病历书写(英文)

英语病历作文格式模板英文回答：Medical History Template。

Patient Information。

Name:Date of Birth:Address:Phone Number:Email:Insurance Information:Chief Complaint。

A brief summary of the patient's primary reason for the visit.Example: "The patient presents with a 3-day history of fever and chills."History of Present Illness。

A detailed description of the patient's symptoms, including:Onset: When did the symptoms first appear?Duration: How long have the symptoms been present?Severity: How severe are the symptoms?Location: Where are the symptoms located?Associated symptoms: Any other symptoms that are present, such as nausea, vomiting, or headache.Past Medical History。

A list of any previous medical conditions, surgeries, or hospitalizations.Example: "The patient has a history of hypertension and hyperlipidemia."Family History。

英文病历书写：疼痛(1)当上楼梯时，突然痛了起来，并且持续不止。

The pain came on suddenly while walking up the stairs and it was persistent.疼痛的发生感觉疼痛 feel (have; suffer from) a pain; pain is felt in ; feel painful头痛 have a headache; be troubled with a headache; feel a pain in one's head患剧烈头痛 have a nasty (bad) headache时常头痛 be subject (a martyr) to headaches有撞击似的两侧性头痛 have bilateral pounding headaches头痛逐渐地变为频发(较不严重) headaches gradually become more frequent (less severe)ex1:咀嚼时，有偶发的、暂时的、不可言状的疼痛或敏感。

There is occasional， transient， nondescript pain， or sensibility during mastication.ex2:该齿对于压迫作痛，且有钝麻如咬的疼痛。

The tooth became sore to pressure and there is a dull gnawing pain.发生时间ex1:Epigastric pain comes immediately after meal.ex2:Colic pain came on and off since yesterday.ex3:This pain has been relentlessly postprandial， regardless of the character of her meals.ex4:The joint pains were present mainly at night， with relief during the day.ex5:The mild frontal headaches were usually present upon awakening，but not severe enough to require analgesics.ex6:The pain usually commenced within 30 minutes after meals and lasted 1 to 3 hours.发生原因ex1:He described the pain as dull and aching， occurring approximately once a week， unrelated to food intake， and radiating to his back.(2)起初疼痛无变化，但数小时时变成发作性的'痛。

化疗病人病历书写范文英文回答：Chemotherapy Patient Medical Record Writing Sample.Patient Name: John Smith.Age: 45。

Gender: Male.Date of Admission: 12th September 2021。

Diagnosis: Stage III Lung Cancer.Chief Complaint:The patient presented with persistent cough, shortness of breath, and chest pain for the past two months. He also reported unintentional weight loss and fatigue.Present Illness:The patient's symptoms started gradually with a persistent cough and progressively worsened over the past two months. He experienced increasing shortness of breath and chest pain, which prompted him to seek medical attention. The patient also noticed a significant weight loss of approximately 10 kg during this period. He reported feeling fatigued and weak, unable to perform his daily activities.Past Medical History:The patient has a history of smoking for the past 20 years. He has no known allergies or previous surgeries. There is no family history of cancer.Physical Examination:Upon examination, the patient appeared pale and fatigued. He had decreased breath sounds on the left lungwith dullness to percussion. No lymphadenopathy or hepatosplenomegaly was noted. Vital signs were stable, with a blood pressure of 120/80 mmHg, heart rate of 80 bpm, respiratory rate of 18 breaths per minute, and oxygen saturation of 95% on room air.Investigations:Chest X-ray revealed a large mass in the left lung with mediastinal lymphadenopathy. Computed tomography (CT) scan confirmed the presence of a 7 cm tumor in the left upper lobe of the lung. Biopsy results confirmed the diagnosis of stage III lung cancer.Treatment Plan:The patient will undergo chemotherapy as the primary treatment modality. The chemotherapy regimen will consist of a combination of platinum-based drugs, such as cisplatin or carboplatin, along with a taxane-based drug, such as paclitaxel or docetaxel. The treatment plan will be administered in cycles, with each cycle lasting for threeweeks. The patient will receive a total of six cycles of chemotherapy.Expected Outcomes:The goals of chemotherapy in this patient are to shrink the tumor, alleviate symptoms, and prolong survival. The expected outcomes include a reduction in tumor size, improvement in respiratory symptoms, and an increase in overall quality of life.Follow-up Plan:The patient will be closely monitored during the chemotherapy treatment. Regular blood tests will be performed to assess the patient's blood counts and organ function. Imaging studies, such as CT scans, will be repeated after completion of chemotherapy to evaluate treatment response. The patient will also receive supportive care, including antiemetic medications to manage chemotherapy-related side effects.中文回答：化疗病人病历书写范文。

