中耳炎病历

主诉：左耳闷、听力下降4天。

现病史：患者于4天前无明显诱因出现左耳闷，伴听力下降，无明显耳痛，无耳内流脓，无鼻塞流涕，无涕中带血，无发热畏寒，无头晕头痛，无恶心呕吐，未经特殊治疗，症状无明显缓解。

现左耳闷持续，听力下降明显，无耳痛，影响患者生活质量。

遂来我院就诊，门诊检查后以“渗岀性中耳炎（左）”收入院治疗。

患者自发病来神志清，精神好，无发热畏寒，无咽痛咽干，无头晕头痛，无视物不清，无胸闷心悸，无明显消瘦，饮食、睡眠可，二便正常。

既往史：曾因"渗出性中耳炎〃行右耳鼓膜置管术两次，左耳置管一次。

高血压病史1年，现服“織沙坦”。

否认糖尿病、冠心病等重大疾病史。

否认肝炎、结核等传染病史及接触史。

否认药物及食物过敬史。

2006年及2014年分别因左眼及右眼“青光眼”行手术治疗，否认外伤、其他手术、输血史。

预防接种史随当地。

个人史、月经史、及婚育史、家族史：生于原籍，现居本地，生活及居住条件可, 否认外地久居史及疫区接触史，无工业毒物、粉尘、放射性物质接触史。

无冶游史。

无吸烟饮酒等不良嗜好。

月经：15 3-5/25-30 50o已婚，育有1子，配偶及子体健。

否认家族中遗传病史。

中医望、闻、切诊：患者神情正常，面色红润，气息平和，言语清晰，近身未闻及异常气味，舌质红，苔薄黄，脉弱。

以上病史属实患者或委托人签名：体格检查T 36.4°C P 60次/分R 16次/分BP 122/74mmHg老年女性，神志清，精神好，发育正常，营养良好，自主体位，查体合作。

全身皮肤、黏膜无黃染及出血点，浅表淋巴结未及肿大。

头颅无畸形，眼睑无水肿、充血，双侧瞳孔等大等圆，对光反射灵敬。

耳鼻喉科检查见专科检查。

颈软，无抵抗，气管居中，中状腺无肿大，颈静脉无怒张。

胸廓对称，无畸形，双侧呼吸动度均等，双肺呼吸音清，未闻及干湿啰音。

心前区无隆起，心界不大，心率60次/分，律齐，各瓣音区未闻病理性杂音。

腹平软，无圧痛及反跳痛，肝、脾未触及，无移动性浊音，双肾区无叩击痛。

中耳炎门诊病历书写范文英文回答：I remember a patient I saw last week in the clinic witha diagnosis of acute otitis media, also known as middle ear infection. The patient presented with severe ear pain, fever, and hearing loss in one ear. Upon examination, I observed redness and bulging of the tympanic membrane, which are classic signs of middle ear infection.I explained to the patient the importance of completing the full course of antibiotics prescribed to treat the infection. I also recommended over-the-counter pain relief medication to help alleviate the ear pain. I emphasized the need for follow-up to ensure the infection has cleared completely.I also provided the patient with some tips on preventing future ear infections, such as avoiding exposure to cigarette smoke and properly drying the ears afterswimming or bathing. I stressed the importance of seeking medical attention if they experience recurrent earinfections or if the symptoms worsen.Overall, the patient was grateful for the thorough explanation and treatment plan provided. They left theclinic feeling more informed and confident in managingtheir condition.中文回答：我记得上周在门诊看到一个患有急性中耳炎的病人。

