病历书写-皮肤科病历

皮肤黑色素瘤病历书写范文英文回答:Patient Name: [Patient's Name]Gender: [Patient's Gender]Age: [Patient's Age]Date of Admission: [Date of Admission]Chief Complaint:The patient presented with a pigmented lesion on the skin, which has been gradually increasing in size over the past few months. The lesion is painless and does not cause any discomfort.History of Present Illness:The patient noticed the pigmented lesion on the skin about 6 months ago. Initially, it was small and did not bother the patient. However, over time, the lesion has grown in size and has become more prominent. The patient denies any associated symptoms such as itching, bleeding, or changes in color.Past Medical History:The patient has no significant past medical history. No history of chronic illnesses, surgeries, or allergies.Family History:There is no significant family history of skin conditions or melanoma.Social History:The patient is a non-smoker and does not consume alcohol. The patient works indoors and has limited sun exposure. No history of tanning bed use.Physical Examination:On examination, there is a well-defined, irregularly shaped, pigmented lesion on the patient's skin. The lesion measures approximately 1.5 cm in diameter. It has variegated colors with shades of brown and black. The lesion is asymmetric and has an irregular border. There is no associated lymphadenopathy.Differential Diagnosis:1. Melanoma.2. Benign melanocytic nevus.3. Seborrheic keratosis.4. Lentigo maligna.Investigations:1. Dermoscopy: Dermoscopic examination of the lesion reveals irregular pigment network, asymmetric structure, and multiple colors, which are suggestive of melanoma.2. Biopsy: A punch biopsy of the lesion was performed to confirm the diagnosis.Diagnosis:Based on the clinical presentation and dermoscopic findings, the diagnosis of melanoma is suspected. The biopsy results will confirm the diagnosis.Treatment Plan:The patient will undergo surgical excision of the lesion. The excised tissue will be sent for histopathological examination to determine the depth of invasion and presence of any metastasis. Further treatment will be planned based on the histopathology report.Prognosis:The prognosis of melanoma depends on various factors, including the stage of the disease, depth of invasion, and presence of metastasis. Early detection and treatment significantly improve the prognosis.中文回答:患者姓名，[患者姓名]性别，[患者性别]年龄，[患者年龄]入院日期，[入院日期]主诉：患者主诉皮肤上有一个黑色素沉着的病变，过去几个月逐渐增大。

皮肤科门诊病历书写范文
前言
皮肤科门诊是医院中常见的科室之一，因为皮肤病的种类繁多，所以在门诊中，医生需要详细了解患者的病情，以便做出正确的诊断和治疗方案。

而病历则是医生了解患者病情的重要依据，因此，正确书写病历对于医生来说至关重要。

本文将介绍皮肤科门诊病历的书写范例，希望对医生们有所帮助。

病历书写范例
基本信息
•姓名：张三
•性别：男
•年龄：35岁
•就诊日期：2021年6月1日
•就诊科室：皮肤科门诊
•主诉：皮肤瘙痒、红斑、脱屑2年
现病史
患者于2年前出现皮肤瘙痒、红斑、脱屑等症状，自行使用药膏治疗，但症状未能缓解。

近期病情加重，出现皮肤瘙痒、红斑、脱屑等症状，伴有轻度疼痛，就诊于本院皮肤科门诊。

既往史
患者无高血压、糖尿病等慢性疾病史，无过敏史。

个人史
患者无吸烟、饮酒等不良生活习惯。

体格检查
•皮肤：全身皮肤有红斑、脱屑，局部皮肤有瘙痒感，无明显皮损。

•神经系统：无明显异常。

辅助检查
•血常规：白细胞计数正常。

•尿常规：正常。

•皮肤刮片：真菌检测阳性。

诊断
•皮肤真菌感染。

治疗方案
•外用抗真菌药膏治疗。

随访计划
•患者每周复诊一次，观察病情变化。

结语
以上是皮肤科门诊病历书写的范例，希望对医生们有所帮助。

在书写病历时，需要注意的是，要详细了解患者的病情，包括病史、体格检查、辅助检查等方面，以便做出正确的诊断和治疗方案。

同时，书写病历时也要注意语言简洁明了，避免使用过于专业的术语，以便患者和其他医生能够理解。

华北石油管理局总医院性病科2014年11月18日
主诉：龟头、阴茎、外阴、肛周发现赘生物3天
现病史：患者3天前发现龟头、阴茎、外阴、肛周有赘生物，无痛痒及其他不适，于我院皮肤科/妇产科/肛肠科就诊，怀疑我科病，随来就诊
既往史：无冠心病、糖尿病、肝炎、结核病史；已婚。

