英文病历书写范例
内科CASE ....................................................................................................................... 1
外科CASE ....................................................................................................................... 3
儿科CASE ....................................................................................................................... 5
妇科CASE ....................................................................................................................... 6
如何写好一份英文病历 .................................................................................................. 9
英文病历书写系列一 .................................................................................................... 11
内科CASE
Medical Records for Admisson
Medical Number: 701721
General information
Name: Liu Side
Age: Eighty
Sex: Male
Race: Han
Nationality: China
Address: NO.35, Dandong Road, Jiefang Rvenue, Hankou, Hubei. Tel: 857307523
Occupation: Retired
Marital status: Married
Date of admission: Aug 6th, 2001
Date of record: 11Am, Aug 6th, 2001
Complainer of history: patient’s son and wife
Reliability: Reliable
Chief complaint: Upper bellyache ten days, haematemesis, hemafecia and unconsciousness for four hours. Present illness:
The patient felt upper bellyache about ten days ago. He didn’t pay attention to it and thought he had ate something wrong. At 6 o’clock this morning he fainted and rejected lots of blood and gore. Then hemafecia began. His family sent him to our hospital and received emergent treatment. So the patient was accepted because of “upper gastrointestine hemorrhage and exsanguine shock”.
Since the disease coming on, the patient didn’t urinate.
Past history
The patient is healthy before.
No history of infective diseases. No allergy history of food and drugs.
Past history
Operative history: Never undergoing any operation.
Infectious history: No history of severe infectious disease.
Allergic history: He 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
He was born in Wuhan on Nov 19th, 1921 and almost always lived in Wuhan. His living conditions were good. No bad personal habits and customs.
Menstrual history: He is a male patient.
Obstetrical history: No
Contraceptive history: Not clear.
Family history: His parents have both deads.
Physical examination
T 36.5℃, P 130/min, R 23/min, BP 100/60mmHg. He is well developed and moderately nourished. Active position. His consciousness was not clear. His face was cadaverous and 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 found enlarged.
Head
Cranium: Hair was black and white, 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 not smooth, and there were ulcer can be seen. Tongue was in midline. Pharynx was 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.
Lungs: Respiratory movement was bilaterally symmetric with the frequency of 23/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 150/min. Cardiac rhythm was not regular. No pathological murmurs.
Abdomen: Flat and soft. No bulge or depression. No abdominal wall varicosis. Gastralintestinal type or peristalses were not seen. Tenderness was obvious around the navel and in upper abdoman. There was not rebound
tenderness on abdomen or renal region. Liver and spleen was untouched. No masses. Fluidthrill negative. Shifting dullness negative. Borhorygmus not heard. 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 69g/L RBC 2.70T/L WBC 1. 1G/L PLT 120G/L
History summary
1. Patient was male, 80 years old
2. Upper bellyache ten days, haematemesis, hemafecia and unconsciousness for four hours.
3. No special past history.
4. Physical examination: T 37.5℃, P 130/min, R 23/min, BP 100/60mmHg Superficial lymph nodes were not found enlarged. No abdominal wall varicosis. Gastralintestinal type or peristalses were not seen. Tenderness was obvious around the navel and in upper abdoman. There was not rebound tenderness on abdomen or renal region. Liver and spleen was untouched. No masses. Fluidthrill negative. Shifting dullness negative. Borhorygmus not heard. No vascular murmurs. No other positive signs.
5. investigation information:
Blood-Rt: Hb 69g/L RBC 2.80T/L WBC 1.1G/L PLT 120G/L
Impression: upper gastrointestine hemorrhage
Exsanguine shock
外科CASE
Medical Number: 682786
General information
Name: Wang Runzhen
Age: Forty three
Sex: Female
Race: Han
Occupation: Teacher
Nationality: China
Marital status: Married
Address: NO.38, Hangkong Road, Jiefang Rvenue, Hankou, Hubei. Tel: 82422500
Date of admission: Jan 11st, 2001
Date of record: 11Am, Jan 11st, 2001
Complainer of history: the patient herself
Reliability: Reliable
Chief complaint: Right breast mass found for more than half a month.
Present illness: Half a month ago, the patient suddenly felt pain in her right chest when she put up her hand. After touching it, she found a mass in her right breast, but no tendness, and the patient didn’t pay attention it. Then the pain became more and more serious, so the patient went to tumour hospital and received a pathology centesis. Her diagnosis was breast cancer. Then she came to our hospital and asked for an operation.
