第一篇：英文病历示范范文
妇科英文病历
CASE
Medical Number: 756943 General information Name: Yue Jun-rong Age: Forty- two years old Sex: Female Race: Han Occupation: Unemployment Nationality: China Marital status: Married Address: Xiaochang county
of
Xiaogan city in Hubei. Tel: 4835963
Date of admission: Feb.27th, 2003 Date of record: 3pm, Feb.27th, 2003 Complainer of history: the patient herself
Reliability: Reliable Chief complaint: The patient was found “myoma of uterus” over two years ago and menometrorrhagia for 5 months. Present illness: In 1999, the patient was found “myoma of uterus” in a physical examination. But she had nothing uncomfortable and her catamenia was normal. She used some Chinese traditional medicine. About 5 months ago, she found the cycle of her catamenia was shorten from 30 days to 20 days and the period lasted from 2 days to 4 days. She felt no pain and the quantity was normal. She was accepted in our hospital and her diagnosis was “subserous myoma of uterus”. Since onset, her appetite was good, and both her spiritedness and physical energy are normal. Defecation and urination are normal, too.
Past history Operative history: Never undergoing any operation. Infectious history: No history of severe infectious disease. Allergic history: She was not allergic to penicillin or sulfamide. Respiratory system: No history of respiratory disease.
Circulatory system: No history of precordial pain. Alimentary 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 system: No history of headache or dizziness. Personal history She was born in Hubei on July 16th, 1956 and almost always lived in Wuhan. She graduated from senior high school. Her living conditions were good. No bad personal habits and customs. Menstrual history: The first time when she was 14. Lasting 2 days every times and its cycle is about 30 days. Obstetrical history: Pregnacy 3 times, once nature production, induced abortion twice.
Contraceptive history: Not clear. Family history: His parents are both alive.
Physical examination
T 36.8℃, P 80/min, R 20/min, BP 120/80mmHg. She is well developed and moderately nourished. Active position. The skin was not stained yellow. No cyanosis. No pigmentation. No skin eruption. Spider angioma was not seen. No pitting edema. Superficial lymph nodes were not enlarged. Head
Cranium: Hair was black and well distributed. No deformities. No scars. No masses. No tenderness.
Ear: Bilateral auricles were symmetric and of no masses. No discharges were found in external auditory 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 nares flaring. No tenderness in nasal sinuses.
Eye: Bilateral eyelids were not swelling. No ptosis. No entropion. Conjunctiva was not congestive. Sclera was anicteric. Eyeballs were not projected or depressed. Movement was normal. Bilateral pupils were round and equal in size. Direct and indirect pupillary reactions to light were existent.
Mouth: Oral mucous membrane was smooth, and of no ulcer or erosion. Tongue was in midline. Pharynx was not congestive. Tonsils were not enlarged.
Neck: Symmetric and of no deformities. No masses. Thyroid was not enlarged. Trachea was in midline. Chest
Chestwall: Veins could not be seen easily. No subcutaneous emphysema. Intercostal space was neither narrowed nor widened. No tenderness.
Thorax: Symmetric bilaterally. No deformities.
Breast: Symmetric bilaterally. Neither nipples nor skin were retracted. Elasticity was fine.
Lungs: Respiratory movement was bilaterally symmetric with the frequency of 20/min. Thoracic expansion 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 impulse was in 5th left intercostal space inside of the mid clavicular line and not diffuse. No pericardial friction sound. Border of the heart was normal. Heart sounds were strong and no splitting. Rate 80/min. Cardiac rhythm was regular. No pathological murmurs. Abdomen: Flat and soft. No bulge or depression. No abdominal wall varicosis. Gastralintestinal type or peristalses were not seen. There was not tenderness and rebound tenderness on abdomen or renal region. Liver was not reached. Spleen was not enlarged. No masses. Fluidthrill negative. Shifting dullness negative. Borhorygmus 5/min. No vascular murmurs. 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 exaned
Investigation Blood-Rt: Hb 127g/l RBC 3.93T/l WBC 3.9G/l Urine-Rt: SG 1.070 pH 6.0 B-ultrasound: 1. subserous myoma of uterus
2. position of loop is normal Hepatic function: Normal PT & APTT: Normal
Professional Examination Pudendum: Married type
Vagina: unobstructed, secretion is excessive, white and ropy. Os of cervix: No bleeding, slight anabrosis. Body of uterus: Big like a fist of man, hard and its surface is smooth. Others: Normal
History summary
1. Patient was female, 45 years old 2. The patient was found “myoma of uterus” over two year ago and menometrorrhagia for 5 months.. 3. No special past history. 4. Physical examination showed no abnormity in lung, heart and abdoman. Professional examination can been seen above. 5. investigation information: see above
Impression: subserous myoma of uterus
Signature: He Lin (95-10033)
第二篇：呼吸科英文病历
ENGLISHCASE700756(Respiratory department)
----------------------------Name: Liyuzhen `Age:42 yearsSex: FemaleRace: HanOccupation: Free occupationNationality: ChinaMarried status: married
Address: Qianjing Road No.16, Wuhan Hankou.