角膜炎病历书写范文英文回答：Patient Name: John Smith.Age: 35。

Date of Admission: 10/15/2021。

Chief Complaint:The patient presents with redness, pain, and blurred vision in the right eye for the past 3 days.History of Present Illness:The patient reports a gradual onset of symptoms, including eye pain, light sensitivity, and excessive tearing. He denies any trauma or foreign body sensation in the eye. The symptoms have not improved with over-the-counter eye drops.Past Medical History:The patient has a history of seasonal allergies and occasional dry eye symptoms. He denies any previous eye infections or surgeries.Medications:The patient takes over-the-counter allergy medication as needed.Family History:Non-contributory.Social History:The patient is a non-smoker and denies alcohol or drug use.Review of Systems:Negative for fever, chills, headache, or changes in vision in the left eye.Physical Examination:Visual acuity 20/30 in the right eye, 20/20 in the left eye. Slit-lamp examination reveals corneal opacity, conjunctival injection, and decreased corneal sensation in the right eye. The left eye examination is unremarkable.Diagnosis:Right eye keratitis, likely due to bacterial or viral etiology.Plan:The patient will be started on topical antibiotic eye drops and will be scheduled for a follow-up appointment in 3 days to monitor the response to treatment.英文回答结束。

英文病历书写范例（内科）Medical Records for AdmissonMedical Number: 701721General informationName: Liu SideAge: EightySex: MaleRace: HanNationality: ChinaAddress: NO.35, Dandong Road, Jiefang Rvenue, Hankou, Hubei.Tel: 857307523Occupation: RetiredMarital status: MarriedDate of admission: Aug 6th, 2001Date of record: 11Am, Aug 6th, 2001Complainer of history:patient’s son and wifeReliability: ReliableChief complaint: Upper bellyache ten days, haematemesis, hemafecia and unconsciousness for fo ur hours.Present illness:The patient felt upper bellyache about ten days ago. He didn’t pay attention to it and thought heha date something wrong. At 6 o’cloc k this morning he fainted and rejected lots of blood and gore. T hen hemafecia began. His family sent him to our hospital and received emergent treatment. So the patient was accepted because of “upper gastrointestine hemorrhage and exsanguine shock”. Since the disease coming on, the patient didn’t urinate. Past historyThe patient is healthy before.No history of infective diseases. No allergy history of food and drugs.Past history Operative history: Never undergoing any operation. Infectious history: No history of s evere infectious disease. Allergic history: He was not allergic to penicillin or sulfamide. Respirator y system: No history of respiratory disease. Circulatory system: No history of precordial pain. Ali mentary 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 sys tem: No history of headache or dizziness. Personal historyHe was born in Wuhan on Nov 19th, 1921 and almost always lived in Wuhan. His living condition s were good. No bad personal habits and customs.Menstrual history: He is a male patient. Obstetrical history: NoContraceptive history: Not clear.Family history: His parents have both deads. Physical examinationT 36.5℃, P 130/min, R 23/min, BP 100/60mmHg. He is well developed and moderately nourished.Active position. His consciousness was not clear. His face was cadaverous and the skin was not sta ined yellow. No cyanosis. No pigmentation. No skin eruption. Spider angioma was not seen. No pi tting edema. Superficial lymph nodes were not found enlarged. HeadCranium: Hair was black and white, well distributed. No deformities. No scars. No masses. No ten derness.Ear: Bilateral auricles were symmetric and of no masses. No discharges were found in external au ditory 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 nare s flaring. No tenderness in nasal sinuses. Eye: Bilateral eyelids were not swelling. No ptosis. No e ntropion. Conjunctiva was not congestive. Sclera was anicteric. Eyeballs were not projected or dep ressed. Movement was normal. Bilateral pupils were round and equal in size. Direct and indirect p upillary reactions to light were existent.Mouth: Oral mucous membrane was not smooth, and there were ulcer can be seen. Tongue was in midline. Pharynx was congestive. Tonsils were not enlarged.Neck: Symmetric and of no deformities. No masses. Thyroid was not enlarged. Trachea was in mi dline. ChestChestwall: Veins could not be seen easily. No subcutaneous emphysema. Intercostal space was nei ther narrowed nor widened. No