturition (Retching)] 干呕·[Feel nauseated] 恶心感·[Postprandial nausea] 饭后恶心·[Hiccup] 呃逆·[Sour regurgitation] 返酸·[Fecal (Stercoraceous) vomiting] 吐粪·[undigested food Vomiting] 吐不消化食物·[Bilious Vomiting] 吐胆汁（10）腹泻与便秘的表示方法·[Moning diarrhea] 晨泻·[Watery (Liquid)diarrhea] 水泻·[Mucous diarrhea] 粘液泻·[Fatty diarrhea] 脂肪泻·[Chronic (Acute)] 慢性（急性）·[Mild diarrhea] 轻度腹泻·[Intractable (Uncontrolled)diarrhea] 难治性腹泻·[Protracted diarrhea] 迁延性腹泻·[Bloody stool] 血梗·[Frothy stool] 泡沫样便·[Formless (Formed)stool] 不成形（成形）便·[Loose (Hard) stool] 稀（硬）便·[Rice-water stool] 米泔样便·[Undigested stool] 不消化便·[Dysenteric diarrhea] 痢疾样腹泻·[Inflammatory diarrhea] 炎症性腹泻·[Osmotic] 渗透性·[Secretory] 分泌性·[Malabsorption] 吸收不良性·[Lienteric] 消化不良性·[Pancreatic diarrhea] 胰性腹泻·[Tenesmus] 里急后重·[Pass a stool (Have a passage; open or relax the bowel)] 解大便·[Have a call of nature] 便意·[Fecal incontinence (Copracrasia)] 大便失禁·[Functional constipation] 功能性便秘·[Organic constipation] 器质性便秘·[Habitual constipation] 习惯性便秘·[Have a tendency to be constipated] 便秘倾向（11）黄疸的表示方法·[Latent (occult) jaundice] 隐性黄疸·[Clinical jaundice] 显性黄疸·[Nuclear icterus] 核黄疸·[Physiologic icterus] 生理性黄疸·[Icterus simplex] 传染性黄疸·[Toxemic icterus] 中毒性黄疸·[Hemolytic] 溶血性·[Hepatocellular] 肝细胞性·[Obstructive] 阻塞性·[Congenital] 先天性·[Familial] 家族性·[Cholestatic] 胆汁淤积性·[Hematogenous] 血源性·[Malignant] 恶性·[Painless] 无痛性（12）意识障碍的表示方法·[Somnolence] 嗜睡·[Confusion] 意识模糊·[Stupor] 昏睡·[Coma] 昏迷·[Delirium] 谵妄·[Syncope (swoon; faint)] 晕厥·[Drowsiness] 倦睡（13）排尿的表示方法·[Enuresis (Bed-wetting)] 遗尿·[Anuria] 无尿·[Emiction interruption] 排尿中断·[Interruption of urinary stream] 尿线中断·[Nocturia] 夜尿·[Oliguria] 少尿·[Polyuria] 多尿·[Pass water (Make water; urinate; micturition)] 排尿·[Frequent micturition (Frequency of micturition; fruquent urination;Pollakiuria)] 尿频·[Urgent micturition (Urgency of urination or micturition)] 尿急·[Urodynia (Pain on micturition; painful micturition; alginuresis; micturition pain)] 尿痛·[Dysuria (Difficulty in micturition; disturbance of micturition)] 排尿困难·[Small urinary stream] 尿线细小·[Void with a good stream] 排尿通畅·[Guttate emiction (Dribbling following urination;terminal dribbling)] 滴尿·[Bifurcation of urination] 尿流分叉·[Residual urine] 残余尿·[Extravasation of urine] 尿外渗·[Stress incontinence] 压力性尿失禁·[Overflow incontinence] 溢出性尿失禁·[Paradoxical in continence] 反常性尿失禁3．少见症状·[Weekness( Debility; asthenia; debilitating)] 虚弱（无力）·[Fatigue (Tire; lassitude)] 疲乏·[Discomfort (Indisposition; malaise)] 不适·[Wasting (thin; underweight; emaciation; lean)] 消瘦·[Night sweating] 盗汗·[Sweat (Perspiration)] 出汗·[Cold sweat] 冷汗·[Pruritus (Iching)] 搔痒·[Asthma] 气喘·[Squeezing (Tightness; choking; pressing) sensation of the chest] 胸部紧缩（压榨）感·[Intermittent claudication] 间歇性跛行·[Difficulty in swallowing( Dysphagia; difficult swallowing; acataposis)] 吞咽困难·[Epigastric (Upper abdominal) discomfort] 上腹部不适·[Anorexia (Sitophobia)] 厌食·[Poor appetite (Loss of appetite)] 纳差·[Heart-burn( Pyrosis)] 胃灼热·[Stomachache( Pain in stomach)] 胃部痛·[Periumbilial pain] 脐周痛·[Belching (Eructation)] 嗳气·[Sour regurgitation] 返酸·[Abdominal distention(bloating)] 腹胀·[Pass gas( Break wink)] 肛门排气·[Small(Large) stool] 大便少（多）·[Expel(Pass) worms] 排虫·[Pain over the liver] 肝区痛·[Lumbago] 腰痛·[Pica(Parorexia; allotriophagy)] 异食癖·[Dysmenorrhea] 痛经·[Menoxenia (Irregular menstruation)] 月经不调·[Polymenorrhea (Epimenorrhea)] 月经过频·[Oligomenorrhea] 月经过少·[Excessive