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 Wuhan on Nov 19th, 1957 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 3 to 4 days every times and its cycle is about 30 days. Obstetrical history: Pregnacy 3 times, once nature production, abortion twice.
Contraceptive history: Not clear.
Family history: His parents have both died.
Physical examination
T 36.4℃, P 80/min, R 20/min, BP 90/60mmHg. 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 bila
儿科CASE
Medical Records for Admisson
Medical Number: 696235
General information
Name: Zhang Yi
Age: thirteen
Sex: Female
Race: Han
Nationality: China
Address: NO.23, Yunchun Road, Jiefang Rvenue, Hankou, Hubei. Tel: 85763723
Parents Name: father Zhang Hesheng
Mother Yang Chiulian
Date of admission: May 8th, 2001
Date of record: 11Am, May 8th, 2001
Complainer of history: patient’s mother
Reliability: Reliable
Chief complaint: Pharyngalgia and fever for four days.
Present illness:
The patient felt pharyngalgia and weak about four days ago. She ate some medicine (not clear), but it do nothing. Then she found ulcer in her mouth and fever all along, but she felt no nausea and never vomited. So her parents took her to Wuhan Children’s Hospital, there she received treatment of antibiotics, but her symptoms didn’t abate. So her parents took her to our hospital, she was admitted with a diagnosis of “fever of unknown”
Since onset, her appetite was not good, and both her spiritedness and physical energy are bad. Defecation and urination are normal.
Past history
The patient is healthy before.
No history of “measles” or “pertussis” etc and no contact history with T.B or other infective diseases. No allergy history of food but she was allergy to sulfa.
Personal history
1.Natal: First birth born, uneventfully and on full term with birth weight 2.7 Kg. The state of her at birth was good, no cyanosis, apnea, convulsion or bleeding.
2.Development: Able to raise head at second month. The first tooth erupted at 6th. She began to walk at one. Her
intelligence was normal.
3.Nutrition: She was only feeded with breast milk before she was 6 months old. Then the additives were added. She was weaned from the breast at 14th month.
4.Immunization: Inoculated on schedule after birth (such as B.C.G, D.P.T and smallpox voccination).
Physical examination
T 39.5℃, P 120/min, R 30/min, BP 110/90mmHg. 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 found enlarged in her neck, but no flare and tenderness. 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 not smooth, and there were ulcer can be seen. Tongue was in midline. Pharynx was 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.
Lungs: Respiratory movement was bilaterally symmetric with the frequency of 30/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 ar
妇科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 retr
出院小结（DISCHARGE SUMMARY）
===============
Department of Gastroenterology
Changhai Hospital，No.174 Changhai Road Shanghai, China
Phone: 86-21-25074725-803
DISCHARGE SUMMARY
DA TE OF ADMISSION: October 7th, 2005
DA TE OF DISCHARGE: October 12th, 2005
ATTENDING PHYSICIAN: Yu Bai, MD
PATIENT AGE: 18
ADMITTING DIAGNOSIS:
V omiting for unknown reason: acute gastroenteritis?
BRIEF HISTORY
A 18-year-old female with a complaint of nausea and vomiting for nearly one month who was seen at Department of Gastroenterology in Changhai Hospital, found to have acute gastroenteritis and non-atrophic gastritis. The patient was subsequently recovered and discharged soon after medication.
REVIEW OF SYSTEM
She has had no headache, fever, chills, diarrhea, chest pain, palpitations, dyspnea, cough, hemoptysis, dysuria, hematuria or ankle edema.
PAST MEDICAL HISTORY
She has had no previous surgery, accidents or childhood illness.
SOCIAL HISTORY: She has no history of excessive alcohol or tobacco use.
FAMIL Y HISTORY
She has no family history of cardiovascular, respiratary and gastrointestinal diseases.