tenderness.Thorax: Symmetric bilaterally. No deformities. Breast: Symmetric bilaterally.Lungs: Respiratory movement was bilaterally symmetric with the frequency of 23/min. thoracic e xpansion 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 imp ulse was in 5th left intercostal space inside of the mid clavicular line and not diffuse. No pericardi al friction sound. Border of the heart was normal. Heart sounds were strong and no splitting. Rate 150/min. Cardiac rhythm was not regular. No pathological murmurs.Abdomen: Flat and soft. No bulge or depression. No abdominal wall varicosis. Gastralintestinal ty pe or peristalses were not seen. Tenderness was obvious around the navel and in upper abdoman. T here was not rebound tenderness on abdomen or renal region. Liver and spleen was untouched. No masses. Fluidthrill negative. Shifting dullness negative. Borhorygmus not heard. No vascular mur murs. 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 exanedInvestigationBlood-Rt: Hb 69g/L RBC 2.70T/L WBC 1. 1G/L PLT 120G/L History summary1. Patient was male, 80 years old2. Upper bellyache ten days, haematemesis, hemafecia and unconsciousness for four hours.3. No special past history.4. Physical examination: T 37.5℃, P 130/min, R 23/min, BP 100/60mmHg Superficial lymph node s were not found enlarged. No abdominal wall varicosis. Gastralintestinal type or peristalses were not seen. Tenderness was obvious around the navel and in upper abdoman. There was not rebound tenderness on abdomen or renal region. Liver and spleen was untouched. No masses. Fluidthrill ne gative. Shifting dullness negative. Borhorygmus not heard. No vascular murmurs. No other positive signs. 5. investigation information:Blood-Rt: Hb 69g/L RBC 2.80T/L WBC 1.1G/L PLT 120G/LImpression: upper gastrointestine hemorrhage Exsanguine shock出院小结（DISCHARGE SUMMARY）， ===============Department of GastroenterologyChanghai Hospital，No.174 Changhai Road Shanghai, China Phone: 86-21-25074725-803 DISCHARGE SUMMARYDA TE OF ADMISSION: October 7th, 2005 DA TE OF DISCHARGE: October 12th, 2005 ATTE NDING PHYSICIAN: Yu Bai, MD PA TIENT AGE: 18ADMITTING DIAGNOSIS:V omiting for unknown reason: acute gastroenteritis?BRIEF HISTORYA 18-year-old female with a complaint of nausea and vomiting for nearly one month who was see n at Department of Gastroenterology in Changhai Hospital, found to have acute gastroenteritis and non-atrophic gastritis. The patient was subsequently recovered and discharged soon after medicati on.REVIEW OF SYSTEMShe has had no headache, fever, chills, diarrhea, chest pain, palpitations, dyspnea, cough, hemopty sis, dysuria, hematuria or ankle edema.PAST MEDICAL HISTORYShe has had no previous surgery, accidents or childhood illness.SOCIAL HISTORY: She has no history of excessive alcohol or tobacco use.FAMIL Y HISTORYShe has no family history of cardiovascular, respiratary and gastrointestinal diseases. PHYSICAL EXAMINA TIONTemperature is 37, pulse 80, respirations 16, blood pressure 112/70. General: Plump girl in no app arent distress. HEENT: She has no scalp lesions. Her pupils are equally round and reactive to light and accommodation. Extraocular movements are intact. Sclerae are anicteric. Oropharynx is clear. There is no thyromegaly. There is no cervical or supraclvicular lymphadenopathy. Cardiovascular: Regular rate andrhythm, normal S1, S2. Chest: Clear to auscultation bilateral. Abdomen: Bowel sounds present, no hepatosplenomagaly. Extremities: There is no cyanosis, clubbing or edema. Neurologic: Cranial n erves II-XII are intact. Motor examination is 5/5 in the bilateral upper and lower extremities. Sens ory, cerebellar and gait are normal.LABORATORY DATAWhite blood cells count 5.9, hemoglobin 111g/L, hematocrit 35.4. Sodium 142, potassium 4.3, chl oride 106, CO2 25, BUN 2.6mmol/L, creatinine 57μmol/L, glucose 4.1mmol/L, Albumin 36g/L. Endoscopic ExamChronic non-atrophic gastritisHOSPITAL COURSEThe patient was admitted and placed on fluid rehydration and mineral supplement. The patient im proved, showing gradual resolution of nausea and vomiting. The patient was discharged in stable c ondition.DISCHARGE DIAGNOSIS Acute gastroenteritisChronic non-atrophic gastritisPROGNOSISGood. No medications needed after discharge. But if this patient can not get used to Chinese food, she had better return to UK as soon as possible to prevent the relapse of acute gastroenteritis. The patient is to follow up with Dr. Bai in one week. ___________________________ Yu Bai, MD D: 12/10/2005。