thDate of admission: July 26, 2001
thDate of record: July 26, 2001
Complainer of history: Patient herselfReliability: Reliable----------------------------Chief Complaint: Cough and dyspnea for 2 days.
Present illness:
Two days ago the patient suddenly started to cough and feel
dyspnea after having a bath. It became more and more serious, so the patient went adjacent hospital. After some treatment, her symptoms were still. So she came to our hospital. Since its coming on, she never felt headache, nausea, bellyache and her phlegm was few.
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, expectoration, hemoptysis, asthma, dyspneaor chest pain.
Circulation system: No history of palpitation, hemoptysis, legsedema, short breath after sports, hypertension,precordium pain or faintness.
Digestive system: No history of low appetite, sour regurgitation,belching, nausea, vomiting, abdominal distension,abdominal pain, constipation, diarrhea, hemaptysis,melena, hematochezia or jaundice.
Urinary system: No history of lumbago, frequency of urination,urgency of urination, odynuria, dysuria, bloodyurine, polyuria or facial edema
Hematopoietic system: No history of acratia, dizziness, gingival
bleeding, nasal bleeding, subcutaneous bleeding
or ostealgia.
Endocrine system: No history of appetite change, sweating, chilly
excessive thirst, polyuria, hands tremor, character
alternation, obesity, emaciation, hair change, pig-
mentation or amenorrhea.
Kinetic system: No history of wandering arthritis, joint pain,
red swelling of joint, joint deformity, muscle pain
or myophagism.
Neural system: No history of dizziness ,headache, vertigo, in-
somnia, disturbance of consciousness, tremor, conv-
ulsion, paralysis or abnormal sensation.---------------------------
Personal History:
She was born in Hubei.She never smokes and
Drinks.No exposurehistory to toxic substances,
and infected water.Her menstruation was normal.
LMP:23/7,2001----------------------------
Family History:
Her parents are living and well. No congenital
disease in her family.----------------------------
PhysicalExamination
Vital signs:T 36.6`C , P 80/min, R 22/min, BP120/80mmHg.
General inspection: The patient is a well developed, well nou-
rished adult female apparently in no acute distress,
pleasant and cooperative.
Skin:Normally free of eruption or unusual pigmentation.
Lymphnodes: There are no swelling of lymphnodes.
Head: Normal skull. No baldness, noscars.
Eyes: No ptosis. Extraocular normal. Conjuctiva normal. The
Pupils are round, regular, and react to light and ac-
Commodation.
Ears: Externally normal. Canals clear. The drums normal.
Nose: No abnormalities noted.
Mouth and throat: lips red, tongue red. Alveolar ridges normal.
Tonsils atrophil and uninfected.
Neck: No adenopathy. Thyroid palpable,but not enlarged. No
Abnormal pulsations. Trachea in middle.
Chest and lung: Normal contour. Breast normal. Expansion equal.
Fremitus normal. No unusual areas of dullness. Diaphr-
agmatic position and excursion normal. No abnormal br-
eath sound. No moist rales heard. No audible pleural fric-
ion. There are lots of rhonchi rales and whoop can be heard
thHeart: P.M.I 0.5cm to left of midolavicular line in 5 inter-
Space. Forceful apex beat.No thrills.No pathologic
heart murmur. Heart beat 80 and rhythm is normal.
Abdomen: Flat abdomen. Good muscle tone. No distension. No v-
isible peristalsis. No rigidity. No mass palpable.
Tenderness (-), rebound tenderness (-).Liver and spleen
are not palpable. Shifting dullness (-). Bowl sounds
normal. Systolic blowing murmur can be heard at the
right side of the navel.
Extremities: No joint disease. Muscle strength normal. No ab-
normal motion. Thumb sign(+). Wrist sign(+).
Neural system:Knee jerk (-).Achilles jerk (-).
Babinski sign (-).Oppenheim sign (-).
Chaddock sign (-).Conda sign (-).