食物、药物过敏史：（-）
个人史：无特殊；吸烟史（-）；饮酒史（-）；冶游史（有）；
家族史：（-）
查体：龟头、阴茎、外阴、宫颈、阴道壁、肛周有实质性凸起赘生物，米粒至黄豆大小，表面粗糙颗粒状，菜花样、乳头样、草莓样，醋酸实验（+），有无出血。

余（-）。

辅助检查：
诊断：尖锐湿疣
治疗意见：
1. 半年内禁同房，请性伴来我科门诊检查，治疗期间禁酒，避免进食辛辣
刺激性食物、牛羊肉；
2. 进一步排查其他性疾病；
3. 局麻下行微波手术；
4. 药物预防伤口感染；
5. 本病易复发，首次术后15天来复查，以后每月来复查，持续6个月。

6. 不适随诊。

皮肤科带状疱疹病历书写范文英文回答：Patient: Mr. Zhang.Age: 55。

Gender: Male.Chief Complaint:The patient complains of a painful and itchy rash on the left side of his body. He also experiences a burning sensation in the affected area.History of Present Illness:The patient noticed the rash about a week ago. It started as small red bumps and gradually developed into fluid-filled blisters. The rash is limited to the left sideof his chest and back, following a dermatomal distribution. The patient reports severe pain in the affected area, which is exacerbated by touch and movement. He also experiences tingling and numbness in the same area. The patient denies any recent trauma or injury to the affected site.Past Medical History:The patient has a history of hypertension and type 2 diabetes, which are well-controlled with medication. He has no known allergies and has not undergone any surgeries in the past.Social History:The patient is a non-smoker and denies any alcohol or drug abuse. He works as an office manager and has no significant exposure to chemicals or irritants.Family History:There is no family history of skin diseases or othersignificant medical conditions.Physical Examination:On examination, there is a rash consisting of grouped vesicles and erythematous papules in a dermatomal pattern involving the left side of the chest and back. The rash is tender to touch and shows no signs of infection. There are no other significant findings on general physical examination.Diagnosis:Based on the clinical presentation and examination findings, the patient is diagnosed with herpes zoster, also known as shingles.Treatment:The patient will be prescribed antiviral medication, such as acyclovir, to reduce the duration and severity of the rash. Pain management will be initiated with analgesics,such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs). The patient will also be advised to keep the affected area clean and dry, and to avoid scratching or picking at the blisters to prevent secondary infection. Follow-up will be scheduled in one week to monitor the progress and adjust the treatment plan if necessary.Prognosis:With appropriate treatment, the rash and pain associated with herpes zoster typically resolve within 2-4 weeks. However, some patients may continue to experience postherpetic neuralgia, a persistent pain that can last for months or even years after the rash has healed.中文回答：患者，张先生。

患者自诉于一月前在户外劳动中无明显诱因出现全身皮疹、瘙痒，皮疹呈呈阵发性剧痒、因痒进行瘙抓、出现皮肤溃破；以双手背、前臂、颈部显著;夜间瘙痒加重；同时伴有皮疹、乏力;但是无寒战、高热；无咳嗽、咳痰；无心慌、心悸，无尿频尿急及血尿。

曾经到当地卫生室就诊（具体不详)后上述症状未见好转。

为求进一步诊治于11月07日10:30来我院就诊。

门诊以“接触性皮炎"收入院。

病程中患者精神饮食尚可，睡眠欠佳，二便正常，体重无显著变化。

周身片状皮疹，高出皮肤，疹发红，点状密集皮疹,周身发痒。

患处成片红斑，密集或疏散的小丘疹，顶部可见水泡.。

大片渗液及糜烂。

皮肤湿疹，以四肢为多,开始散在全身，以后逐成片状增多，瘙痒,搔破后流黄水,无发热，饮食尚佳，睡眠不实，大小便正常，舌质正常，苔黄腻，脉陈弦细数。

患者自诉于一月前在户外劳动中无明显诱因周身出现点片状密集皮疹，高出皮肤,疹发红充血，皮疹呈呈阵发性剧痒、因痒进行瘙抓、出现皮肤溃破；以双手背、前臂显著；夜间瘙痒加重，睡眠困难。