PHYSICAL EXAMINATION
Temperature is 37, pulse 80, respirations 16, blood pressure 112/70. General: Plump girl in no apparent distress. HEENT: She has no scalp lesions. Her pupils are equally round and reactive to light and accommodation. Extraocular movements are intact. Sclerae are anicteric. Oropharynx is clear. There is no thyromegaly. There is no cervical or supraclvicular lymphadenopathy. Cardiovascular: Regular rate and rhythm, normal S1, S2. Chest: Clear to auscultation bilateral. Abdomen: Bowel sounds present, no hepatosplenomagaly. Extremities: There is no cyanosis, clubbing or edema. Neurologic: Cranial nerves II-XII are intact. Motor examination is 5/5 in the bilateral upper and lower extremities. Sensory, cerebellar and gait are normal.
LABORATORY DATA
White blood cells count 5.9, hemoglobin 111g/L, hematocrit 35.4. Sodium 142, potassium 4.3, chloride 106, CO2 25, BUN 2.6mmol/L, creatinine 57μmol/L, glucose 4.1mmol/L, Albumin 36g/L.
Endoscopic Exam
Chronic non-atrophic gastritis
HOSPITAL COURSE
The patient was admitted and placed on fluid rehydration and mineral supplement. The patient improved, showing gradual resolution of nausea and vomiting. The patient was discharged in stable condition.
DISCHARGE DIAGNOSIS
Acute gastroenteritis
Chronic non-atrophic gastritis
PROGNOSIS
Good. No medications needed after discharge. But if this patient can not get used to Chinese food, she had better return to UK as soon as possible to prevent the relapse of acute gastroenteritis.
The patient is to follow up with Dr. Bai in one week.
___________________________
Yu Bai, MD
D: 12/10/2005
如何写好一份英文病历
学校规定，实习期间的完全病历中必须有一定比例的英文病历。虽然平时对英语还算感兴趣，但对于连一个中文病历都是刚开始写的实习生来说，写好甚至仅仅是写出来一份英文病历都不是容易的事情，战战兢兢地写过几份之后，深感写英文病历实乃一项非常重要但常常被人忽视或当作形式主义完成的东西。本文并非英文病历教学帖，只是就写英文病历中的一些注意事项谈一谈自己的体会，希望能抛砖引玉吧。 记得开始写第一份时，甚至连" 现病史" 、" 月经史" 、" 初步诊断" 这些基本项目中以前没有注意的名称都不知道如何写，快速翻阅了一通诊断学之后，OK ，从identification 到impression 的项目名称基本会写了，菜鸟迈出了第一步。别急，我说的是" 基本" 会写了，其实认真起来还有很多细节值得琢磨，case record ，
admission note 之间有没有区别，用哪个比较正规？" 性别" 是***还是gender ？" 国籍" 、" 民族" 英文都是nationality ，两个怎么区分？当然我们可以把问题暂时留到以后，现在要解决的是没有的问题，知道了一份病历中各个项目的写法，就像建房子有了基本的框架，虽然你还不知道要往里面放些什么家具，但起码你知道哪是卧室哪是厨房东西往哪搁了。
病历的第一部分identification 比较简单，只要把基本的几十百把个单词记住了就可以应付，我能想起来的注意事项主要有这么几个，都很简单，让牛人们见笑了。［医学教 育网 搜集整理］
l. 姓名的写法，单名两个字的拼音首字母均大写，中间空格，双名姓和名的第一个字同单名，名第二个字首字母小写并紧挨名的第一字，如" 高鹏程" 写作"Gao Pengcheng"，而"Pengcheng Gao"的假洋鬼子写法现在很少看到了采用，在和外国人的交流中感觉他们对国人的first name即为family name这一文化差异都普遍了解，大可不必随老外的用法别扭地把姓放在后面。
2." 性别" 应该是用***，按在下浅见，***多表示生物学上的性别差异，而gender 则多表示社会心理学上的差异，如性别歧视gender discrimination等等，故用于医学文档还是用***合适。
3. 民族" 一般用"Race" ，不用"nationality" 估计就是为了避免和国籍冲突吧。好像外国人不存在这个问题，日本人就说Japanese ，应该不会问他是不是Yamato race 吧？就算是移民后的美国人也就是说自己是" ～～born American"
4. 很多医院的入院记录上基本资料里都有" 门诊诊断" 一项，而似乎国外没有这一说。
5. 病史称述者" 、" 病历号" 的译法很多，未见有一定的标准，只要写出来看得懂就可以了吧，source of history ，complainer ，medical record NO.，case NO.都可以
Chief complain一般由症状和持续时间两部分构成，不出现人物称谓和a ，the 等冠词。
主要有以下几种写法
l. 症状+for+时间 [Chest pain for 2 hours] 胸痛2小时
2. 症状+of+时间如： [Nausea and vomiting of three days` duration] 恶心呕吐3天
3. 症状+时间+in duration如： [Headache 1 month in duration] 头痛1月
4. 时间+of+症状 如： [Two-day history of fever] 发热2天
发觉几份英文病历范例都没有我们的主诉里常常还要提到的症状性质—— " 阵发性" 、" 持续性" 还是" 反复" 等等，是不是又一个英文和中文病历的不同不得而知，我一般把" 阵发性" 译作intermittent ，" 持续性" 译作persistent ，而" 反复发作的" 就是recurrent ，如果是" 周期性的" 则是periodic.