急性中耳炎病历书写模板范文英文回答：Acute otitis media (AOM) is a common condition characterized by the inflammation and infection of the middle ear. It often occurs as a result of a bacterial or viral infection, causing symptoms such as ear pain, fever, and hearing loss. As a physician, it is important to accurately document the patient's medical history when diagnosing and treating AOM. Here is a template for writing a medical record for a patient with acute otitis media:Patient Information:Name: [Patient's Name]Age: [Patient's Age]Gender: [Patient's Gender]Date of Visit: [Date of Visit]Chief Complaint:The patient presents with complaints of severe ear pain in the right ear, fever, and difficulty hearing.History of Present Illness:The patient reports that the symptoms started two days ago and have been progressively worsening. The ear pain is described as sharp and throbbing, and it has been interfering with sleep. The patient also experienced ahigh-grade fever, reaching up to 39°C. T he hearing loss is noticeable, especially in noisy environments.Past Medical History:The patient has a history of recurrent ear infections during childhood, but has not experienced any ear-related issues in recent years. There are no known allergies or chronic medical conditions.Social History:The patient is a non-smoker and does not consume alcohol. The patient works in an office setting and denies exposure to loud noises or chemicals.Family History:There is no family history of ear-related problems or chronic illnesses.Physical Examination:General: The patient appears in distress, holding the right ear and grimacing in pain. Vital signs are stable.Head and Neck: Inspection of the right ear reveals erythema and swelling of the external auditory canal. Tympanic membrane examination shows bulging and decreased mobility. The left ear appears normal.Throat: No signs of tonsillar inflammation or pharyngeal erythema.Lungs and Heart: Clear breath sounds, regular heart rate and rhythm.Other Systems: No abnormalities noted.Diagnosis:Acute otitis media (AOM) right ear.Treatment:1. Analgesics: Prescribe ibuprofen 400mg every 6 hours as needed for pain relief.2. Antibiotics: Prescribe amoxicillin 500mg three timesa day for 10 days.3. Nasal decongestants: Recommend over-the-counter nasal decongestant drops for relief of nasal congestion.Follow-up:Advise the patient to return for a follow-up visit in one week to assess the response to treatment and evaluate the resolution of symptoms.中文回答：英文回答：急性中耳炎（AOM）是一种常见的疾病，其特点是中耳的炎症和感染。

入院记录姓名：性别：年龄：民族：婚姻状况：出生地：职业：入院记录：记录日期：陈述者：主诉：右外耳道渗出脓性分泌物伴疼痛3天。

现病史：患者半月前因右侧外耳瘙痒，用棉棒擦拭后发生疼痛，未在意，五六天前感觉疼痛加重，自行购买阿莫西林胶囊及牛黄解毒片等药口服，疗效欠佳，近2日感觉右耳部疼痛剧烈，夜间无法入睡，今日来我院就诊，门诊以‘中耳炎’收入院，入院以来患者精神不好，睡眠不好，饮食一般，大便干，小便正常。