同时伴有乏力,但是无寒战、高热；无咳嗽、咳痰;无心慌、心悸，无尿频尿急及血尿。

曾经到当地卫生室就诊（具体不详）后上述症状未见好转.为求进一步诊治来院。

病程中患者精神饮食睡眠差，二便正常，体重无显著变化。

周身片状皮疹，高出皮肤，疹发红，点状密集皮疹，周身发痒。

患处成片红斑，密集或疏散的小丘疹,顶部可见水泡。

.。

大片渗液及糜烂。

皮肤湿疹,以四肢为多，开始散在全身，以后逐成片状增多，瘙痒，搔破后流黄水,无发热，饮食尚佳，睡眠不实，大小便正常，舌质正常，苔黄腻，脉陈弦细数。

虫咬症：典型皮损为风团样丘疹，顶端有小疱，多无全身症状。

药疹：有明确的服药吏，有一定的潜伏期，皮损突然发生，除固定型药疹外，多对称分布。

疥疮：有接触传染史、好发部位及典型皮损,若能查到疥螨即可确诊。

入院记录姓名：李祖恩民族：哈尼族性别：男性工作单位:无年龄：53岁入院日期:2013年11月07日10：30婚姻：已婚记录日期：2013年11月07日15:30职业：农民病史提供者：患者本人籍贯：云南墨江家庭住址:墨江县雅邑镇雅邑村拉东组主诉：全身瘙痒伴皮疹、乏力半月余 .现病史:患者自诉于半月前在野外劳动接触有机磷农药后夜间开始出现全身皮肤瘙痒，呈阵发性剧痒、因痒进行瘙抓、出现皮肤溃破、疼痛；以双手背、前臂、颈部显著；早晨及夜间稍有减轻，白天瘙痒及疼痛加重；同时伴有皮疹、乏力；但是无寒战、高热；无咳嗽、咳痰；无心慌、心悸，无尿频尿急及血尿。

