第一篇：英文病例范本
Note for Jane Doe on 4/8/03Electronic Medical Records
Dr.Dermatology, MD
DEA#:
_____________________________________________________________
Name: Jane DoeDate: 4/8/03
Addr: 1231 8th Street, Suite 222
West Des Moines , IA 50265
_____________________________________________________________
Tetracycline
250 mg capsule
BID
X_____________________________________ X_____________________________________ Substitution PermittedDispense as written
Refills: 0
Disp: 60
Allow Generic: Yes
Sample Referral Letter
Charting Plus™Electronic Medical Records
Patient Instructions for Jane Doe on 04/11/2022
ACNE VULGARIS
What is it?
Acne vulgaris, commonly referred to as just acne, is a chronic inflammation of the skin that occurs most often during adolescence but can occur off and on throughout life.The skin eruptions most often appear on the face, chest, back and upper arms and are more common in males than females.Signs and symptoms:
* Blackheads the size of a pinhead.* Whiteheads similar to blackheads.* Pustuleslarge, firm swollen lesions in severe acne.* Abscess-infected lesion that is swollen, tender, inflamed, filled with pus, also seen in severe acne.Causes:
Oil glands in the skin become plugged for reasons unknown but during adolescence, sex-hormone changes play some role.When oil backs up in the plugged gland, a bacteria normally present on skin causes an infection.Acne is NOT caused by foods, uncleanliness or masturbation.Cleaning the skin can decrease its severity but sexual activity has no effect on it.A family history of acne can indicate if an individual will get acne and how severe it might be.Currently, acne can´t be prevented.Acne can be brought on or made worse by:
* Hot or cold temperatures.* Emotional stress.* Oily skin.* Endocrine(hormone)disorder.* Drugs such as cortisones, male hormones, or oral contraceptives.* Some cosmetics.* Food sensitivities.Again, foods do not cause acne but some certain ones may make it worse.To discover any food sensitivities, eliminate suspicious foods from your diet and then start eating them again one at a time.If acne worsens 2-3 days after consumption, then avoid this food.Acne usually improves in summer so some foods may be tolerated in summer that can´t be eaten in winter.Treatment:
* Most cases of acne respond well to treatment and will likely disappear once adolescence is over.Even with adequate treatment, acne will tend to flare up from time to time and sometimes permanent facial scars or pitting of the skin may occur.* If your skin is oily, gently clean face with a fresh, clean wash cloth using unscented soap for 3-5 minutes;an antibacterial soap may work better.A pre viously used wet washcloth will harbor bacteria.Don´t aggressively scrub tender lesions as this may spread infection;be gentle.Rinse the soap off for a good 1-2 minutes.Dry face carefully with a clean towel and use an astringent such as rubbing alcohol that will remove the skin oil.Other tips that may help acne:
* Shampoo hair at least twice a week.Keep hair off of face even while sleeping as hair can spread oil and bacteria.If you have dandruff, use a dandruff shampoo.Avoid cream hair rinses.* Wash sweat and skin oil off as soon as possible after sweating and exercising.* Use thinner, water-based cosmetics instead of the heavier oil-based ones.* Avoid skin moisturizers unless recommended by your doctor.* Do not squeeze, pick, rub or scratch your skin or the acne lesions.This may damage the skin
causing scarring and delay healing of acne.Only a doctor should remove blackheads.* Keep from resting face on hands while reading, studying or watching TV.* Try to avoid pressing the phone receiver on you chin while talking on the phone.* Ultraviolet light may be a treatment recommended by your doctor but this is by no means a license to sunbathe!Don´t use the sun to treat acne.* Dermabrasion may be another option to treat acne scars.This is a type of cosmetic surgery to help remove unsightly scars.Medications that may be prescribed to help acne include:
* Oral or topical antibiotics.* Cortisone injections into acne lesions.* Oral contraceptives.* Tretinoin, which may increase sun sensitivity and excessive dryness, is not recommended during pregnancy.*Accutane(isotretinoin)is a powerful drug to treat acne but causes birth defects.A woman taking this drug must be on two types of birth control and have negative pregnancy tests.This drug also increases sun sensitivity.Other more serious side effects can occur and your doctor will discuss those with you if Accutane is to be prescribed.TETRACYCLINE
Your doctor has prescribed Tetracycline for your condition.Tetracycline is a very safe antibiotic.It is not related to penicillin and an allergy to it is unusual.There are several potential side effects:
1.Tetracycline can cause nausea or heartburn.2.Tetracycline can cause vaginitis.3.Tetracycline can cause excessive sun burn.CAUTIONS:
1.Do not take Tetracycline with milk or milk products(ice cream, cheese, yogurt, etc.).This will cancel out the Tetracycline.Separate the Tetracycline from these products by one and one-half hours before and after each capsule.Do have a small amount of non milk-containing food in your stomach first to prevent nausea.2.Do not take Tetracycline if you are pregnant.3.Do not take Tetracycline if you are taking birth control pills unless specifically instructed to do so.4.If at the beach or skiing in the sun, use an effective sunblock(SPF-15 or greater)to prevent burning.If problems or questions arise, call the office for assistance.Side effects can occur and your doctor will discuss those with you if Accutane is to be prescribed._______________________________A.Dermatologist, MD
第二篇：英文病例汇报实用句型
英文病例汇报实用句型
1.一般情况（完全套话）
Mr./Ms.**(family name), a **(age)year-old **(profession), was admitted on **(admission date).2.病史
He complains that...He complains of one-month history of palpitation and short of breathness after exertion.He complained about epigastric pain which has lasted for 3 months.He noticed a hardened lump on the left neck 3 months ago.Pancytopenia was found a month ago.He presented with dyspnea since 10 days ago.His chief complaint was...既往诊疗~~~~~~~~
He was confirmed as / definitely diagnosed as...(确诊为)
To make a definite diagnosis, bone marrow aspiration was performed.He was suspected as...(疑似)
The discomfort tended to worsening, which urged him to seek for medical care.He has been given 3 cycles of DA regimen for chemotherapy and complete remission was achieved only after the first cycle.He was given the thyroidectomy of the left lobe in local hospital.He was treated with antibiotics(details unknown), which didn't take effect as expected.The general condition is good at present.He was pain free now and hemodynamically stable.3.查体
Nothing noteworthy was found in the physical examination.There was nothing remarkable in the physical examination except for… The physical examination was otherwise normal except that…（上点小菜~~~血液科常见体征）
皮肤粘膜 generalized pallor，scattered petechiae，oral mucosal hematoma 淋巴结enlarged lymph nodes
头部yellow eyes(yellow-stained sclera)
胸部tenderness in sternum，coarse breath sound, cardiac murmur, arrhythmia
腹部enlargement of liver，splenomegaly
4．辅助检查
The laboratory findings suggested/indicated/demonstrated/showed that… Bone marrow film was performed, which confirmed the diagnosis of ALL.The results of blood routine showed that WBC count was 4,000 /cm3, while NEU count 2,500/cm3, hemoglobin 100 g/L, PLT count 100,000 /cm3.(/cm3 is pronounced as per cubic millimeter)
Chest CT scan supported the diagnosis of NHL.