menstruation (Menorrhagia; menometrorrhagia; hypermenorrhea)] 经量过多·[Hypomenorrhea (Scantymenstruation)] 经量过少·[Menopause (Menostasia; menostasis)] 绝经·[Amenorrhea (Menoschesis)] 闭经·[Leukorrhagia] 白带过多·[Asexuality (lack of libido)] 无性欲·[Hyposexuality] 性欲低下·[Hypersexuality] 性欲亢进·[Prospermia (Ejaculatio praecox)] 早泄·[Impotency (impotence)] 阳萎·[Nocturnal emission (Spermatorrhea)] 遗精·[Lack of potency] 无性交能力·[Hair loss] 脱发·[Joint pain (Arthralgia; arthrodynia)] 关节痛·[Polydipsia (Excessive thirst)] 多饮（烦渴）·[Polyphagia (Excessive appetite; hyperorexia; bulimia)] 多食·[Cold (Heat) intolerance] 怕冷（热）·[Dwarfism (Excessive height)] 身材矮小（高大）·[Excessive sweating] 多汗·[Hands tremble] 手抖·[Obesity (Fatty)] 肥胖·[Agitation (Anxiety;nervous irritability)] 焦虑（忧虑）·[Mania] 躁狂·[Hallucination] 幻觉·[Aphasia (Logopathy)] 失语·[Amnesia (Poor memorization;memory deterioration)] 记忆力下降·[Hemianesthesia] 偏身麻木·[Formication] 蚁走感·[Tingling] 麻刺感·[Hyperpathia] 痛觉过敏·[Hypalgesia] 痛觉减退·[Illusion] 错觉·[Hemiplegia] 半身不遂·[Insomnia (Poor sleepness;sleeplessness)] 失眠·[Nightmare] 多梦·[Numbness] 麻木·[Pain in limbs (Acrodynia)] 肢体痛·[Limitation of motion] 活动受限·[Tetany] 手足抽搐·[Discharge of pus] 流脓·[Blurred vision(Hazy vision;blurring of vision; dimness of vision)]视物模糊·[Burning (Dry) sensation] 烧灼（干燥）感·[Tearing (Dacryorrhea;Lacrimation)] 流泪·[Double vision (Diplopia)] 复视·[Strabismus] 斜视·[Hemianopia] 偏盲·[Tired eyes (Eyestrain)] 眼疲劳·[Foreign body sensation] 异物感·[Lose the sight (Lose of vision)] 失明·[Diminution of vision] 视力减退·[Nictition] 眨眼·[Ophthalmodynia (Eye-ache;ocular pain)] 眼痛·[Photophobia] 畏光·[Spots before the eyes] 眼前黑点·[Deafness(Anacusia)] 耳聋·[Auditory dysesthesia] 听力减退·[Otalgia (Otodynia;pain in the ear ;ear-ache)] 耳痛·[Stuffy feeling in the ear] 耳闭气·[Tinnitus] 耳鸣·[Outophony] 自声过强·[Nasal obstruction (blockage)] 鼻塞·[Dryness of the nose] 鼻干燥·[Rhinorrhea (Snivel;Nasal discharge)] 流鼻涕·[Sneezing] 打喷嚏·[Snoring] 打鼾·[Hyposmia (Reduction of the sense of smell)] 嗅觉减退·[Anosmia (Complete loss of sense of smell)] 嗅觉丧失·[Dysphonia] 发音困难·[Hoarseness] 声嘶·[Pain on swallowing] 吞咽痛·[Saliva dribblies from the mouth] 流涎·[Troaty voice] 声音沙哑·[Stridor] 喘鸣·[Red and swollen] 红肿·[Scurf] 头皮屑·[Show] 见红·[Amniotic fluid escaped] 破水·[Uterine contraction] 宫缩·[Acalculia] 计算不能·[Apathy] 情感淡漠·[Delusion] 妄想4、时间的表示方法（1）月（Month）·[January,Jan.] 一月·[February,Feb.] 二月·[March,Mar.] 三月·[April,Apr.] 四月·[May] 五月·[June,Jun.] 六月·[July,Jul.] 七月·[August,Aug.] 八月·[September,Sept.] 九月·[October,Oct.] 十月·[November,Nov.] 十一月·[December,Dec.] 十二月（2）周（Week）·[Monday] 星期一·[Tuesday] 星期二·[Wednesday] 星期三·[Thursday] 星期四·[Friday] 星期五·[Saturday] 星期六·[Sunday] 星期日（3）年（Year）和日[Day]·[1st (First) year] 第1年·[2nd (Second) year] 第2年·[3rd (Third)year] 第3年·[4th (Forth) year] 第4年·[One year (day)] 1年（天）·[Two years (days)] 2年（天）·[Whole year] 整年·[1st (First)] 1日·[2rd (Second)] 2日·[3rd (Third)] 3日·[5th (Fifth)] 5日·[Today] 今天·明天[Tomorrow]·昨天[Yesterday]·前天[The day bdfore yesterday]·后天[The day after tomorrow]·大前天[3 days ago]·大后天[3 days hence]·今晚[Tonight]·昨晚[Last night]·明晚[Next night]·通宵[All night]·整天[All day (the whole day)] （4）季节[Season]和时节[Solar terms] ·春季[Spring]·夏季[Summer]·秋季[Autumn]·冬季[Winter]·立春（夏、秋、冬）[the Beginning of Spiring (Summer;Autumn;Winter)] ·小暑（雪、寒）[Slight Heat (Snow;Cold)]·大暑（雪、寒）[Great Heat (Snow;Cold)]·雨水[Rain Water]·惊蛰[the Waking of Insects]·春（秋）分[the Spiring (Autumnal) Equinox]·清明[Pure Brightness]·谷雨[Grain Rain]·小满[Grain Full]·芒种[Grain in Ear]·夏（冬至）[the Summer (Winter) Solstice]·处暑[the Limit of Heat]·白（寒）露[White (Cold) Dew]·霜降[Frost’s De scent]（5）时间的表示方法·In[在……内（后）]▲在2003年[In 2003]▲在3月[In March(Mar.)]