History of present illness可以说是整个病历中最难的部分，想一想也是，清晰有条理地用中文记录好现病史都很不容易，何况要用英文准确的描述出整个疾病的发生、发展过程。在下以为需要注意的事项如下：
1. 时态的问题，整个现病史的的应主要为过去时，以用于描述起病及就诊等" 时间点" 上的动作，例如The patient felt fatigue and nausea three days ago without any obvious inducing factors.及So the patient came to our hospital and was accepted as "chronic hepatitis B".而现病史最后的" 一般情况" 部分则用现在时较佳，以为是" 一直如此到现在" 的情况，如Since onset， her appetite is not good， and both her spiritedness and physical energy are bad. Defecation and urination are normal.如果要突出" 疾病一直持续至今" 则用现在完成时，如" 发现患糖尿病五年" 译作He has suffered from DM for five years.较好，而译作He suffered from DM for five years.则让人有不知已愈未愈之感。而提到" 以前有但是现在未再出现" 的症状或疾病时，应该用过去完成时或加上说明的过去时，如He had suffered from abdominal pain for one week by March 8th. 及Two weeks prior to this admission， he had an episode of abdominal pain that lasted one week.
2. 要保持主语和谓语的一致，整个现病史的主语应该是the patient，不应有He found lung cancer 1 year ago 之类的句子出现。被动式也少用为妙，" 接受检查，治疗" 可以用receive ，accept 等词汇（receive 又较accept ），太多的被动式会把自己绕晕的。
3. 口语和医学术语的区分。不要用口语化的描述代替专业词汇，He got heart attack twice in the past. 就不如He experienced acute MI twice in the past正式，另一种相对的错误是是该使用口语化的词汇时（描述症状）用了专业词汇（体征），如将" 病人出现皮肤巩膜黄染" 中的" 黄染" 误用了" 黄疸"jaundice ，正确的用法应
该是he got stained yellow on skin and sclera. 以及不要在病历中使用一些情绪化的副词如Unfortunately ， Surprisingly ， To our surprise， Unexpectedly 等等。
此外还有一些注意事项，但是非英文病历写作独有，如何时用a 何时用the ，and ， so 及but 等介词的用法等等，在此不再赘述。
History of past illness，至Impression 部分的写法比较固定，相对较简单，主要是解决词汇问题。
英文病历书写系列一
A 63 year-old male presents to the emergency department after resolution of a 20-minute episode of chest pain, which began while he was raking leaves. The pain was described as a "pressure" sensation. The pain radiated down his arms and into his jaw and was associated with palpitations and dyspnea. The pain resolved shortly after resting. The patient had 3 prior episodes of similar pain today, lasting approximately 10 minutes each, and all with activity. He denies nausea, vomiting, diaphoresis, cough or any other associated complaints, nor is there change in the pain with inspiration or movement. He has had no recent illnesses. His past medical history is significant for diet controlled diabetes and hypertension. He hasn't smoked in "many years" and denies drug use. He presently takes HCTZ and states that he is compliant. Family history is significant for a sister who had an acute MI at age
55. He has no known allergies.
On physical examination he is an anxious, thin male who looks appropriate for age. His vitals are as follows: BP 150/85, pulse is 80, respirations 24/min, room air oxygen saturation 94%, and temperature 37.3. His external jugular veins are not distended. He has basilar crackles ¼ up bilaterally and his chest is nontender to palpation. Cardiovascular exam reveals no murmurs, gallops or rubs. His abdomen is soft and non-tender. His skin is dry and pink. He has equal bounding pulses in all four extremities. The rest of his examination is unremarkable.