第三篇：英文病例对照
住院病历的英汉对照
分享 宋丽秀 21:06分享
随着中外交流的加强，专业英语对医院也是越来越重要！花了点时间整理了下“住院病历的英汉对照”的格式，发上来和大家分享，希望对能用到的人有所帮助！
POMR(Problem-Oriented Medical Records)表格式住院病历 Biographical data: 一般项目：
Name Age Sex Marital status Nativity Race 姓名 年龄 性别 婚否 籍贯 民族
Occupation Date of admission Informant
History 职业 入院日期 病史叙述者 病史 Chief complaint 主诉
History of present
illness 现病史
Past
history 既往史：
Previous health status: well ordinary bad
Infectious diseases平素健康状况： 良好 一般 较差 传染病史
Immunizations Allergies: N Y
clinical manifestation 预防接种史 过敏史 无 有 临床表现 allergen: Trauma: Surgery: 过敏原 外伤史 手术史
Review of systems:(Tick if positive, cross out if negative.If postive, you should write down your disease history and brief course of diagnose and therapy)系统回顾：(有打√无打×阳性病史应在下面空间内填写发病时间及扼要诊疗经过)Respiratory system: 呼吸系统
Sore throat chronic cough sputum hemoptysis wheezing 咽痛 慢性咳嗽 咳痰 咯血 哮喘 dyspnea chest pain 呼吸困难 胸痛
cadiovascular system: 循环系统
Palpitation dyspnea on exertion hemoptysis syncope 心悸 活动后气促 咯血 晕厥
edema of lower limbs precordial pain hypertention 下肢水肿 心前区疼痛 高血压 Digestive system: 消化系统
Anorexia sour regurgitation belching nausea vomitting 食欲减退 反酸 嗳气 恶心 呕吐
abdominal distention abdominal pain constipation diarrhea 腹胀 腹痛 便秘 腹泻
hematemesis melena hematochezia jaundice 呕血 黑便 便血 黄疸 Urinary system: 泌尿系统
Lumbago frequent micturition urgent micturition urodynia 腰痛 尿频 尿急 尿痛
dysuria hematuria nocturia polyuria oliguria facial edema 排尿困难 血尿 夜尿 多尿 少尿 面部水肿 Hematopoietic system 造血系统
Fatigue dizziness blurred vision gingival bleedig 乏力 头昏 牙龈出血
subcutaneous hemorrhage ostealgia epistaxis 皮下出血 骨痛 鼻衄
Metabolic and endocrine system: 代谢及内分泌系统
Excessive appetite anorexia sweats cold intolerance 食欲亢进 食欲减退 多汗 畏寒
polydipsia tremor hands change of character obvious obesity 多饮 双手震颤 性格改变 显著肥胖
emaciation hirsutism hair losing pigmentation 消瘦 多毛 毛发脱落 色素沉着
chang of sexual function amenorrhea 性功能改变 闭经
Musculoskeletal system 肌肉骨骼系统
Floating arthralgia arthraliga swelling of joints 游走性关节痛 关节痛 关节红肿
deformiteies of jionts myalgia atrophy of muscle 关节变形 肌肉痛 肌肉萎缩
Nervous system 神经系统
Dizziness headache vertigo syncope degeneration of memory 头昏 头痛 眩晕 晕厥 记忆力减退
visual disturbance insomnia disturbance of consciousness 视力障碍 失眠 意识障碍
tremor spasm paralysis paresthesia 颤动 抽搐 瘫痪 感觉异常
Personal history: 个人史 Birthplace Occupation sexual history smoking N Y 出生地 职业 冶游史 吸烟 无 有
about years average pieces per day ceased for years 约 年平均 支/日 戒烟 年
alcohol intake N occasional frequent about years 嗜酒 无 偶有 经常 约为 年 average ml per day others 平均 ml/日 其他
Marital history: 婚姻史：
Marrying age companion’s state of health 结婚年龄 配偶健康状况 Menorrhea and Childbearing: 月经及生育史
Menarche age cycle lasting for days date of last period 初潮 每次持续时间 末次月经时间(age of menopause)绝经年龄
Amount of flow: little normal large menstrual pain: N Y 经量 少 正常 多 痛经 无 有
cycle: regular irregular pregnancy times natural labor 经期 规则 不规则 妊娠 次 顺产
times abortions times premature delivery times 胎 流产 胎 早产 胎
stillbirths times difficult labor and its condition 死产 胎 难产及病情
Familly history(pay attention to the congenital diseases and
communicable diseases and communicable dieases related to the paitent 家族史（注意与患者现病有关的遗传病和传染性疾病）Father: still alive illness died cause of deaths mother:
父：健在 患病 已故 死因 母 still alive illness died cause of death siblings: others: 健在 患病 已故 死因 兄弟姐妹 子女其他
Physical examination体格检查 Vital signs生命体征: Temperature体温
pulse脉搏 /min次/分
respiration呼吸 /min次/分
B.P血压 mmHg General Appearance一般状况: Development发育: ortho-sthenic type正常
asthenic type不良
sthenic type超常 nutrition营养: well良好
fairly中等 poor不良
cachexia恶病质
Facial features面容: normal无病容
acute急性
chronic慢性病容
others其他
Expression表情: natural自知
painful痛苦
anxious忧虑
dreadful恐惧
indifferent淡漠
Position: active semi-recumbent others 体位： 自主 半卧位 其他 Gait: normal abnormal 步态 正常 不正常
Conciousness: aware somnolence confusion stupor coma 神志 清楚 嗜睡 模糊 昏睡 昏迷
delirium coppperatio;well badly 谵妄 配合检查 合作 不合作
Mucocutaneous color: normal red pale cyaosis stainted 皮肤粘膜 色泽 无病容 潮红 苍白 紫绀
yellow pigmentation lesions:N Y(type and distribution)黄染 色素沉着 皮疹 无 有（类型及分布）
Subcutaneous hemorrhange: N Y(type and distribution)皮下出血 无 有（类型及分布）
Hair: normal reduced edema: N Y(position and degree)头发分布 正常 减退 水肿 无 有（部位及程度）
Hepatic palm: N Y spider angionma:N Y（position numbers）others: 肝掌 无 有 蜘蛛痣 无有(部位 数目)其他 Lymphnodes: 淋巴结
Superficial lymph nodes: non-swelling swelling(position and characteristics)全身淋巴结肿大 无肿大 肿大（部位及特征）Head : cranium : size : normal large small deformity: 头部 头颅 大小 正常 大 小 畸形
N Y(coxycephaly squared skull deforming skull)无 有（尖颅 方颅 变形颅）Others: tenderness mass sunk(position)其他异常：压痛 包块 凹陷（部位）
Eyes eyelid: normal edema ptosis trichiasis conjunctive : 眼睑 正常 水肿 下垂 倒睫 结膜 normal hyperemia edema hemrrhage 正常 充血 水肿 出血
eye ball: normal proptosis depression tremor 眼球 正常 突出 凹陷 震颤
motion dysfunction(left right)运动障碍
Sclera :normal yellow cornea : normal abnormal(left right)巩膜 无黄染 有黄染 角膜 正常 异常（左 右）Pupils: equal roundness same size unequal left cm 瞳孔 等圆 等大 不等 左 cm
reaction to light: normal delay(left right)disappear(left right)对光反射 正常 迟钝（左 右）消失（左 右）Others: 其他
Ears: auricle :normal deformity fistula others(left right)耳 耳廓 正常 畸形 瘘管 其他（左 右）
excretions of external auditory canal: N Y(left right feature)外耳道分泌物 无 有（左 右 性质）
Tenderness of mastoid : N Y audation dysfunction: N Y(left right)乳突压痛 无 有 听力粗试障碍 无 有（左 右）
Nose: shape : normal: abnormal()other abnormalities:N Y 鼻 外形 正常 异常（）其他异常 无 有
Nosalala flap obsruction excretions nasal sinus tenderness: 鼻翼扇动 鼻塞 分泌物 鼻旁窦压痛 N Y(position)无 有（部位）
Mouth lips :red syanosis pale herpes fissure mucosa :normal 口唇 红润 发绀 苍白 疱疹 皲裂 粘膜 正常 abnormal(pale petechia)异常（苍白 出血点）
Opening of parotid gland duct: normal abnormal(swelling 腮腺导管开口 正常 异常（肿胀 suppurative excretions)脓性分泌物）
Tongue:normal abnormal(coverings tremor leaning to left or right)舌 正常 异常（舌苔 伸舌震颤 向左、向右偏斜）Gums: normal swelling pus overflow hemorrhage pigments 牙龈 正常 肿胀 溢脓 出血 色素沉着 lead line tooth:regular edentulous carious teeth 铅线 牙列 齐 缺牙—|— 龋齿—|— Tonsils: pharynx: voice: normal hoarse 扁桃体 咽 声音 正常 嘶哑
Neck:resistence:N Y carotid artery pulsation: normal increased 颈部 抵抗感 无 有 颈动脉搏动 正常 增强
decreased(left right)jugular vein:normal distention 减弱（左 右）颈静脉 正常 充盈
high distention trachea:middle deviation to(left right)怒张 气管 正中 偏移（向左 向右）
Hepatojugular reflux:(-)( )thyroid: normal swelling degree 肝颈静脉回流征：（-）（ ）甲状腺 正常 肿大 度
Symmetry 对称
Dominance in one side: spreading nodular:soft hard others :N Y 侧为主 弥漫性 结节性 质软 质硬 其他 无 有(tenderness tremor bruits)（压痛 震颤 血管杂音）