▲在去年10月[In last Oct.]▲在早晨[In the morning]▲在上午[In the forenoon]▲在下午[In the afternoon]▲在晚上[In the evening]▲在近5天[In the past 5 days]▲在10分钟后[In 10 minutes]▲在秋季[In autumn]▲在这2～3天内[In a couple of days]·Within[在……中]▲在近8个月中[Within the last 8 months]▲在过去的2年中[Within the preceding 2 years]·On[在……时候]▲在2002的9月18日[On the 18th of September,2002(英国)or On sept.18th,2002(美国) ▲在星期三[On Wednesday]▲在本月7日[On 7th instant]·At[在……时]▲在中午[At noon]▲在晚上[At night]▲在昨晚[At last (preceding;previous )night]▲在半夜[At midnight]▲在上午10点钟[At 10AM]▲在5岁时[At the age of five]▲在2000年底（中、初）[At the end (middle;beginning) of 2000]·For[计……时间]▲一周[For one week]▲近2个月来[For the past 2 months]▲几乎（整整）一年[For nearly a month (a full month)]▲3个月左右[For 3 months or so]▲至少3个月[For at least 3 months]▲3个月以上[For more than 3 months]▲3个月或以上[For 3months or more]▲时间不详[For an unknown(indefinite) period (time)]·Of[在……时期]▲10年内[Of 10 years` duration]▲期间[Length of time]▲6月6日[The 6th of June]·Dring[在……期间]▲在2000-2005年的几年中[During the years form 2000 to 2005]▲在这4年中[During four years]▲在过去的几周中[During the past(Last) couple of weeks]▲在夜间[During the night]▲整天[During the entire day]·About [约]▲约1个半小时[About one and half an hour]▲大约半年[About half a year]·To[至；在……之前]▲从今下午点至明上午8点[Form 6 PM today to 8 AM tomorrow]▲6点45分[At fifteen to seven]·From[从……起]▲从14岁至52岁[From 14 to 52 year-old]▲从上午7点30分开始[Form 7:30AM]▲从周一至周五[From Monday through Friday]·Past[过去；超过]▲在过去的3周中[In the past 3 weeks]▲8点10分[ten minutes past eight]·Through or throughout[在……整个期间]▲通宵值班[Be on duty through the night]▲从一月到六月[From January through June]▲熬过明晚[Through the next nigut]▲整天（晚）[Throughout the day (night)]·Over[在……期间]▲在过去的2个月内[Over the past two months]▲一夜间[Overnight]（6）其他表示方法·每月（年、日）一次[Monthly (Yearly; daily)]·整整一年[Yearlong (Year-round)]·满周岁[Yearling]·工作日[Weekday]·周末[Weekend]·每周末[Weekends]·8小时工作日[An eight-hour day]·整天[Daylong]·白天[Daytime]·昼夜[Nighttime]·日常的[Day-to-day]·夏令时间[Daylight saving time]·每晚[Nightly]·黄昏[Nighfall]·过期的[Overdue]·前天晚上（一夜间）[Overnight]·After [在……之后]▲婚后[After one`s marriage]▲七点十分[Ten after (past) seven]▲住（出）院后[After admission (discharge)]▲起病后2天[2 days after the onset(attack) of symptoms] ·Before[在……之前]▲7点50分之前[Before seven fifty]▲医生到达前[Before the doctor come]▲以前未有种症状[Have had not the same symptom before]·Ago[以前]▲5年前[5 years ago]▲直到一个月前[Up to one month ago]▲大前天[Three days ago]·Prior to[在……之前]▲入（出）院前[Prior to admission (discharge)]▲前天之前[Prior to the day before yesterday]·Up to[直到]▲直到3周前[Up to 3 weeks ago]▲直到现在（出院）[Up to now (discharge)]·Until or till[直到]▲直到80岁[Until 80 years old]▲直到今晨8点[Until 8 o`clock this moning]▲直到医生查完房[Until the doctor have finished the ward round] ▲直到3年以前[Until 3 years ago]▲直到出院前一天[Until 1 day prior to discharge]·By[在……之前]▲下午点钟前[By 5 PM]▲下个月之前[By next month]·Since[从……开始]▲自从去年术后[Since operation was performed last year]▲前天起[Since the day before yesterday]▲从2002年6月起[Since June 2002]·超时(加班)[Overtime]·上午8点[8：00AM]·下午2点30分[2：30PM]·7点50分[Seven fifty (Ten to eight)]·9点20分[Nine twenty(Twenty past or after nine)]·术前[Pre-operation]·术后[Post-operation]第三章现病史[History of present illness (HPI/PI)]现病史书写的重点包括：一、主诉中症状的详细描述；二、疾病的发展过程；三、诊疗经过；四、目前的一般情况。