11
英文病历书写范例
内科CASE ....................................................................................................................... 1
外科CASE ....................................................................................................................... 3
儿科CASE ....................................................................................................................... 5
妇科CASE ....................................................................................................................... 6
如何写好一份英文病历 .................................................................................................. 9
英文病历书写系列一 .................................................................................................... 11
内科CASE
Medical Records for Admisson
Medical Number: 701721
General information
Name: Liu Side
Age: Eighty
Sex: Male
Race: Han
Nationality: China
Address: NO.35, Dandong Road, Jiefang Rvenue, Hankou, Hubei. Tel: 857307523
Occupation: Retired
Marital status: Married
Date of admission: Aug 6th, 2001
Date of record: 11Am, Aug 6th, 2001
Complainer of history: patient’s son and wife
Reliability: Reliable
Chief complaint: Upper bellyache ten days, haematemesis, hemafecia and unconsciousness for four hours. Present illness:
The patient felt upper bellyache about ten days ago. He didn’t pay attention to it and thought he had ate something wrong. At 6 o’clock this morning he fainted and rejected lots of blood and gore. Then hemafecia began. His family sent him to our hospital and received emergent treatment. So the patient was accepted because of “upper gastrointestine hemorrhage and exsanguine shock”.
Since the disease coming on, the patient didn’t urinate.
Past history
The patient is healthy before.
No history of infective diseases. No allergy history of food and drugs.
Past history
Operative history: Never undergoing any operation.
Infectious history: No history of severe infectious disease.
Allergic history: He 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
He was born in Wuhan on Nov 19th, 1921 and almost always lived in Wuhan. His living conditions were good. No bad personal habits and customs.
Menstrual history: He is a male patient.
Obstetrical history: No
Contraceptive history: Not clear.
Family history: His parents have both deads.
Physical examination
T 36.5℃, P 130/min, R 23/min, BP 100/60mmHg. He is well developed and moderately nourished. Active position. His consciousness was not clear. His face was cadaverous and 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 found enlarged.
Head
Cranium: Hair was black and white, 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 not smooth, and there were ulcer can be seen. Tongue was in midline. Pharynx was 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.
Lungs: Respiratory movement was bilaterally symmetric with the frequency of 23/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 150/min. Cardiac rhythm was not regular. No pathological murmurs.
Abdomen: Flat and soft. No bulge or depression. No abdominal wall varicosis. Gastralintestinal type or peristalses were not seen. Tenderness was obvious around the navel and in upper abdoman. There was not rebound
tenderness on abdomen or renal region. Liver and spleen was untouched. No masses. Fluidthrill negative. Shifting dullness negative. Borhorygmus not heard. 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 69g/L RBC 2.70T/L WBC 1. 1G/L PLT 120G/L
History summary
1. Patient was male, 80 years old
2. Upper bellyache ten days, haematemesis, hemafecia and unconsciousness for four hours.
3. No special past history.
4. Physical examination: T 37.5℃, P 130/min, R 23/min, BP 100/60mmHg Superficial lymph nodes were not found enlarged. No abdominal wall varicosis. Gastralintestinal type or peristalses were not seen. Tenderness was obvious around the navel and in upper abdoman. There was not rebound tenderness on abdomen or renal region. Liver and spleen was untouched. No masses. Fluidthrill negative. Shifting dullness negative. Borhorygmus not heard. No vascular murmurs. No other positive signs.
5. investigation information:
Blood-Rt: Hb 69g/L RBC 2.80T/L WBC 1.1G/L PLT 120G/L
Impression: upper gastrointestine hemorrhage
Exsanguine shock
外科CASE
Medical Number: 682786
General information
Name: Wang Runzhen
Age: Forty three
Sex: Female
Race: Han
Occupation: Teacher
Nationality: China
Marital status: Married
Address: NO.38, Hangkong Road, Jiefang Rvenue, Hankou, Hubei. Tel: 82422500
Date of admission: Jan 11st, 2001
Date of record: 11Am, Jan 11st, 2001
Complainer of history: the patient herself
Reliability: Reliable
Chief complaint: Right breast mass found for more than half a month.
Present illness: Half a month ago, the patient suddenly felt pain in her right chest when she put up her hand. After touching it, she found a mass in her right breast, but no tendness, and the patient didn’t pay attention it. Then the pain became more and more serious, so the patient went to tumour hospital and received a pathology centesis. Her diagnosis was breast cancer. Then she came to our hospital and asked for an operation.