-----------皮肤科病历书写要求皮肤科病案记录应按内科病历内容要求规定书写，并应注意下列各项：（一）病史1．主诉应记述病损的部位、性质、自觉症状与病期。

2．现病史应详询以下各点：①可能的病因或诱因，如饮食、接触史、药物史、感染史等。

②初发病损的类型、形态、部位。

③病损发生的次序，进展速度和演变情况。

④局部和全身的自觉症状与程度。

⑤病情与季节、气候、饮食、环境、职业、精神状态等有何关系。

⑥治疗经过与疗效，有无不良反应。

3．过去史曾患过何种皮肤病，有无药物过敏与其他变态反应性疾病及传染病史。

4．个人史应注意职业、族居地，有无与类似患者接触及不洁性交史。

5．家庭或在单位中有无同类皮肤病患者。

必要时记明父母是否近亲婚配。

（二）体格检查全身检查要求详见一般病历（第2页）。

皮肤检查检查时应有充足的光线（以自然线为佳）及适当的室温，应检视全身皮肤，注意毛发、指甲、粘膜是否正常，必要时可用放大镜协助检查，并画简图说明。

检查皮肤病损时所应注意的项目如下：1．视诊①类型：原发或继发，单型或多型。

②分布：部分局限或泛发，单侧或对称，何处病损较多，遮盖部位或暴露部位，侵及伸侧或屈侧，皮肤粘膜交界与皮肤皱褶处有无病损，是否沿神经血管或按毛囊分布。

③排列：成群、散在、融合、孤立、弥漫性、线条性、环形或多弧形、蛇形或地图形。

④数目、大小与形态。

⑤颜色及表面状态（湿润或干燥，。

有无鳞屑及结痂）。

⑥界限是否分明，周围皮肤色泽如何。

2．触诊病损硬度、肥厚及浸润程度，局部温度，有无压痛或波动，能否推动，必要时检查浅感觉有无障碍。

3．压诊以手指或玻片压迫局部，了解玻片下病损的色调及有无皮内出血。

了解水肿是凹陷性还是非凹陷性。

4．刮诊用钝器在病损上轻刮，观察有无糠粃样鳞屑。

或检视鳞屑下面病损情况，如有无点状出血现象等。

5．嗅诊检查病损及分泌物有无特殊臭味。

6．皮肤划痕试验以钝器划痕后观察局部皮肤有无条状风团形成。

-----------皮肤科病历举例入院记录仇天柱。

皮肤科大病历书写范文英文回答：As a dermatologist, I come across a variety of skin conditions in my practice. One common condition that Ioften see is eczema. Eczema is a chronic inflammatory skin disorder that can cause itching, redness, and dryness. It can be quite uncomfortable for the patients and can affect their quality of life.When a patient with eczema comes to see me, I start by taking a detailed medical history. I ask about their symptoms, such as when they first noticed the rash, if itis itchy, and if they have any triggers that worsen the condition. I also inquire about their personal and family history of eczema or other allergic conditions.After taking the medical history, I conduct a thorough physical examination of the patient's skin. I look for any signs of inflammation, such as redness, swelling, or oozing.I also inspect the affected areas for any secondary infections that may have developed due to scratching.In some cases, I may need to perform additional tests to confirm the diagnosis or rule out other skin conditions. These tests may include a skin biopsy or patch testing to identify specific allergens that may be triggering the eczema.Once the diagnosis is confirmed, I discuss the treatment options with the patient. I explain that eczemais a chronic condition that cannot be cured, but it can be managed effectively. I recommend a combination of lifestyle modifications and medications to control the symptoms.Lifestyle modifications may include avoiding triggers such as certain fabrics or detergents that irritate the skin. I also advise patients to keep their skin moisturized and to avoid excessive bathing or hot water, as it can dry out the skin further.In terms of medications, I may prescribe topicalcorticosteroids to reduce inflammation and itching. In severe cases, I may prescribe oral corticosteroids forshort-term use. Other options include topical calcineurin inhibitors, antihistamines, and immunomodulators.Regular follow-up visits are essential to monitor the patient's progress and adjust the treatment plan if necessary. I encourage my patients to ask questions and express any concerns they may have during these visits. Itis important to have open and honest communication toensure the best possible outcome.中文回答：作为一名皮肤科医生，我在我的实践中经常遇到各种皮肤疾病。

美容皮肤科门诊病历书写范文英文回答：As a dermatologist, I often encounter patients with various skin concerns in my cosmetic dermatology clinic. It is essential to maintain accurate and detailed medical records to provide the best possible care for my patients. Here is an example of how I would write a medical recordfor a patient with a common skin condition.Patient Information:Name: John Smith.Age: 35。

Gender: Male.Date of Visit: 1st October 2021。

Chief Complaint:The patient presented with a complaint of persistent acne on his face.History of Present Illness:The patient reports that he has been experiencing acne breakouts for the past six months. He mentions that the acne primarily affects his forehead, cheeks, and chin. The patient has tried over-the-counter acne treatments without significant improvement. He is concerned about the appearance of his skin and the negative impact it has on his self-esteem.Past Medical History:The patient has no significant past medical history. He has never experienced any skin conditions before.Review of Systems:The patient denies any other symptoms or complaints. There is no history of allergies or sensitivities to medications.Physical Examination:Upon examination, the patient has multiple comedones, papules, and pustules on his forehead, cheeks, and chin. The lesions are predominantly inflammatory with some evidence of scarring. The rest of the physical examination is unremarkable.Assessment and Plan:Based on the patient's history and physical examination findings, the diagnosis of moderate acne vulgaris is made.I explained to the patient that acne is a common skin condition caused by a combination of factors such as excess oil production, clogged pores, bacteria, and inflammation.I discussed the treatment options with the patient, including topical retinoids, benzoyl peroxide, and oral antibiotics. I also emphasized the importance of a properskincare routine and lifestyle modifications, such as avoiding excessive sun exposure and maintaining a healthy diet.I prescribed a topical retinoid cream to be applied once daily in the evening, along with a benzoyl peroxide wash to be used twice daily. I also prescribed an oral antibiotic to be taken daily for six weeks to help reduce the inflammation and control the acne. I informed the patient about possible side effects and advised him to follow up in four weeks to assess the treatment's effectiveness and make any necessary adjustments.中文回答：作为一名皮肤科医生，在我的美容皮肤科门诊中，我经常遇到各种皮肤问题的患者。