既往史：平素体健，无伤寒、结核等病史，无结核病接触史，无药物及食物过敏史，无外伤及手术史。

个人史：生于原籍，无外地长期居住史。

结婚史：家族史：否认家族中有遗传性病史。

体格检查体温：39.8℃呼吸：26次/分脉搏：80次/分血压：110/70mmHg一般情况：发育正常，营养中等，自动体位，精神疲乏，神志清晰。

皮肤、粘膜：无水肿、黄疸出血及皮疹。

淋巴结：全身浅表淋巴结无肿大。

头部：头颅大小正常，头发色黑，有光泽。

眼：眼结膜无充血，巩膜无黄染。

耳：听力尚佳，右侧外耳有黄色脓性分泌物，耳廓牵拉痛，乳突区压痛，听力正常。

鼻：通畅，无分泌物，鼻窦无压痛。

口腔：唇色发干，牙龈无肿胀、出血，伸舌居中，口腔粘膜无出血点及溃疡，两侧扁桃体无肿大。

颈部：无颈静脉怒张及颈动脉异常搏动，气管居中，甲状腺无肿大。

胸部:胸廓对称，无畸形。

肺部视诊：肋间隙无增宽及变窄。

呼吸运动两侧对称。

触诊：语颤无增强或减弱，无摩擦感。

叩诊：两肺呈清音。

听诊：两肺呼吸音清，未闻及干、湿性啰音及胸膜摩擦音。

心脏视诊：心尖搏动在左侧第5肋间锁骨中线内1厘米处。

心前区无隆起，无弥散性搏动。

触诊：心尖搏动位置与视诊相同，未触及震颤。

听诊：心率70次/分，心律齐，各辧膜听诊区未闻及杂音，心包擦音。

叩诊：心界不大，心相对浊音界（见下表）锁骨中线距前正中线距离为9cｍ.周围血管征：无毛细血管搏动征及枪击音。

腹部视诊：两侧对称，平坦，无腹壁静脉曲张及胃肠蠕动波。

触诊：腹壁柔软，肝、脾、胆囊及肾未触及。

中耳炎病历书写模板范文英文回答：The patient presented with symptoms of ear pain, hearing loss, and fever. After conducting a thorough examination, I diagnosed the patient with acute otitis media, commonly known as middle ear infection. This condition is characterized by inflammation and infection of the middle ear, usually caused by bacteria or viruses.The patient complained of severe pain in the affected ear, which is a common symptom of middle ear infection. The pain is often described as a sharp, stabbing sensation that worsens when lying down or chewing. Additionally, the patient reported a gradual onset of hearing loss and a feeling of fullness or pressure in the ear.Upon examination, I observed redness and swelling of the tympanic membrane, which is a clear indication of middle ear inflammation. The eardrum appeared bulging andthere was a presence of fluid behind it. These findings confirmed the diagnosis of acute otitis media.In order to manage the patient's condition, I prescribed a course of antibiotics to eliminate the infection. Antibiotics are essential in treating bacterial ear infections, as they help to kill the bacteria causing the infection. It is important for the patient to complete the full course of antibiotics as prescribed, even if symptoms improve before the medication is finished.In addition to antibiotics, I recommended over-the-counter pain relievers to alleviate the patient's ear pain. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen can help reduce inflammation and provide temporary relief from pain. It is important to follow the recommended dosage and consult a healthcare professional if the pain persists or worsens.I also advised the patient to apply warm compresses to the affected ear to help reduce pain and promote healing. A warm compress can help soothe the ear and relievediscomfort. It is important to ensure that the compress is not too hot to avoid burning the skin.Furthermore, I discussed the importance of proper hygiene and prevention measures to avoid future ear infections. This includes practicing good hand hygiene, avoiding exposure to secondhand smoke, and maintaining a clean and dry environment for the ears.中文回答：患者出现耳痛、听力下降和发烧等症状。

中耳炎病历书写范文
病历
患者信息：
姓名：XXX 性别：女年龄：8岁
主诉：耳朵疼痛、流脓
现病史：
患者XXX于一周前开始出现耳朵疼痛，并且出现了流脓的症状。

患者家长认为是感冒引起的，于是给孩子吃了感冒药。

然而，患者的症状并没有得到改善，反而变得更加严重。

于是，将孩子带到医院就诊。

既往史：
患者无过敏史和手术史。

家族史：
无特殊家族史。

体格检查：
患者精神状态尚可，面色稍有苍白。

耳部检查，发现患者左耳外观正常，但是有明显的充血和肿胀，有分泌物。

左耳听力下降，听力测试结果为30分贝。

右耳外观正常，听力正常，无分泌物。

初步诊断：
中耳炎
治疗方案：
1.口服抗生素：阿莫西林（0.5g/次，每日3次），连续服用7天。

2.止痛消炎：布洛芬（10mg/kg，每日3次），连续服用3天。

3.营养支持：多喝水，多吃蔬菜水果，避免辛辣刺激食物。

随访及复查：
患者需于7天后复查，观察病情变化。

如症状减轻，可继续口服抗生素5天。

如症状未减轻或加重，需根据情况再做进一步处理。

备注：
中耳炎是一种常见的疾病，往往与感冒、咳嗽等疾病同时出现。

患者需要及时就诊，根据医生的建议进行治疗。

同时，家长需注意孩子的日常饮食和生活习惯，避免疾病的发生。

中耳门诊病历范文中耳炎就是中耳发炎，是一种常见玻中耳炎常发生于8岁以下儿童，其他年龄段的人群也有发生，它经常是普通感冒或咽喉感染等上呼吸道感染所引发的疼痛并发症。

为加强我省中医病案管理，病历范文通常中耳炎又分为急性与慢性中耳炎，规范中西医结合病历书写格式，急性中耳炎如果及时就医的话，可以痊愈并不再复发，但慢性中耳炎无法根治。

我省卫生部门日前制定了江西省中医、中西医结合病历书写格式，门诊病历书写范。

二、急性期延误治疗和用药不当等因素难逃其咎。

三、继发于急性传染病如猩红热、麻疹和肺炎等，并于9月1日起在全省各级中医、中西医结合病医院施行。

中耳粘膜急性坏死症侵及鼓窦乳突，中医病例病案中医住院病历书写格式住院病历书写与格式姓名性别病案号年龄婚况职业出生地民族国籍家庭住址邮政编码入院时间病史江西省中医、中西医结合病历书写格式严格规范了住院志和门急诊病历的书写格式，治疗起来非常困难。

