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英文病历模版

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Name: ______________ Sex: __________ Age: ___________ Nation: ___________

Birth Place: ________________________________ Marital Status:____________

Work-organization & Occupation: _______________________________________

Living Address & Tel: _________________________________________________

Date of admission: _______Date of history taken:_______ Informant:__________

Chief Complaint: ___________________________________________________

History of Present Illness:

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Past History:

General Health Status: 1.good 2.moderate 3.poor

Disease history: (if any, please write down the date of onset, brief diagnostic

and therapeutic course, and the results.) 精选文档

II / 9 Respiratory system:

1. None 2.Repeated pharyngeal pain 3.chronic cough 4.expectoration:

5. Hemoptysis 6.asthma 7.dyspnea 8.chest pain

_______________________________________________________________

Circulatory system:

1.None 2.Palpitation 3.exertional dyspnea 4..cyanosis 5.hemoptysis

6.Edema of lower extremities 7.chest pain 8.syncope 9.hypertension

_______________________________________________________________

Digestive system:

1.None 2.Anorexia 3.dysphagia 4.sour regurgitation 5.eructation

6.nausea 7.Emesis 8.melena 9.abdominal pain 10.diarrhea

11.hematemesis 12.Hematochezia 13.jaundice

_______________________________________________________________

Urinary system:

1.None 2.Lumbar pain 3.urinary frequency 4.urinary urgency 5.dysuria

6.oliguria 7.polyuria 8.retention of urine 9.incontinence of urine

10.hematuria 11.Pyuria 12.nocturia 13.puffy face

_______________________________________________________________

Hematopoietic system:

1.None 2.Fatigue 3.dizziness 4.gingival hemorrhage 5.epistaxis

6.subcutaneous hemorrhage

_______________________________________________________________

Metabolic and endocrine system:

1.None 2.Bulimia 3.anorexia 4.hot intolerance 5.cold intolerance

6.hyperhidrosis 7.Polydipsia 8.amenorrhea

9.tremor of hands 10.character change 11.Marked obesity

12.marked emaciation 13.hirsutism 14.alopecia

15.Hyperpigmentation 16.sexual function change

_______________________________________________________________

Neurological system:

1.None 2.Dizziness 3.headache 4.paresthesia 5.hypomnesis

6. Visual disturbance 7.Insomnia 8.somnolence

9.syncope 10.convulsion 11.Disturbance of consciousness

12.paralysis 13. vertigo

_______________________________________________________________

Reproductive system:

1.None 2.others

_______________________________________________________________

Musculoskeletal system:

1.None 2.Migrating arthralgia 3.arthralgia 4.artrcocele 5.arthremia

6.Dysarthrosis 7.myalgia 8.muscular atrophy

_______________________________________________________________

Infectious Disease: 精选文档

III / 9 1.None 2.Typhoid fever 3.Dysentery 4.Malaria 4.Schistosomiasis

4.Leptospirosis 7.Tuberculosis 8.Epidemic hemorrhagic fever

9.others

_______________________________________________________________

Vaccine inoculation:

1.None 2.Yes 3.Not clear

Vaccine detail __________________________________________

Trauma and/or operation history:

Operations:

1.None 2.Yes

Operation details:_______________________________________

Traumas:

1.None 2.Yes

Trauma details:_________________________________________

Blood transfusion history:

1.None 2.Yes ( 1.Whole blood 2.Plasma 3.Ingredient transfusion)

Blood type:____________ Transfusion time:___________

Transfusion reaction

1.None 2.Yes

Clinic manifestation:_____________________________

Allergic history:

1.None 2.Yes 3.Not clear

allergen:________________________________________________

clinical manifestation:_____________________________________

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淋巴瘤病历模板范文

淋巴瘤病历模板范文

淋巴瘤病历模板范文

英文回答：

Lymphoma Medical Record Template Sample.

Patient Information:

Name: John Smith.

Age: 45。

Gender: Male.

Date of Admission: 15th March 2022。

Chief Complaint:

The patient presented with persistent fatigue,

unexplained weight loss, and enlarged lymph nodes in the

neck and groin region.

Medical History:

The patient has no significant past medical history. He

is a non-smoker and has no known allergies. There is no

family history of lymphoma or any other malignancies.

Physical Examination:

Upon physical examination, the patient appeared pale

and fatigued. Multiple enlarged lymph nodes were palpable

in the neck, axilla, and groin regions. The largest lymph

node measured approximately 3 cm in diameter. No

hepatosplenomegaly or other abnormal findings were noted.

呼吸科英文病历范文

呼吸科英文病历范文

呼吸科英文病历范文

ENGLISHCASE700756(Respiratory department)

----------------------------Name: Liyuzhen `Age:42 yearsSex: FemaleRace:

HanOccupation: Free occupationNationality: ChinaMarried status: married

Addre: Qianjing Road No.16, Wuhan Hankou.

thDate of admiion: July 26, 2001

thDate of record: July 26, 2001

Present illne:

Two days ago the patient suddenly started to cough and feel

Her spirit,sleep,appetite were normal.stool and urine were

normal, too.

----------------------------PastHistory:

General health status: normal

Operation history: thyroidectomy.

Infection history: No history of tuberculosis or hepatitis.Allergic history: allergic to a

lot of drugs such as sulfanilamideTraumatic history: No traumatic history

----------------------------Systemreview

Respiratorysystem: No history of repeated pharyngodynia, chroniccough,

淋巴瘤病历书写范文

淋巴瘤病历书写范文

淋巴瘤病历书写范文

英文回答：

Patient Name: [Patient's Name]

Gender: [Patient's Gender]

Age: [Patient's Age]

Date of Admission: [Admission Date]

Chief Complaint:

The patient presented with complaints of persistent

fatigue, unexplained weight loss, and night sweats for the

past few months.

History of Present Illness:

The patient initially noticed fatigue and weight loss, which was accompanied by night sweats. The symptoms

gradually worsened over time, prompting the patient to seek

medical attention. There was no history of fever, cough, or

any other respiratory symptoms. The patient denied any

recent travel or exposure to sick contacts.

Past Medical History:

The patient had no significant past medical history.

There were no known allergies or adverse reactions to

medications.

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皮肤科带状疱疹病历书写范文

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 side of 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