Chest topography:normal barrel chest pigeon chest funnel chest 胸部 胸廓 正常 桶状胸 鸡胸 漏斗胸 flat chest bulging or retraction(left right)扁平胸 膨隆或凹陷（左 右）
bulging in the precordial region tenderness of sternum 心前区膨隆 胸骨压痛
Breast: normal symmetrical abnormal : left right(gynecomastia 乳房 正常对称 异常 左 右（男乳女化 mass tenderness excretions of nipples)包块 压痛 乳头分泌物）Lung 肺
Inspection : movement of respiration : normal abnormal : left 视诊 呼吸运动 正常 异常 左 right(increased decreased)右（增强 减弱）
Intercostal space :normal wide narrow(position)肋间隙 正常 增宽 变窄（部位）
Palpation : vocal fremitus:normal abnormal :left right(increased 触诊 ： 语颤 正常 异常 左 右（增强
decreased)pluernal friction rubs: N Y（position）减弱 胸膜摩擦感： 无 有（部位）
Subcutaneous crepitus: N Y(posotion)percussion: resonance 皮下捻发感 无 有（部位）叩诊 正常清音 abnormal dullness flatness hyperresonance tympany 异常叩诊音 浊音 实音 过清音 鼓音 Lower borders:scapular line: right intercostal space, left 肺下界 肩胛线 右肋间 左
intercostal space Range of mobility: right cm , left cm 肋间 移动度 右 cm，左 cm Dusculation: breath regular irregular 听诊 呼吸 规整 不规整
Breath sound: normal abnormal(feature, position)呼吸音 正常 异常（性质，部位描写）Rale: N Y ：ronchi: sonorous sibilant 啰音：无 有： 干性 鼾音 哨笛音
Moist rales: coarse medium fine rales crepitus 湿性 大 中 小水泡音 捻发音
Vocal conduction: normal abnormal: reduced increased(position)语音传导 正常 异常 减弱 增强（部位）
Plueral friction rubs: N Y(position)胸膜摩擦音 无 有（部位）Heart 心
Inspection:bulging in precordial region : N Y apex impulse: 视诊 心前区隆起 无 有 心尖搏动
normal unseen increased diffusing position: normal 正常 未见 增强 弥散 心尖搏动位置 正常
deviation(the distance from midclavicular line cm)移动（距左锁骨中线内外 厘米）
Other precordial pulsations: N Y(position)其他部位搏动 无 有（部位）
Palpation:apex impulse:normal increased thrust unclear 触诊 心尖搏动 正常 增强 抬举感 触不清
thrills :N Y(position period)percardial friction rubs:N Y 震颤 无 有（部位 时期）心包摩擦感 无 有
Percussion:relative cardiac outline: normal shrink extant(right left)叩诊 相对浊音界 正常 缩小 扩大（右 左）
Ausculation: heart rate bpm/min rhythm(regular irregular 听诊 心率 次/分 心律（齐 不齐）
absolutly irrgelar)heart sound:S1 normal increased decreased 绝对不齐 心音 S1 正常 增强 减弱 split S2 normal increased decreased split 分裂 S2 正常 增强 减弱 分裂 S3 N Y S4 N Y A2 P2 S3 无 有 S4 无 有 A2 P2 Extra heart sound N gallop(diastolic presystotic summalion 额外心音 无 奔马律（舒张期 收缩前期 重叠
gallop)opening snap others murmurs: N Y(degree conduction)开瓣音 其他 杂音 无 有（图示并描述传导）Pericardial friction rubs N Y 心包摩擦音 无 有
Peripheral vessals: normal pistal shot of big arteries 周围血管 无异常血管征 大血管枪击音
Duroziez’s sign water hammer pulse capillary pulsation 二重杂音 水冲脉 毛细血管搏动
pulse deficit paradoxical pulse pulsus alternans other 脉搏短绌 奇脉 交替脉 其他 Abdoman 腹部
Inspection: shape normal distention frog abdomen(size cm)视诊 外形 正常 膨隆 蛙腹（腹围 厘米）
scaphoid apical abdomen gastral pattern intestinal pattern 舟腹 尖腹 胃型 肠型
peristalsis abdominal respiration:existance disappear umbilicus: 蠕动波 腹式呼吸 存在 消失 脐
normal protruding excretions others: N Y(venous distention of 正常凸出 分泌物 其他异常 无 有（腹壁静脉曲张 abdoman purple striae surgical scars hernia)条纹 手术疤痕 疝）
Palpation: soft muscle tension position tenderness N Y
触诊 柔软 腹肌紧张 部位 压痛 无 有rebound tenderness N Y fluidthtill N Y succussions plash N Y 反跳痛 无 有 液波震颤 无 有 振水音 无 有
Mass N Y(position size)discription of feature liver:can’t be 腹部包块 无 有（部位 大小）特征描述 肝 未触及