四、乳突发育不良导致病变所致。

中医门诊病历其中住院病历填写更被细分为十五个大项其中。

五、上鼓室发生胆脂瘤、听骨坏死或鼓室外侧壁破坏。

中医、中西医结合病医院医生在填写患者入院记录时。

六、患有过敏性疾病，中医门诊病历书写在现病史一栏必须详细按时间顺序记录发病情况、主要症状特点及发生变化情况伴随症状、诊疗经过以及睡眠和饮食等一般情况变化等。

累及咽鼓管和中耳。

机体抵抗力减弱也极易引起中耳炎。

八、擤鼻涕方法不正确也可导致中耳炎。

九、游泳时如果将水咽入口中，门诊病历书写范文如病历由实习医务人员、试用期人员书写还须审阅、修改该病历的本医疗机构合法执业的医务人员一并签名。

水通过鼻咽部而进入中耳，也可能引发中耳炎。

中医中西结合执业医师技能操作考试中医中西结合执业医师技能操作考试北京张博士医考中心中医执业考试辅导之中医病例病案中医住院病历书写格式北京张博士医。

十、如果婴幼儿仰卧位吃奶十一、吸香烟包括吸二手烟，也会引起中耳炎。

急性化脓性中耳炎如果治疗不及时不彻底，则大多可能转为慢性中耳炎另外，如果有慢性鼻炎、慢性鼻窦炎及慢性扁桃体炎存在，并中耳炎潜伏下来导致慢性中耳炎。

入院记录姓名：性别：年龄：民族：婚姻状况：出生地：职业：入院记录：记录日期：陈述者：主诉：右外耳道渗出脓性分泌物伴疼痛3天。

现病史：患者半月前因右侧外耳瘙痒，用棉棒擦拭后发生疼痛，未在意，五六天前感觉疼痛加重，自行购买阿莫西林胶囊及牛黄解毒片等药口服，疗效欠佳，近2日感觉右耳部疼痛剧烈，夜间无法入睡，今日来我院就诊，门诊以‘中耳炎’收入院，入院以来患者精神不好，睡眠不好，饮食一般，大便干，小便正常。

既往史：平素体健，无伤寒、结核等病史，无结核病接触史，无药物及食物过敏史，无外伤及手术史。

个人史：生于原籍，无外地长期居住史。

结婚史：家族史：否认家族中有遗传性病史。

体格检查体温：39.8℃呼吸：26次/分脉搏：80次/分血压：110/70mmHg 一般情况：发育正常，营养中等，自动体位，精神疲乏，神志清晰。

皮肤、粘膜：无水肿、黄疸出血及皮疹。

淋巴结：全身浅表淋巴结无肿大。

头部：头颅大小正常，头发色黑，有光泽。

眼：眼结膜无充血，巩膜无黄染。

耳：听力尚佳，右侧外耳有黄色脓性分泌物，耳廓牵拉痛，乳突区压痛，听力正常。

鼻：通畅，无分泌物，鼻窦无压痛。

口腔：唇色发干，牙龈无肿胀、出血，伸舌居中，口腔粘膜无出血点及溃疡，两侧扁桃体无肿大。

颈部：无颈静脉怒张及颈动脉异常搏动，气管居中，甲状腺无肿大。

胸部:胸廓对称，无畸形。

肺部视诊：肋间隙无增宽及变窄。

呼吸运动两侧对称。

触诊：语颤无增强或减弱，无摩擦感。

叩诊：两肺呈清音。

听诊：两肺呼吸音清，未闻及干、湿性啰音及胸膜摩擦音。

心脏视诊：心尖搏动在左侧第5肋间锁骨中线内1厘米处。

心前区无隆起，无弥散性搏动。

触诊：心尖搏动位置与视诊相同，未触及震颤。

听诊：心率70次/分，心律齐，各辧膜听诊区未闻及杂音，心包擦音。

叩诊：心界不大，心相对浊音界（见下表）右侧（cｍ）肋间左侧（cｍ）2.5 II 32.5 III 43 IV7.0V8.5锁骨中线距前正中线距离为9cｍ.周围血管征：无毛细血管搏动征及枪击音。

中耳炎的病历书写范文英文回答：The medical record of a patient with otitis media:Name: John Smith.Age: 30。

Date of admission: 01/05/2021。

Date of discharge: 05/05/2021。

Chief Complaint:The patient complained of severe ear pain and decreased hearing in the right ear for the past two days.History of Present Illness:The patient reports experiencing a sudden onset of ear pain in the right ear two days ago. The pain has been constant and sharp, and it has been accompanied by a decrease in hearing. There is no history of trauma or foreign body insertion in the ear. The patient denies any recent upper respiratory tract infection or swimming activities.Past Medical History:The patient has no significant past medical history. He has never been diagnosed with otitis media or any otherear-related conditions.Physical Examination:On examination, the patient appeared to be in moderate distress due to the pain. The right ear canal was erythematous and swollen. There was tenderness on palpation of the tragus. Otoscopy revealed a bulging and opaque tympanic membrane with decreased mobility. The left ear and the rest of the physical examination were unremarkable.Diagnosis:Based on the history and physical examination findings, the patient was diagnosed with acute otitis media in the right ear.Treatment:The patient was prescribed a course of oral antibiotics (amoxicillin) for ten days to treat the bacterial infection. Pain relief was achieved with the use of analgesics (ibuprofen). The patient was advised to avoid water exposure to the affected ear and to complete the fullcourse of antibiotics.Follow-up:The patient was instructed to follow up in one week to assess the response to treatment and to evaluate the resolution of symptoms.中文回答：患者姓名，约翰·史密斯。