s0ap病历胃炎门诊病历书写范文英文回答：Gastritis Clinic Medical Record.Demographic Information.Name: [Patient Name]Date of Birth: [Date]Sex: [Gender]Occupation: [Occupation]Chief Complaint.Gastritis.History of Present Illness.The patient presents with a chief complaint of [symptoms] that have been present for [duration].The patient has a history of [relevant medical conditions].The patient has been taking [medications].Medical History.Past medical history: [List of past medical conditions]Surgical history: [List of surgical procedures]Medication history: [List of medications]Social history: [Smoking, alcohol use, drug use, etc.]Family history: [Relevant family history]Physical Examination.General: [General appearance, vital signs]Abdominal examination: [Palpation, percussion, auscultation]Other relevant examinations: [E.g., skin, mucous membranes]Diagnostic Tests.Blood tests: [Complete blood count, chemistry panel]Imaging studies: [Upper endoscopy, barium swallow]Other tests: [As indicated]Differential Diagnosis.Peptic ulcer disease.Gastroesophageal reflux disease.Irritable bowel syndrome.Inflammatory bowel disease.Other.Diagnosis.Gastritis.Treatment Plan.Medications:Proton pump inhibitors (PPIs)。

噎食病人病历书写范文英文回答：Choking Patient Medical Record Template.I. Patient Information.Name:Date of Birth:Gender:Address:Contact Number:II. Chief Complaint.Choking episode.III. History of Present Illness.Describe the circumstances leading up to the choking episode, including any potential triggers.Outline the symptoms experienced by the patient, including difficulty breathing, coughing, and gagging.Indicate the duration and severity of the symptoms.IV. Past Medical History.Any previous history of choking episodes or respiratory problems.Known allergies or medical conditions.Current medications.V. Physical Examination.Airway: Assess the patency of the airway and any signs of obstruction.Neck: Examine for any swelling, pain, or tenderness.Chest: Auscultate for wheezing, crackles, or other abnormal sounds.Vital Signs: Measure blood pressure, pulse, and oxygen saturation.VI. Investigations.Chest X-ray: May be indicated to rule out any underlying pulmonary conditions.Flexible Bronchoscopy: May be used to visualize the airway and remove any foreign bodies.VII. Diagnosis.Choking episode.VIII. Management.Initial Stabilization:Assess and maintain airway patency.Provide supplemental oxygen if needed.Initiate cardiac monitoring.Foreign Body Removal:Attempt manual removal of the foreign body using the Heimlich maneuver or finger sweeps.If unsuccessful, consider using endoscopic or surgical techniques.Post-Procedure Care:Monitor the patient for any complications, such asaspiration or pneumonia.Provide antibiotics if indicated.IX. Discharge Instructions.Explain the symptoms and signs of respiratory distress.Advise the patient to seek immediate medical attention if these symptoms occur.Provide follow-up appointments as necessary.中文回答：噎食病人病历书写范文。

急诊抢救病历的书写范文英文回答：Emergency Department Resuscitation Note Template.Patient Information:Name:Medical Record Number:Date of Birth:Sex:Time of Arrival:Presenting Complaint:Brief description of the patient's chief complaint.Vital Signs on Arrival: Blood pressure:Pulse:Respiratory rate:Temperature:Oxygen saturation:Physical Examination: General appearance:Skin:Head and neck:Thorax:Abdomen:Ext extremities:Neurological:History of Present Illness:Detailed description of the patient's symptoms, onset, duration, and any aggravating or relieving factors.Past Medical History:Significant past medical history, including any medical conditions, surgeries, or allergies.Medications:List