touched can be touched :subcostal cm under xipfoid process 可触及 肋下 厘米 剑突下
discription of feature gallbladder: can’t be touched can be touched 特征描述 胆囊 未触及 可触及 size cm tenderness N Y Murphy’s sign spleen: can’t be 大小 厘米 压痛 无 有 Murphy征 脾 未触及
touched can be touched distance from costal margin cm 可触及 肋下 厘米
Kideny:can’t be touched can be touched size consistency 肾 未触及 可触及 大小 硬度
tenderness mobility tenderness of ureters: N Y(position)压痛 移动度 输尿管压痛点 无 有（部位）
percussion: borders of liver dull(existance shrink obliteration)叩诊 肝浊音界（存在 缩小 消失）
Upper borders of liver on right midclavicular line intercostal space 肝上界位于右锁骨中线 肋间
shifting dullness N Y tenderness in renal region N Y(right left)移动性浊音 无 有 肾区叩痛 无 有（右 左）ausculation : borhorygmus normal increased decreased 听诊 肠鸣音 正常 增强 减弱
disappear gurgling N Y vessal bruits N Y(position)消失 气过水声 无 有 血管杂音 无 有（部位）
Genitalia :not examined normal abnormal Rectum and Anus : 生殖器 未查 正常 异常 肛门直肠 not examined normal abnormal 未查 正常 异常
Spine and Extremities 脊柱四肢
Spine : normal deformities(lateral anterior posterior protruding)脊柱 正常 畸形（侧 前 后凸）
Spinous process : tenderness pain while percussed(position)棘突 压痛 叩痛（部位）
Mobility : normal restricted extremeties: normal abnormal 移动度 正常 受限 四肢 正常 异常
deformity swelling of joints joints stiffness 畸形 关节红肿 关节强直
tenderness of muscles atrophy of muscles 肌肉压痛 肌肉萎缩
Venous distention of lower limbs(position and feature)acropachy 下肢静脉曲张（部位及特征）杵状指
Nervus System 神经系统
Abdominal wall reflex(normal)muscle tone(normal)腹壁反射（正常）肌张力（正常）
Myodynamia(degree)paralysis of limbs N Y(left right 肌力（级）肢体瘫痪 无 有（左 右
upper lower)biceps reflex left(normal)right(normal)上 下）肱二头肌反射 左（正常）右（正常）knee jerk left(normal)right(normal)achilles jerk left
膝健反射 左（正常）右（正常）跟腱反射 左(normal)right(normal)正常 右（正常）
Hoffmann’s dign left( )(-)right( )(-)Hoffmann征 左（ ）(-)右（ ）（-）Babinski’s sign left( )（-）right( )(-)Babinski 左（ ）（-）右（ ）（-）
Kernig’s sign left( )（-）right( )(-)others Kernig征 左（ ）（-）右（ ）（-）其他 Laboratory findings 实验室及器械检查结果（The important laboratory examination.X-ray.ECG and other result areincluded）(重要的化验、X线、心电图及其他有关化验)Nunber of X-ray X线片号 Abstract 病历摘要
Diagnosis(impressions)入院诊断
Recorder 病史记录者 Examiner 并使审阅者 Date of record 记录日期
第四篇：英文病例汇报常用体格检查术语
英文病例汇报常用体格检查术语
1、肋骨和软组织[ribs and soft tissure]
•胸骨上切迹[suprasternal notch]
•浮肋[free ribs]
•胸壁[chest wall]
•扁平（桶状、佝偻、漏头、鸡）胸[flat(barrel,rachitic, funnel, pigeon)chest] •皮下气肿[subcutaneous emphysema]
•捻发音[Crepitus]
•佝偻病串珠[rachitic rosary]
•软骨病[chondrosteoma]
•脂肪瘤[lipoma]
•软骨发育不全[achondroplasia(chondrodysplasia)]
•软组织损伤[soft tissue injury]
•肋骨畸形[abnormality of the ribs(rib deformity, costal anomaly)] •肋骨串珠（错位）[beading(displacement)of rib]
•肋软骨畸形[costochondral deformity]
•肋软骨增生[costal cartilage hyperplasia]
•肋下切口[subcostal incision]
•肋间隙宽（窄）[wide(narrow)intercostal space]
2、乳房[breast]
•对称性[symmetry]
•乳头内陷（内缩）[crater(retracted)nipple]
•乳头皱裂[cracked nipple]
•乳头偏斜（抬高）[nipple skewness(elevation)]
•乳头溢液[nipple discharge]
•乳头脓肿（溃疡、血肿）[abscess(ulcer, hematoma)of nipple]
•乳头过小[hypomastia]
•乳斑[milk spots]
•乳房潮红[breast flush]
•乳房出血[mastorrhagia]
•乳房过早发育[premature thelarche]
•乳房肿胀（脓肿）[mammary swelling(abscess)]
•乳房湿疹[eczema mammae]
•乳房下垂[mastoptosis(pendulous breast)]
•乳房萎缩[mastatrophy]
•巨乳[macromastia]