英文病例汇报实用句型1. 一般情况（完全套话）Mr./Ms. **(family name), a **(age) year-old **(profession), was admitted on**(admission date).2. 病史He complains that...He complains of one-month history of palpitation and short of breathness after exertion.He complained about epigastric pain which has lasted for 3 months.He noticed a hardened lump on the left neck 3 months ago.Pancytopenia was found a month ago.He presented with dyspnea since 10 days ago.His chief complaint was ...既往诊疗~~~~~~~~He was confirmed as / definitely diagnosed as ...(确诊为)To make a definite diagnosis, bone marrow aspiration was performed.He was suspected as...(疑似)The discomfort tended to worsening, which urged him to seek for medical care.He has been given 3 cycles of DA regimen for chemotherapy and complete remission was achieved only after the first cycle.He was given the thyroidectomy of the left lobe in local hospital.He was treated with antibiotics (details unknown), which didn't take effect as expected.The general condition is good at present.He was pain free now and hemodynamically stable.3. 查体Nothing noteworthy was found in the physical examination.There was nothing remarkable in the physical examination except for…The physical examination was otherwise normal except that…（上点小菜~~~血液科常见体征）皮肤粘膜generalized pallor，scattered petechiae，oral mucosal hematoma淋巴结enlarged lymph nodes头部yellow eyes (yellow-stained sclera)胸部tenderness in sternum，coarse breath sound, cardiac murmur, arrhythmia腹部enlargement of liver，splenomegaly4．辅助检查The laboratory findings suggested/indicated/demonstrated/showed that…Bone marrow film was performed, which confirmed the diagnosis of ALL.The results of blood routine showed that WBC count was 4,000 /cm3, while NEU count 2,500/cm3, hemoglobin 100 g/L, PLT count 100,000 /cm3.(/cm3 is pronounced as per cubic millimeter)Chest CT scan supported the diagnosis of NHL.Welcome To Download !!!欢迎您的下载，资料仅供参考！。