of all medications the patient is currently taking, including doses and frequency.Allergies:List of any known allergies, including medications, food, or environmental triggers.Social History:Brief overview of the patient's social history, including occupation, smoking status, alcohol use, and drug use.Family History:Significant family history, including any medical conditions or genetic disorders.Assessment and Plan:Summary of the patient's overall clinical condition and a diagnostic impression.Description of the resuscitative measures performed,including medications, fluids, and procedures.Outline of the patient's immediate and long-term treatment plan.Disposition:Indication of the patient's disposition, such as admission to the hospital, discharge home, or transfer to another facility.中文回答：急诊抢救病历书写范文。

口腔科英文病历书写范文Patient Information.Name: [Patient Name]Age: [Patient Age]Chief Complaint.[Patient's chief complaint, e.g., "Pain in the lower left quadrant of the mouth"]History of Present Illness.Onset: [Date or time of onset]Duration: [How long the symptoms have been present]Severity: [Patient's description of the pain or discomfort]Associated symptoms: [Other symptoms associated with the chief complaint, e.g., swelling, bleeding, discharge]Aggravating factors: [Activities or situations that worsen the symptoms]Alleviating factors: [Activities or situations that relieve the symptoms]Previous treatment: [Any previous treatments the patient has received for the symptoms]Medical History.Past medical history: [Any significant past medical conditions, surgeries, or hospitalizations]Current medications: [All medications the patient is currently taking, including prescription and over-the-counter drugs]Allergies: [Any known allergies to medications orother substances]Social history: [Relevant social history, such as tobacco use, alcohol use, or occupational exposures]Dental History.Last dental visit: [Date of the patient's last dental appointment]Dental problems: [Any previous or current dental problems, including cavities, gum disease, or dental trauma]Dental habits: [Patient's daily oral hygiene routine, including brushing, flossing, and using mouthwash]Extraoral Examination.Head and neck: [Evaluation of the head and neck, including symmetry, lymph nodes, and range of motion]Face: [Evaluation of the face, including skin texture, color, and symmetry]Intraoral Examination.Soft tissues: [Examination of the soft tissues of the mouth, including the lips, cheeks, tongue, and palate]Hard tissues: [Examination of the hard tissues of the mouth, including the teeth and supporting structures]Periodontal examination: [Evaluation of theperiodontal tissues, including the gums, periodontal pockets, and bone levels]Occlusion: [Examination of the patient's bite]Radiographic Examination.[List of any radiographic examinations performed, e.g., X-rays, panoramic views, or CT scans]Findings: [Description of the radiographic findings]Diagnosis.[Diagnosis based on the history, examination, and radiographic findings]Treatment Plan.[Description of the recommended treatment plan, including any medications, procedures, or lifestyle modifications]Patient education: [Instructions for the patient onhow to care for their oral health and manage their symptoms]Progress Notes.[Follow-up progress notes documenting the patient's response to treatment, any changes in their symptoms, and any adjustments to the treatment plan]Additional Information.[Any other relevant information, such as the patient's dental insurance information or contact information for their primary care physician]。