Hoffmann sign (-).
Neck tetany (-)Kernig sign (-).
Brudzinski sign (-).
Genitourinary system: Normal.
Rectum: No tenderness------
Out-patient department data:
No----------------------------
Historysummary
1). Li Yuzhen, female, 42y.
2). Cough and dyspnea for 2 days
3). PE: T 36.6`C, P 80/min, R 22/min, BP120/80mmHg.superficial
nodes were not palpable. Normal vision. Upper palate haunch-
-uped. HR: 80bpm, rhythm is normal. There are lots of rho-
nchi rales and whoop can be heard .Flat abdomen, Tenderness
(-),rebound tenderness (-).Liver and spleen are not pal-
pable.Shifting dullness (-). Bowl sounds normal..
4).Outpatient data: see above.
----------------------------
Impression: Bronchial asthma
Signature:He Lin 95-10033
第三篇：企业介绍英文翻译示范
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第四篇：妇科入院病历排序妇科出院病历排序
入院证
入院评估单
体温单
长期医嘱单首页
(一) 首页
(二) 出院记录 住院病历
临时医嘱单住院记录
住院病历检查单(B超心电图肝功能三大常规) 住院记录(2张)化验单
贴验单纸(3张)长期医嘱单
首页
(一)
首页
(二)
出院记录
产科入院病历排序
入院证
护理记录单
产科家属谈话记录
体温单
长期医嘱单
临时医嘱单
产科入院记录
(一)
产科入院记录
(二)
侯产记录
产程进展图
产后记录表
贴验单纸(3张)
产科护理评估单
体温单
长期医嘱单
临时医嘱单
新生儿记录
婴儿情况记录单
首页
(一)
首页
(二)
产科出院小结
临时医嘱单入院评估单护理记录单 体温单顺产出院病历排序剖宫产出院病历排序 首页
(一)首页
(一) 首页
(二)首页
(二) 产科出院小结产科出院小结 病程记录入院记录侯产记录首次病记 产程进展图侯产记录 阴道检查阴道检查分娩记录分娩记录 产后记录术前总结 谈话记录手术同意书 胎监麻醉同意书 B超心电图肝功能三大常规麻醉记录 长期医嘱单手术记录 临时医嘱单术后记录 产科护理评估单谈话记录 护理记录胎监 体温单B超心电图肝功能三大常规 新生儿记录长期医嘱单 新生儿护理记录临时医嘱单 母乳记录产科护理评估单 听力筛查单护理手术记录 新生儿长期医嘱单护理记录
新生儿临时医嘱单体温单
新生儿体温单围产记录
新生儿排序一样
第五篇：江苏省2015年病历书写规范出院病历排序
一、病历内容目录表
二、住院病案首页及住院证
三、住院病历或入院记录
四、病程记录(按页数次序顺排)
1、术前小结
2、术前讨论记录
3、手术审批书(手术报审记录)
4、手术知情同意书、授权委托书、委托双方有效身份证明复印件
5、麻醉知情同意书
6、麻醉术前访视记录
7、手术安全核查记录
8、手术清点记录
9、麻醉记录(或待产记录)
10、手术记录(或产时记录)
11、麻醉术后访视记录
12、术后病程记录(或产后记录)
五、出院记录或24小时内入出院记录
六、死亡记录或24小时内入院死亡记录
七、疑难病例讨论记录
八、死亡病例讨论记录
九、输血治疗知情同意书(按页数次序顺排)
十、特殊检查知情同意书(按页数次序顺排) 十
一、特殊治疗知情同意书(按页数次序顺排) 十
二、、会诊记录(按页数次序顺排) 十
三、病危(重)通知书
十四、患者知情同意、沟通记录、授权委托书 十
五、辅助检查报告单
1、病理资料(按日期先后顺序排)
2、血、尿、粪常规检验报告单(按日期先后顺排，自上而下贴于专用纸左边线上)
3、临床化学、免疫、微生物及其他检验报告单(按日期先后顺排，自上而下贴于专用纸左边线上)
4、医学影像检查资料(按分类及日期先后顺排)
5、其他检查资料
十六、、体温单(按页数次序倒排) 十
七、长期医嘱单(按页数次序倒排) 十
八、临时医嘱单(按页数次序倒排)
十九、病危(病重)患者护理记录(按页数次序倒排) 二
十、ICU记录单、各类监测记录单(按页数次序倒排) 二十
一、特殊治疗记录单(按页数次序倒排) 二十
二、死亡患者的门诊病历