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 Wuhan on Nov 19th, 1957 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 3 to 4 days every times and its cycle is about 30 days. Obstetrical history: Pregnacy 3 times, once nature production, abortion twice.
Contraceptive history: Not clear.
Family history: His parents have both died.
Physical examination
T 36.4℃, P 80/min, R 20/min, BP 90/60mmHg. 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 bila
儿科CASE
Medical Records for Admisson
Medical Number: 696235
General information
Name: Zhang Yi
Age: thirteen
Sex: Female
Race: Han
Nationality: China
Address: NO.23, Yunchun Road, Jiefang Rvenue, Hankou, Hubei. Tel: 85763723
Parents Name: father Zhang Hesheng
Mother Yang Chiulian
Date of admission: May 8th, 2001
Date of record: 11Am, May 8th, 2001
Complainer of history: patient’s mother
Reliability: Reliable
Chief complaint: Pharyngalgia and fever for four days.
Present illness:
The patient felt pharyngalgia and weak about four days ago. She ate some medicine (not clear), but it do nothing. Then she found ulcer in her mouth and fever all along, but she felt no nausea and never vomited. So her parents took her to Wuhan Children’s Hospital, there she received treatment of antibiotics, but her symptoms didn’t abate. So her parents took her to our hospital, she was admitted with a diagnosis of “fever of unknown”
Since onset, her appetite was not good, and both her spiritedness and physical energy are bad. Defecation and urination are normal.
Past history
The patient is healthy before.
No history of “measles” or “pertussis” etc and no contact history with T.B or other infective diseases. No allergy history of food but she was allergy to sulfa.
Personal history
1.Natal: First birth born, uneventfully and on full term with birth weight 2.7 Kg. The state of her at birth was good, no cyanosis, apnea, convulsion or bleeding.
2.Development: Able to raise head at second month. The first tooth erupted at 6th. She began to walk at one. Her
intelligence was normal.
3.Nutrition: She was only feeded with breast milk before she was 6 months old. Then the additives were added. She was weaned from the breast at 14th month.
4.Immunization: Inoculated on schedule after birth (such as B.C.G, D.P.T and smallpox voccination).
Physical examination
T 39.5℃, P 120/min, R 30/min, BP 110/90mmHg. 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 found enlarged in her neck, but no flare and tenderness. 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 not smooth, and there were ulcer can be seen. Tongue was in midline. Pharynx was 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.
Lungs: Respiratory movement was bilaterally symmetric with the frequency of 30/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 ar
妇科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 retr
出院小结（DISCHARGE SUMMARY）
===============
Department of Gastroenterology
Changhai Hospital，No.174 Changhai Road Shanghai, China
Phone: 86-21-25074725-803
DISCHARGE SUMMARY
DA TE OF ADMISSION: October 7th, 2005
DA TE OF DISCHARGE: October 12th, 2005
ATTENDING PHYSICIAN: Yu Bai, MD
PATIENT AGE: 18
ADMITTING DIAGNOSIS:
V omiting for unknown reason: acute gastroenteritis?
BRIEF HISTORY
A 18-year-old female with a complaint of nausea and vomiting for nearly one month who was seen at Department of Gastroenterology in Changhai Hospital, found to have acute gastroenteritis and non-atrophic gastritis. The patient was subsequently recovered and discharged soon after medication.
REVIEW OF SYSTEM
She has had no headache, fever, chills, diarrhea, chest pain, palpitations, dyspnea, cough, hemoptysis, dysuria, hematuria or ankle edema.
PAST MEDICAL HISTORY
She has had no previous surgery, accidents or childhood illness.
SOCIAL HISTORY: She has no history of excessive alcohol or tobacco use.
FAMIL Y HISTORY
She has no family history of cardiovascular, respiratary and gastrointestinal diseases.