•乳晕[mammary areola]
•乳房硬化[zaranthan]医.学.全.在线.网.站.提供
•异常泌乳[abnormal lactation]
•男子女性化乳房[gynecomastism]
•乳房皮肤红肿[erythroswelling of mammary skin]
•乳房桔皮征[mammary orange-peel sign]
•乳记局限性凹陷[mammary localized pitting]
•乳房瘘管[breast fistula]
•正常女性乳房[normal female breasts]
•无压痛性肿块[nontender mass]
3、肺[lung]
•呼吸缓慢（急促）[bradypnea(tachypnea)]
•呼吸浅慢（深快）[hypopnea(hyperpnea)]
•呼吸不规则[irregular respiration]
•点头呼吸[nodding breathing]
•端坐呼吸[orthopnea]
•三凹征[retraction sign of three fossae]
•叹息样呼吸[sighing respiration]
•浅快[shallow and rapid]
•呼（吸）气性呼吸困难[expiratory(inspiratory)dyspnea]
•呼吸道烧伤（塌陷）[burn(collapse)of respiratory tract(airway)]
•呼吸道阻塞[respiratory tract obstruction]
•呼吸均匀（呼吸加深或加快）[eupnea(exaggerated or acclerated respiratory)]
•呼吸停止[apnea]
•呼吸费力[respiration is labored]
•语音（触觉）震颤[vocal(tactile)fremitus]
•语颤相等（减弱、增强）[vocal fremitus is equal(diminished, accentuated)]
•间接（直接）叩诊[mediate(immediate)percussion]
• 浊（实、鼓、清、过清、金属）音[dullness(flatness, tympany, vesicular resonance, hyperresonance, bell)]
•移动范围[range of movement]医学.全.在线.网.站.提供
• 呼吸音消失（减弱，增强）[absence(diminution, exaggeration)of breath sound] •呼吸音粗（清）[sound of breath(SOB)is rough(clear)]
•支气管（支气管肺泡，肺泡）音[bronchophony(bronchovesicular sound, vesicular sound)] •管状呼吸音[tubular breath sound]
•捻发音[crepitantrales]
•爆裂音[crackles]
•干（湿）罗音[dry(moist)rales]
•细（中等、粗）罗音[fine(medium, coarse)rales]
•呼（吸）气未罗音[end-inspiratory(expiratory)rales]
•胸膜摩擦音[pleural friction rub]
•呼（吸）气延长[prolonged inspiratory(expiratory)]
•高（低）调鼾音[sibilant(sonorous)rhonchi(sonorous rales)]
•哨笛音[sibilant rales]
•哮鸣音[wheezing]
•小（中、大）水泡音[small(middle, big)bubbles]
•支气管语音[bronchophony]
•耳语音[whispered]
•羊鸣音[egophony]
•高（低）音调[high(low)-pitched]
•两肺部（右背部）[over both lung fields(right back)]
•两（左）肺底[over the both(left)lower lung]
•整个肺野[the whole lung field]
•左（右）上（下）肺[the left(right)upper(lower)lung]
•肺尖（底）[apex(base)of lung]
4、心脏[Heart]
•用手掌（指尖）触诊心尖搏动[palpate apical area with palm(fingertips)]
•心前区隆起（凹陷）[precordial bulge(retraction)]
•搏动弥漫（局限）[diffuse(local)pulsation]
•负性搏动[inward inpulse]
•心尖搏动[apex beat(apical impulse)]
•剑突下搏动[xiphoideusalpulsaton]
•抬举性心尖搏动[heaving apex impulse]
•心尖搏动最强点[point of maximal impulse(PMI)]
•锁骨中线[mid-calvicular line(MCL)]
•肋间[intercostal space(ICS)]
•收缩（舒张）期震颤[systolic(diastolic)thrill]
•心浊音界[the border of cardiac dullnes]
•心绝对（相对）浊音界扩大（缩小）[enlarged(diminished)absolute(relative)cardiac dullness]
•叩诊心脏大小正常[heart size is normal on(to)percussion]
•心脏向左（右）扩大[cardiac dilation(enlargement)to the left(right)]
•第1（2、3、4）心音[S1(S2,S3,S4)]
•第1心音增强（减弱，听不清）[first heart sound is exaggerate(decreased, muffled)] •生（病）理性杂音（分裂）[physiologic(pathological)murmur(splitting)]
•生理性（固定、反常、逆）分裂[physiologic(fixed, paradoxical, reversed)splitting] •肺动脉瓣第2心音>(=，<)主动脉瓣第2心音[P2>(=，<)A2]
•大炮音[connon sound]
•心音消失[heart sound is absent(disapeared)]
•心音增强（减弱）[accentuated(diminished)cardiac sound]
•心音响亮（遥远）[cardiac sound is loud(distant)]
•收缩期（舒张期，连续性）杂音[systolic(diastolic, continuous)murmur]
•收缩（舒张）前（中、晚）期杂音[pre-(mid-, post)systolic(diastolic)murmur] •全收缩期的[holosystolic(pansystolic)]
•全舒张期的[holodiastolic(pandiastolic)]
•低（高）音调[low(high)pitched]
•递减（递增，递减-递增）性杂音[decrescendo(crescendo, decrescendo-crescendo)murmur] •呈喷射型[be ejection in type]
