1、英文病例寫作范文篇一Name: Joe Bloggs （姓名喬。伯勞格斯）Date: 1st January 2000日期（2000年 1 月 1 日）Time: 0720（時間7 時 20分）Place: AE（地點事故與急診登記處）Age: 47 years什齡 47 歲）Sex: maleG生另1J男）Occupation: HGV（heavy goods vehicle ） driver齦業(yè)大型貨運卡車司機）PC（presenting complaint）住訴）4-hour crushing retrosternal chest pair®骨后壓榨性疼痛 4 小時）HPC（h

2、istory of presenting complaint）（ffl 病史）Onset: 4 hours of crushing tight retrosternal chest pain, radiating to neck and both arms, gradual onset over 5-10 minutes超病特征胸骨后壓榨性疼痛 4小時， 向頸與雙臂放射，5-10分鐘內(nèi)漸起?。〥uration: persistent since 0nset1期發(fā)病起持續(xù)至今 ）Severe: worst pain ever haW重性從未痛得如此厲害過）Relieving/exacerbati

3、ng factors 解與惡化因素GTN（glyceryl trinitrate） provided no relief although normally relieves pain in minutes, no other relieving/exacerbating factors.蠟酸甘油平時能在數(shù)分鐘內(nèi)緩解 疼痛，但本次無效，無其它緩解和惡化因素。 ）英文病例寫作范文篇二Nausea, vomiting2, sweating, dizzy惡心、嘔吐 2 次、出汗、眩暈） 1997:external chest tightness and dyspnea initially contr

4、olled atenolol.1997年出現(xiàn)胸外疼痛與呼吸困難，最終經(jīng)服 atenolol控制。4/12 symptoms worse, exercise tolerance 200 yards on flat, limited by chest pain4月 12 日，癥狀加重，受胸痛限制，僅耐受平地行走200碼No rest pain, no orthopnoea, no PND無靜息時疼痛，無端坐呼吸、無陣發(fā)性夜間呼吸困難英文病例寫作范文篇三Hypertension-no 高血壓無Smoking-20 cigarettes per day for 16 years煙 16 年來每天 20

5、 支Diabetes-no糖尿病無Cholesterol-never checked且固醇未查Ischemic heart disease-angina, previous Mft血性心臟病心絞痛、有心肌梗 死病史PMH（past medical historyM 去史1963: appendectomy 1963年闌尾切除手術(shù)1972: duodenal ulcer, no symptoms since197笄十二指腸潰瘍，之后無癥狀1986: myocardial infarction, full recovery / No subsequent investigation1986 心肌梗

6、死，完全恢復(fù)，無隨訪1989: gout quiescent on treatment198笄痛風(fēng)治療期間癥狀靜止No diabetes, hypertension, rheumatic heart disease, tuberculosis, epilepsy, asthma, jaundice, cerebrovascular disease®尿病、高血壓、風(fēng)濕性心臟病、結(jié) 核病、癲癇、哮喘、黃疸、腦血管疾病S/E(systems inquiry)系統(tǒng)回顧英文病例寫作范文篇四Fatigue lately, appetite unchanged, weight stable, no

7、 sweats or pruritus, sleeping well最近有疲勞感，食欲無改變，體重穩(wěn)定，無出汗或騷癢，睡眠佳。RS 呼吸系統(tǒng)Dyspnea on exertion, particularly uphill, but not limiting; no cough sputum/wheeze勞累時呼吸困難，上坡尤其如此，但無呼吸限制，無咳嗽咳痰、哮喘。GIT gastrointestinal tract 胃腸道No current indigestion 現(xiàn)無消化不良。No symptoms lile previous duodenal ulcerM去無十二指腸潰瘍癥狀。No vo

8、miting/dysphagia/abdominal pain無嘔吐、吞咽困難、腹部疼痛。GUS genitourinary system 生殖泌尿道No urinary systems無泌尿道癥狀。英文病例寫作范文篇五Atenolol 100 mg once daily(Atenolol 100mg 每天 1 次)GTN as required需要服用硝酸甘油。Not taking aspirin 無服用過阿斯匹林。Allergies: penicillin-skin rash 過敏反應(yīng)青霉素 皮疹。FH(family history) 家族史Father died of heart att

9、ack at age 5父親 53 歲死于心臟病。Mother died of old age at 7母親于 76 歲去世。SH(social history)社會史Lives with wife who fit and well. 妻子健在，與其共同生活。Own house 私宅。Completely independent 生活全部自理。Smoking 20 cigs/day for many years年每天抽煙 20 支。Alcohol: 24 units per week飲酒每周 24個單位。Sexual history: not appropriate 性生活未評價。Overse

10、as travel: not appropriate!外旅游未評價。Pets: not appropriated物未評價。Occupation: heavy goods vehicle driveSR 業(yè)大型貨車卡車司機。O/E(on examination淋檢結(jié)果英文病例寫作范文篇六Unwell, sweaty, clammy, no cyanosis/jaundice一般情況不佳，出汗、皮膚濕冷，無青紫、黃疸。temperature: 35體溫 35 。cigarette-stained fingers煙熏手指。no arcus / xanthomas / xanthelasma無老人弓環(huán)

11、、黃瘤、黃斑瘤。CVS 心血管系統(tǒng)Pluse 104 bpm regular, normal character脈搏每分鐘 104 次，規(guī)則，心音正常。BP110/70 mmHg (right), 112/74 mmHg (left)血壓 110/70 mmHg 右，112/74 mmHg 左。JVP(jugular venous pulse) normal頸靜脈博動正常。No precordial scars /chest deformities無心前區(qū)疤痕、胸廓畸形。Apex beat displaced to anterior axillarys line 6th intercostals space心尖博動向腋前線第6 肋間移位。No parasternal heave /thrills無胸骨旁隆起、震顫。Auscultation: heart sounds normal, but soft pan systolic murmur at apex radiating to axilla聽診心音正常，但心尖問及收縮前柔和雜音，向腋窩放射。PSM at apex and ejection systolic murmur in aortic area