英语病历范文

医学英语阅读：英文病历

a sample of complete history

patient's name： mary swan

chart number： 660518

date of birth：10-5-1993

sex： female

date of admission： 10-12-2000

date of discharge： 10-15-2000

final discharge summary

chief complaint：

coughing, wheezing with difficult respirations.

present illness：

this is the first john hopkins hospital admission for

this seven-year-old female with a history of asthma since the

age of 3 who had never been hospitalized for asthma before

and had been perfectly well until three days prior to

admission when the patient development shortness of breath

and was unresponsive to tedral or cough medicine.

the wheezing progressed and the child was taken to john

hopkins hospital emergency room where the child was given

epinephrine and oxygen. she was sent home. the patient was

医学英语病历范文

Medical Record

Patient Information:

Name: John Smith

Age: 45

Gender: Male

Date of admission: [Date]

Date of birth: [Date]

Weight: [Weight]

Height: [Height]

Chief complaint:

Mr. Smith presents with a severe headache that has been ongoing

for the past two days.

History of present illness:

The patient reports experiencing a sudden onset of throbbing

headache, localized primarily on the left side of his head. The pain

is aggravated by physical exertion and is accompanied by nausea

and sensitivity to light and sound. The patient denies any recent

head trauma or sinus congestion. Over-the-counter pain relievers

have provided minimal relief.

Medical history:

Mr. Smith has a history of hypertension, for which he takes

medication. He does not have any known allergies, and there is no

family history of migraines or neurological disorders.

Good morning. Today, I am honored to present a case report on a patient

who recently visited our medical facility. This case highlights a

complex medical condition that required a multidisciplinary approach for

diagnosis and treatment. I will discuss the patient's history, physical

examination findings, laboratory and imaging results, and the subsequent

management plan.

Patient Information:

- Name: John Smith

- Age: 45 years

- Gender: Male

- Date of admission: March 15, 2023

- Date of discharge: March 30, 2023

Medical History:

John Smith presented to our emergency department with a chief complaint

of progressive shortness of breath and fatigue over the past two weeks.

He reported a history of hypertension and type 2 diabetes mellitus,

which were well-controlled on medication. He denied any recent illnesses,

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,