•Ⅳ级喷射型收缩期杂音[grade Ⅳ(I-Ⅳ/6)systolic ejection murmur]
•吹风样杂音[murmur of puffing character]
•低音调隆隆样[low-pitched rumbling quality]
•柔和（粗糙）的[soft(harsh or rough)]
•吹风样（喷射性、隆隆样、沙沙声样、搔抓声样、机器声样、汽笛声样、倒水声样）杂音[blowing(ejection, rumbling, rustting, scratching, machinary, whistling, pouring)murmur]
•功能性（器质性）杂音[functional(organic)murmur]
•血管（静脉）杂音[vascular(venous)murmur]
•枪击音[pistol shot sound]医学全.在线网.站.提供
•静脉营营音[venous hum]
•奔马律[gallop rhythm]
•胎心律[embryocardia]
•心律齐（不齐）[regular(irregular)rhythm]
•心律不齐[arrhythmia]
•二
（三）联律[bigeminy(trigeminy)]
•早搏[premature(extrasystol)]
•喀嗽音[click]
•钟摆律[pendular rhythm]
•二尖瓣开瓣音[mitral opening snap]
•心包摩擦音[pericardial friction sound]
•听诊[on auscultation]
•二尖瓣（主瓣，肺瓣，三尖瓣）听诊区[mitral(aortic, pulmonary, tricuspid)valve area] •心包叩击音[pericardial knock]
•肿瘤扑落音[tumor plop]
5、腹部[abdomen]
•腹（妊娠）纹[abdominal striae(striaegravidarum)]
•腹膨隆[abdominal distention(prominence)]
•腹平坦（凹陷）[abdominal flatness(retraction)]
•蛙状（球状、舟状）腹[frog(bulbous, scaphoid)belly(abdomen)]
•腹围增大[increased abdominal girth]
•肠型[intestinal pattern]
•梯形腹[ladder-shaped abdomen]
•胃（小肠）蠕动波[gastric(intestinal)peristaltic wave]
•静脉曲张[varicosity(dilated tortuous vein)]
•疤痕[scar]
•腹壁紧张（松驰）[guarding(abdominal muscular relaxation)]
•腹壁切口（创伤）[incision(wound)of abdominal wall]
•腹部分区[abdominal region]
•左（右）上（下）腹[left(right)upper(lower)quadrant]
•脐膨出[projection of the umbilicus]
•腹式呼吸[abdominal(diaphragmatic)breathing]
•腹壁松弛[lax abdominal wall]
•肝肿大[hepatomegaly(enlargement of the liver)]
•脾肿大[splenomegaly(enlargement of the spleen)]
•右肋下5厘米[5 cm below the right costal margin]
•肿块（肝）质硬[firm mass(liver)]
•莫菲氏征[murphy`s sigh]
•肌卫现象[muscle guarding(tension)]
•反跳痛[rebound tenderness]
•压痛点[tenderness point]
•剑突下压痛[tenderness beneath the xiphoid process]
•麦氏点压痛[McBurney`s point tenderness]
•腹肌强直（板状腹，板样强直）[rigor of abdominal muscle(wooden belly, board-like rigidity)]
•柔韧感[dough kneeding sensation]医学.全在线
•波动感[fluctuation]
•腹股沟疝[inguinofemoral hernia]
•腹壁反射[abdominal reflex]
•腹水征[sign of ascites]
•膀胱肿大[bladder expansion]
•膀胱区（脊肋角）压痛[tenderness of bladder region(costovertebral angle)]
•肾（肝）区叩击病[percussion tenderness on kidney(liver)region]
•移动性浊音[shifting dullness]
•鼓音[tympany(tampanitic resonance)]
•肝（脾）浊音区[hepatic(splenic)dullness area]
•肠鸣音正常（亢进、减弱、消失）[normal(hyperactive, diminished, absent)bowel sound] •气过水声[gurgling]
•振水声[succusion(splashing)sound]
第五篇：病例
病例范文 2022-06-02 17:40 |(分类:默认分类)
1）一般项目：
籍贯（须写明省、市或县别）、入院日期：急症或重症应注明时刻。均应填年月日
病情陈述者：填“患者”；如系旁人代述，应说明可靠程度。
2）主诉
●电子病历的主诉内容正文与主诉之间距两个空格键。以下小标题如“现病史”等与正文之间的距离要求相同。
●患者入院的主要病状、部位及其持续时间（时间短者如急腹症应注明小时数）如“持续发热6天，全身红色斑丘疹3天”。
●不宜用诊断或检验结果代替症状。
●主诉多于一项时，应按发生时间先后次序，分别列出，如“间歇空腹痛1年，柏油样黑便1天”；“尿频、尿急3小时”。
3）现病史
●将症状按时间先后准确记载其发病日期、发病缓急、发病诱因、每一重要症状发生的时日，及其发展变化的过程。与鉴别诊断有关的阴性症状亦须记载（以能体现本病的症状学与鉴别诊断为主要内容）。
●在描述症状中，应围绕重点并求得系统，如描写疼痛应阐明部位、时间、性质、程度与其他相关因素，以及治疗的影响等。
●按系统询问伴随的症状，以免遗漏。
●过去检查及治疗情况。
●对意外事件、自杀或被杀等经过详情与病况有关者，应力求客观、如实记载，不得加以主观评论或揣测。
●与本科无关的他科重要伤病未愈仍需诊治者，应另段叙述。
4）过去史
●一般健康状况 强壮或虚弱。
●急性传染病史 按时间先后顺序。记载其疾病发生时间，治疗结果，有无并发症。如无传染病史，亦须将与目前病情有关而确未发生的传染病记载于此项中，以备参考，如患带状疱疹，应询有无水痘病史。
●曾否预防接种 其种类及最近一次接种的日期。
●按系统询问有关疾病 包括五官、呼吸系统、循环系统、消化系统、泌尿生殖系统、血液系统、神经精神系统及运动系统（肌肉、骨骼、关节），外伤、手术史，中毒及药物等过敏史。
●过敏药物名称在书写时加黑，加字符边框。电子病历打印后，医生用红笔在药物名称下划红线。如对青霉素过敏，写为“对青霉素过敏”
5）.个人史