【前言】：病历的书写，不管情不情愿，是我们见习、实习生活中十分重要的一部分。

中文病历是基本要求，英文病历是附加题。

对于书写英文病历，首先要明确自己的目的和期望。

比如说通过书写英文病例学习专业词汇，与国际接轨；将来考虑出国；好奇心使然等等。

有此意愿的同学大可好好思考一下，给自己一个理由和动力。

协和有写英文病历的传统，但还没有统一、固定的格式。

不过格式不外乎：国外原版和中文病例对译版。

目前黄老师坚持，如果我们要写英文病历，就要跟国际化的要求接轨，所以支持原格式和写作习惯。

但具体格式，都因医院、因人而异。

故总结中注重的是—提出基本框架，规范术语。

大家可作适合自己的微调。

A COMPLETE History & PhysicalHISTORYDate and Time of history:Identifying Data：Source of history, source of referral:Reliability:Chief complaints:quote the patient’s complaints, like “My stomach hurts and I feel awful”; or report their goals, like “I have come for my regular check-up”;[BATES’]patient’s age, a brief but relevant past medical history, a few words about what problem brings the patient to the hospital(preferable quote the patient), and duration[Writing a history & physical]e.g. 34-year-old male with advanced AIDS complains of a” bad cough” and fevers over the last 8days.56-year-old male with a history of ulcerative colitis complains of 3 months of worsening back stiffness, 2 weeks of “a sore on my leg”, and 3days of fevers and bloody, painless diarrhea.History of Present illness:full sentences in chronological mannerbe descriptive not analyticincluding the setting, onset of the problem, the manifestation and the treatment.Seven Attributes of A Symptom: location, quality, quantity or severity, timing(onset, duration, frequency), the setting in which they occur, factors that have aggravated or relieved the symptom, associated manifestations.Pertinent positives & pertinent negativesPast Medical HistoryChildhood illnesses, such as measles, rubella, mumps, whooping cough, chickenpox, rheumatic fever, scarlet fever(猩红热), polio etc.Adult disease, in four categories:☑Medical, such as: diabetes, hypertension, hepatitis, asthma, and HIV etc.☑Surgical, such as: trauma, operation(date, type);☑Ob/ Gyn:✓Menstruation history(age at menarche, last menstruation period/ age at menopause, menstrual cycle, menstrual period)✓Obstetric history(G_P_, pregnancy、delivery and complications, )✓Sexual function;✓Method of birth control, such as oral contraceptives, condoms, intrauterine ring;☑Psychiatric;Health maintenance☑Immunization(history and recent immunization);☑Screening test, such as tuberculin test, Pap smear, mammogram, stool test for occult blood, cholesterol test etc.Medication: name, dose, route of administration, interval. Note for recent cessation or change;Allergy:List the substance and the reaction. Allergy vs intolerance;NOTE:药物过敏史与烟酒违禁药物使用分开。

英文完全病例书写(呼吸科)编辑整理：尊敬的读者朋友们：这里是精品文档编辑中心，本文档内容是由我和我的同事精心编辑整理后发布的，发布之前我们对文中内容进行仔细校对，但是难免会有疏漏的地方，但是任然希望（英文完全病例书写(呼吸科)）的内容能够给您的工作和学习带来便利。

同时也真诚的希望收到您的建议和反馈，这将是我们进步的源泉，前进的动力。

本文可编辑可修改，如果觉得对您有帮助请收藏以便随时查阅，最后祝您生活愉快业绩进步，以下为英文完全病例书写(呼吸科)的全部内容。

Medical Record of AdmissionName: Guo XX Sex： MaleAge： 41 years old Marital status： Married Race： Han Occupation： WorkerPlace of birth： Chenzhou City， Hunan provinceAddress: Linwu County, Chenzhou City, Hunan provinceDate of admission: 11：12 AM， 05,12,2014 Date of records: 17：20PM, 05,12,2014Complainer: Guo XXChief complaint: Cough for two months, and tachypnea and chest pain for one month。

History of present illness: The patient have no obvious cause cough in October this year, a small amount of white sticky sputum， blood in the sputum， no chest pain, no fever, occasionally night sweats, it has no special treatment。