直肠恶性肿瘤病历书写范文(中英文实用版)英文文档内容:Case History: Rectal Malignant TumorPatient Information:- Name: [Patient"s Name]- Age: [Patient"s Age]- Gender: [Patient"s Gender]- Date of Admission: [Date of Admission]- Date of Discharge: [Date of Discharge]Medical History:- Chief Complaint: [Chief Complaint]- History of Present Illness: [History of Present Illness] - Past Medical History: [Past Medical History]- Surgical History: [Surgical History]- Medications: [List of Medications]Physical Examination:- Vital Signs: [Vital Signs]- General Appearance: [General Appearance]- Abdomen: [Examination of Abdomen]- Anus and Rectum: [Examination of Anus and Rectum] Laboratory Investigations:- Complete Blood Count (CBC): [CBC Results]- Blood Chemistry: [Blood Chemistry Results]- Colonicoscopy: [Colonicoscopy Results]- Biopsy: [Biopsy Results]Diagnosis:- Rectal Malignant Tumor- Stage [Stage]Treatment Plan:- Initial Management: [Initial Management]- Surgical Procedure: [Surgical Procedure]- Adjuvant Therapy: [Adjuvant Therapy]- Follow-up Plan: [Follow-up Plan]Discharge Instructions:- Home Care: [Home Care Instructions]- Follow-up Appointments: [Follow-up Appointments]- Dietary Recommendations: [Dietary Recommendations]- Activity Level: [Activity Level Recommendations]Conclusion:This case history presents a comprehensive overview of a patient diagnosed with a rectal malignant tumor.The document includes essential patient information, detailed medical history, physical examination findings, and laboratory investigations.The treatment planoutlines the necessary interventions and follow-up care.The discharge instructions provide guidance for post-discharge management.中文文档内容：病例摘要：直肠恶性肿瘤患者信息：- 姓名：[患者姓名]- 年龄：[患者年龄]- 性别：[患者性别]- 入院日期：[入院日期]- 出院日期：[出院日期]病史：- 主诉：[主诉]- 现病史：[现病史]- 既往病史：[既往病史]- 手术史：[手术史]- 药物：[药物列表]体格检查：- 生命体征：[生命体征]- 一般情况：[一般情况]- 腹部：[腹部检查]- 肛门和直肠：[肛门和直肠检查]实验室检查：- 血常规：[血常规结果]- 生化检查：[生化检查结果]- 结肠镜检查：[结肠镜检查结果]- 活检：[活检结果]诊断：- 直肠恶性肿瘤- 分期：[分期]治疗计划：- 初始管理：[初始管理]- 手术方案：[手术方案]- 辅助治疗：[辅助治疗]- 随访计划：[随访计划]出院指导：- 家庭护理：[家庭护理指导]- 随访预约：[随访预约]- 饮食建议：[饮食建议]- 活动水平：[活动水平建议]结论：本病例摘要详细介绍了一位被诊断为直肠恶性肿瘤的患者的病历信息。