PHYSICAL EXAMINATION
Temperature is 37, pulse 80, respirations 16, blood pressure 112/70. General: Plump girl in no apparent distress. HEENT: She has no scalp lesions. Her pupils are equally round and reactive to light and accommodation. Extraocular movements are intact. Sclerae are anicteric. Oropharynx is clear. There is no thyromegaly. There is no cervical or supraclvicular lymphadenopathy. Cardiovascular: Regular rate and rhythm, normal S1, S2. Chest: Clear to auscultation bilateral. Abdomen: Bowel sounds present, no hepatosplenomagaly. Extremities: There is no cyanosis, clubbing or edema. Neurologic: Cranial nerves II-XII are intact. Motor examination is 5/5 in the bilateral upper and lower extremities. Sensory, cerebellar and gait are normal.
LABORATORY DATA
White blood cells count 5.9, hemoglobin 111g/L, hematocrit 35.4. Sodium 142, potassium 4.3, chloride 106, CO2 25, BUN 2.6mmol/L, creatinine 57μmol/L, glucose 4.1mmol/L, Albumin 36g/L.
Endoscopic Exam
Chronic non-atrophic gastritis
HOSPITAL COURSE
The patient was admitted and placed on fluid rehydration and mineral supplement. The patient improved, showing gradual resolution of nausea and vomiting. The patient was discharged in stable condition.
DISCHARGE DIAGNOSIS
Acute gastroenteritis
Chronic non-atrophic gastritis
PROGNOSIS
Good. No medications needed after discharge. But if this patient can not get used to Chinese food, she had better return to UK as soon as possible to prevent the relapse of acute gastroenteritis.
The patient is to follow up with Dr. Bai in one week.
___________________________
Yu Bai, MD
D: 12/10/2005
如何写好一份英文病历
学校规定，实习期间的完全病历中必须有一定比例的英文病历。虽然平时对英语还算感兴趣，但对于连一个中文病历都是刚开始写的实习生来说，写好甚至仅仅是写出来一份英文病历都不是容易的事情，战战兢兢地写过几份之后，深感写英文病历实乃一项非常重要但常常被人忽视或当作形式主义完成的东西。本文并非英文病历教学帖，只是就写英文病历中的一些注意事项谈一谈自己的体会，希望能抛砖引玉吧。 记得开始写第一份时，甚至连" 现病史" 、" 月经史" 、" 初步诊断" 这些基本项目中以前没有注意的名称都不知道如何写，快速翻阅了一通诊断学之后，OK ，从identification 到impression 的项目名称基本会写了，菜鸟迈出了第一步。别急，我说的是" 基本" 会写了，其实认真起来还有很多细节值得琢磨，case record ，
admission note 之间有没有区别，用哪个比较正规？" 性别" 是***还是gender ？" 国籍" 、" 民族" 英文都是nationality ，两个怎么区分？当然我们可以把问题暂时留到以后，现在要解决的是没有的问题，知道了一份病历中各个项目的写法，就像建房子有了基本的框架，虽然你还不知道要往里面放些什么家具，但起码你知道哪是卧室哪是厨房东西往哪搁了。
病历的第一部分identification 比较简单，只要把基本的几十百把个单词记住了就可以应付，我能想起来的注意事项主要有这么几个，都很简单，让牛人们见笑了。［医学教 育网 搜集整理］
l. 姓名的写法，单名两个字的拼音首字母均大写，中间空格，双名姓和名的第一个字同单名，名第二个字首字母小写并紧挨名的第一字，如" 高鹏程" 写作"Gao Pengcheng"，而"Pengcheng Gao"的假洋鬼子写法现在很少看到了采用，在和外国人的交流中感觉他们对国人的first name即为family name这一文化差异都普遍了解，大可不必随老外的用法别扭地把姓放在后面。
2." 性别" 应该是用***，按在下浅见，***多表示生物学上的性别差异，而gender 则多表示社会心理学上的差异，如性别歧视gender discrimination等等，故用于医学文档还是用***合适。
3. 民族" 一般用"Race" ，不用"nationality" 估计就是为了避免和国籍冲突吧。好像外国人不存在这个问题，日本人就说Japanese ，应该不会问他是不是Yamato race 吧？就算是移民后的美国人也就是说自己是" ～～born American"
4. 很多医院的入院记录上基本资料里都有" 门诊诊断" 一项，而似乎国外没有这一说。
5. 病史称述者" 、" 病历号" 的译法很多，未见有一定的标准，只要写出来看得懂就可以了吧，source of history ，complainer ，medical record NO.，case NO.都可以
Chief complain一般由症状和持续时间两部分构成，不出现人物称谓和a ，the 等冠词。
主要有以下几种写法
l. 症状+for+时间 [Chest pain for 2 hours] 胸痛2小时
2. 症状+of+时间如： [Nausea and vomiting of three days` duration] 恶心呕吐3天
3. 症状+时间+in duration如： [Headache 1 month in duration] 头痛1月
4. 时间+of+症状 如： [Two-day history of fever] 发热2天
发觉几份英文病历范例都没有我们的主诉里常常还要提到的症状性质—— " 阵发性" 、" 持续性" 还是" 反复" 等等，是不是又一个英文和中文病历的不同不得而知，我一般把" 阵发性" 译作intermittent ，" 持续性" 译作persistent ，而" 反复发作的" 就是recurrent ，如果是" 周期性的" 则是periodic.