●出生地及经历地 特别注意自然疫源地及地方病流行区，注明迁涉年月，并应注明具体疫源或水源，如有无血吸早虫病疫水接触史。
●生活及习惯 包括饮食习惯、烟酒嗜好程度。
●过去及目前职业及其工作情况 包括入伍或参加工作时间、兵种或工种、职务，有无毒物、放射性物质、传染病患者接触史。
●月经史 自月经初潮至现在情况，每次经期相隔日数，每次持续日数,，闭经年龄，可用下列的简单方式表示：
初潮年龄 每次行经日数经期相隔日数 闭经年龄 或
初潮年龄（每次行经日数）/（经期相隔日数）闭经年龄或用语言描述 例如： 16 3～4 30～32 48或
电子病历可用语言描述或下面格式
“16Y,（3~5D）/（30~32D），48Y或1999，8，23。”
并应记明月经来潮时有无疼痛，每次月经量、色泽及其性状，末次月经日期。
●婚姻状况及生产史 何时结婚，配偶健康情况，如已死亡，述明死亡原因及年份，生产正常否，有无早产或流产、节育、绝育史。
●冶游史 对可疑患者、外宾及曾出国半年以上者，均应询问有无不洁性交史。
6）家族史
●父、母、兄、弟、姐妹及子女的健康状况。如已死亡，记明死亡原因。
●遇疑有遗传因素及生活接触因素疾患时，应询问家族中有无相似患者。
注：再次入院的过去史，个人史及家族史等，如无特殊，则可从简。
7）体格检查
●一般状况 体温、脉搏、脉象、呼吸（次数、深浅）、血压、身高及体重（必要时）；发育（正常、异常、欠佳）；营养（良好、中等、欠佳、消瘦、肥胖）；体位和姿势（如屈曲位、斜坡卧位等），面色（如红润、晦暗等）；表情（焦虑、痛苦、慢性病容）；神志（清晰、嗜睡、半昏迷、昏迷）及言语状态（清晰否、流利否、对答切题否），检查时合作否等。
●皮肤 色泽（正常、潮红、发绀、黄染、苍白），弹性，有无水肿、出汗、紫癜、皮疹、色素沉着、血管蛛、瘢痕、创伤、溃疡、结节；并明确记述其部位、大小及程度等。
●淋巴结 全身或局部淋巴结有无肿大，应注明部位（颌下、耳后、颈部、锁骨上、腋部及腹股沟部等）、大小、数目、硬度、有无压痛及粘连；局部皮肤有无红热、瘘管或瘢痕。
●头部
头颅：大小，形状，毛发分布，有无疖、癣、外伤、瘢痕、肿块。
眼：眼裂大小，眼睑及眼球运动，角膜，结膜，巩膜，瞳孔大小、形状、两侧是否对 称、对光反应、调节反应，视力（粗测），必要时眼底检查。
耳：耳廓有无畸形，外耳道有无分泌物，乳突有无压痛，粗测听力。
鼻：有无畸形、阻塞、分泌物，鼻中隔有无异常，嗅觉有无障碍，鼻窦有无压痛。
口腔：呼气气味，口唇色泽，有无疱疹、微血管搏动、口角破裂；牙齿有无龋病、动摇、缺损、镶补等及其位置，如龋病上下左右55 8，缺损4 ,（电子病历可用语言描述）。牙龈有无溢血、溢脓、萎缩、色素沉着；舌苔、舌质、伸舌时有无偏位及震颤；口腔粘膜有无出疹、溃疡、假膜或色素沉着；扁桃体大小，有无充血、水肿及分泌物，咽部有无充血、发疹、分泌物，咽部反射，软腭运动情况，腭垂（悬雍垂）是否居中，吞咽正常否。
●颈部 是否对称，运动有无受限，有无强直，有无压痛、异常搏动、静脉怒张、肿块，气管正中否。甲状腺形态、大小、硬度、有无结节、震颤、压痛、杂音等。
●胸部 胸廓形状，是否对称，肋间饱满或凹陷，运动程度，弓角大小，胸壁有无水肿、皮下气肿、肿块或扩张血管。肋骨及肋软骨有无压痛、凹陷等异常。乳房情况（大小、有无红肿、压痛，肿块形态、大小及硬度等）。
●肺脏
视诊：呼吸类型、快慢、深浅，两侧呼吸运动对称否。
触诊：语音震颤两侧是否相等，有无摩擦感。
叩诊：反响（正常、浊音、实音、鼓音），肺下界位置及呼吸移动度。
听诊：注意呼吸音性质（肺泡音、支气管肺泡音、管性呼吸音）及其强度（正常、减低、增强、消失），语音传导，有无摩擦音、哮鸣音、干口罗音与湿口罗音。注：阳性体征，应按物理诊断学体表划线座标部位描述。
●心脏
视诊：心尖搏动的位置，范围，心前区有无异常搏动及膨隆。
触诊：心尖搏动最强部位，有无抬举性冲动，有无震颤或摩擦感，其出现的部位，时间和强度。
叩诊：左右心界线以每肋间距胸骨中线的厘米（cm）数记载,，心左界如超出锁骨中线，则应以厘米（cm）数记载超出的距离。
———————————————— 右cm 肋间 左cm ———————————————— 2 II 2 2 III 3 3 IV 4.5 V 7
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听诊：心率及心律，如节律不整，应同时计数心率及脉率。各瓣膜音区心音的性质、强度、有无心音分裂及第三、第四心音，比较主动脉瓣与肺动脉瓣第二音的强弱。有无发音，应注意杂音发生的时间、强度、性质、何处最响、向何处传导等，有无心包摩擦音。
●腹部
视诊：呼吸运动情况，腹壁是否对称，有无凹陷、膨隆、静脉曲张、蠕动波或局部性隆起，脐部情况。
触诊：腹壁柔软或紧张，有无压痛，压痛部位及其程度，拒按或喜按，有无反跳痛；有无肿块，其部位、大小、形态、硬度、触痛、活动度，呼吸运动的影响，有无搏动及波动等。
肝：可否触及，如可触及，应记录肝下缘距锁骨中线肋缘及剑突的厘米（cm）数，注意肝缘锐钝、硬度、有无压痛。肝肿大时注意肝表面有无结节。
胆囊：可否触及，大小，有无压痛。
脾：可否触及，如能触及，应注明表面光滑否，有无切迹及压痛，硬度如何，距锁骨中线肋缘厘米（cm）数（垂直径AB及最大斜径AC），平卧及侧卧时脾移动度（图-1）。
图-1 脾脏大小记录法
（电子病历中的人体部位图，以后将建立有关图文库。）
肾：能否触及，大小，活动度，有无压痛等。
叩诊：肝、脾浊单界[上界以肋间计，全长以厘米（cm）计]，肝脾区有无叩击痛，有无过度回响，有无移动性浊音。
听诊：肠蠕动音及其音质与频度，有无胃区振水声及肝脾区磨擦音。有无血管杂音，并记录其部位及性质等。
●外阴及肛门
外生殖器：发育，有无包茎，尿道分泌物，睾丸位置、大小、硬度，精索有无增粗、压痛、结节与静脉曲张。阴囊有无脱屑、皲裂及肿胀；如肿胀，当用透照试验，以明确是否鞘膜积液。女性生殖器检查（参见妇科检查）必须有女护士在旁协助，或由女医师检查。
肛门：有无痔、肛裂、肛瘘、湿疹等。必要时应行肛门、直肠指诊或肛门镜检查。
●脊柱及四肢 脊柱有无畸形、压痛、叩击痛；脊柱两侧肌肉有无紧张、压痛；肋脊角有无压痛或叩痛；四肢有无畸形、杵状指趾、水肿、外伤、骨折、静脉曲张；肌肉张力与肌力，有无萎缩；关节有无红肿、畸形及运动障碍。甲床有无微血管搏动；股动脉及肱动脉有无枪击音；桡动脉搏动及血管硬度。
●神经系统 四肢运动及感觉、膝反射、跟腱反射、二头肌反射、三头肌反射、腹壁反射、提睾反射、巴宾斯基征、凯尼格征等。
8）.专科情况
如外科情况、妇科情况、眼科情况等，应重点突出、详尽、真实、系统地描写各该专科有关体征，参见各专科常规。
9）.检验及其他检查
入院后24h内主要实验室检查：如血、尿、便常规检验，以及X线，心电图检查等。入院前的重要检验结果可记录于现病史中。
10）.小结
用100~300字左右简明扼要地综述病史要点，阳性检查结果、重要的阴性结果及有关的检验数据。
入院时主要伤病已确诊者，可写“诊断”。初步诊断应根据全部病史及初步检查结果，通过综合分析，作出全部现有疾病的诊断，分行列出。其次序依下列原则：主要病在先，次要病在后；本科病在先，他科病在后。主要诊断的可能不止一项时，记录可能性最大的一项或二项。诊断名称先写病名，次按需要记明类型、部位、侧别；诊断记于病历纸右半侧。11）.签名
●上述入院病历由实习医师记载完毕签名后，再由住院医师审阅，用红墨水笔修正并签署全名。字迹必须端正清楚。