History of present illness可以说是整个病历中最难的部分，想一想也是，清晰有条理地用中文记录好现病史都很不容易，何况要用英文准确的描述出整个疾病的发生、发展过程。在下以为需要注意的事项如下：
1. 时态的问题，整个现病史的的应主要为过去时，以用于描述起病及就诊等" 时间点" 上的动作，例如The patient felt fatigue and nausea three days ago without any obvious inducing factors.及So the patient came to our hospital and was accepted as "chronic hepatitis B".而现病史最后的" 一般情况" 部分则用现在时较佳，以为是" 一直如此到现在" 的情况，如Since onset， her appetite is not good， and both her spiritedness and physical energy are bad. Defecation and urination are normal.如果要突出" 疾病一直持续至今" 则用现在完成时，如" 发现患糖尿病五年" 译作He has suffered from DM for five years.较好，而译作He suffered from DM for five years.则让人有不知已愈未愈之感。而提到" 以前有但是现在未再出现" 的症状或疾病时，应该用过去完成时或加上说明的过去时，如He had suffered from abdominal pain for one week by March 8th. 及Two weeks prior to this admission， he had an episode of abdominal pain that lasted one week.
2. 要保持主语和谓语的一致，整个现病史的主语应该是the patient，不应有He found lung cancer 1 year ago 之类的句子出现。被动式也少用为妙，" 接受检查，治疗" 可以用receive ，accept 等词汇（receive 又较accept ），太多的被动式会把自己绕晕的。
3. 口语和医学术语的区分。不要用口语化的描述代替专业词汇，He got heart attack twice in the past. 就不如He experienced acute MI twice in the past正式，另一种相对的错误是是该使用口语化的词汇时（描述症状）用了专业词汇（体征），如将" 病人出现皮肤巩膜黄染" 中的" 黄染" 误用了" 黄疸"jaundice ，正确的用法应
该是he got stained yellow on skin and sclera. 以及不要在病历中使用一些情绪化的副词如Unfortunately ， Surprisingly ， To our surprise， Unexpectedly 等等。
此外还有一些注意事项，但是非英文病历写作独有，如何时用a 何时用the ，and ， so 及but 等介词的用法等等，在此不再赘述。
History of past illness，至Impression 部分的写法比较固定，相对较简单，主要是解决词汇问题。
英文病历书写系列一
A 63 year-old male presents to the emergency department after resolution of a 20-minute episode of chest pain, which began while he was raking leaves. The pain was described as a "pressure" sensation. The pain radiated down his arms and into his jaw and was associated with palpitations and dyspnea. The pain resolved shortly after resting. The patient had 3 prior episodes of similar pain today, lasting approximately 10 minutes each, and all with activity. He denies nausea, vomiting, diaphoresis, cough or any other associated complaints, nor is there change in the pain with inspiration or movement. He has had no recent illnesses. His past medical history is significant for diet controlled diabetes and hypertension. He hasn't smoked in "many years" and denies drug use. He presently takes HCTZ and states that he is compliant. Family history is significant for a sister who had an acute MI at age
55. He has no known allergies.
On physical examination he is an anxious, thin male who looks appropriate for age. His vitals are as follows: BP 150/85, pulse is 80, respirations 24/min, room air oxygen saturation 94%, and temperature 37.3. His external jugular veins are not distended. He has basilar crackles ¼ up bilaterally and his chest is nontender to palpation. Cardiovascular exam reveals no murmurs, gallops or rubs. His abdomen is soft and non-tender. His skin is dry and pink. He has equal bounding pulses in all four extremities. The rest of his examination is unremarkable.
11