第一篇：英文病歷示范范文
婦科英文病歷
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：呼吸科英文病歷
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：企業介紹英文翻譯示范
ChengDu HengDa textile co.,Ltd is a professional manufacturer of medical weaving. Mainly produce medical garments fabric, surgical fabric, and bedding cloth.
We have 2 production line with advanced equipment. Of long-term produce various kind of doctor and nurse grey cloth surgical garment grey fabric sick fabric sickroom bedclothes grey fabric and surgical items grey fabri
Relying on our own strength ,we have established long-term relationship with chuanmian printing and dyeing mill , nanshan printingand dyeing mill , minkang printing and dyeing milland developed and produce 4 types of registered products more than 50 specification of medical fabric including nurse garment , surgical garment , sick garment , sickroom bedclothes, which are washable by the standard of hospital.
The company established long term sells and supplement relationship with 20 franchiser and 50 medical clothing factory outside the province.
At the same time , the company can supply surgical garments , sick garments , sickroom bedclothes etc with low price to other provinces ,we can design and printing kinds of medical fabric according to your request.
Our company supply expect medical garments fabric surgical fabric and sickroom bedclothes fabric to (franchiser and clothing factory inside and outside of province ) and also produce sickroom bedclothes surgical items. Surgical garments doctor and nurse garments sick clothing by subordinate enterprise
Advantage in the production:
1、Provide professional weaving for hospital, ensure the long term supplement with steady quality to hospital and inside outside province.
2、Professional dyed hospital bedclothes and surgical items ,high color fastness , washable by detergent and high temperature steam.
3、The company perennial supply with as many as 230 varieties .including bedclothes , garments , and surgical items which would meet the different needs of hospital.
4、Specialized in designing new type bedclothes with dying pattern of hospital symbol. Making the environment more warmth and more comfortable.
5、Dealing a variety of medical fabric. Satisfying the dealer’s and clothing factory’s requirement inside and outside the province
三、Cargo Network
In order to ensure the products arrive at customers in time , our company have established cargo network outside province.
四、Way of business corporation
Our company willing to established long term sells and supply relationship with all hospitals and a variety of dealers and clothing factory.
No matter what grey cloth or finished products you will purchase , just tell us by a call or a fax . we will make efforts to delivery the good in your hands convenient and safety.
“customers contentment is hengda constant craving” we sincerely hold the tenet of quality first , well serve and good faith work style . we sincerely looking forward to start business with you.
ChengDu HengDa textile Co.,Ltd
第四篇：婦科入院病歷排序婦科出院病歷排序
入院證
入院評估單
體溫單
長期醫囑單首頁
(一) 首頁
(二) 出院記錄 住院病歷
臨時醫囑單住院記錄
住院病歷檢查單(B超心電圖肝功能三大常規) 住院記錄(2張)化驗單
貼驗單紙(3張)長期醫囑單
首頁
(一)
首頁
(二)
出院記錄
產科入院病歷排序
入院證
護理記錄單
產科家屬談話記錄
體溫單
長期醫囑單
臨時醫囑單
產科入院記錄
(一)
產科入院記錄
(二)
侯產記錄
產程進展圖
產后記錄表
貼驗單紙(3張)
產科護理評估單
體溫單
長期醫囑單
臨時醫囑單
新生兒記錄
嬰兒情況記錄單
首頁
(一)
首頁
(二)
產科出院小結
臨時醫囑單入院評估單護理記錄單 體溫單順產出院病歷排序剖宮產出院病歷排序 首頁
(一)首頁
(一) 首頁
(二)首頁
(二) 產科出院小結產科出院小結 病程記錄入院記錄侯產記錄首次病記 產程進展圖侯產記錄 陰道檢查陰道檢查分娩記錄分娩記錄 產后記錄術前總結 談話記錄手術同意書 胎監麻醉同意書 B超心電圖肝功能三大常規麻醉記錄 長期醫囑單手術記錄 臨時醫囑單術后記錄 產科護理評估單談話記錄 護理記錄胎監 體溫單B超心電圖肝功能三大常規 新生兒記錄長期醫囑單 新生兒護理記錄臨時醫囑單 母乳記錄產科護理評估單 聽力篩查單護理手術記錄 新生兒長期醫囑單護理記錄
新生兒臨時醫囑單體溫單
新生兒體溫單圍產記錄
新生兒排序一樣
第五篇：江蘇省2015年病歷書寫規范出院病歷排序
一、病歷內容目錄表
二、住院病案首頁及住院證
三、住院病歷或入院記錄
四、病程記錄(按頁數次序順排)
1、術前小結
2、術前討論記錄
3、手術審批書(手術報審記錄)
4、手術知情同意書、授權委托書、委托雙方有效身份證明復印件
5、麻醉知情同意書
6、麻醉術前訪視記錄
7、手術安全核查記錄
8、手術清點記錄
9、麻醉記錄(或待產記錄)
10、手術記錄(或產時記錄)
11、麻醉術后訪視記錄
12、術后病程記錄(或產后記錄)
五、出院記錄或24小時內入出院記錄
六、死亡記錄或24小時內入院死亡記錄
七、疑難病例討論記錄
八、死亡病例討論記錄
九、輸血治療知情同意書(按頁數次序順排)
十、特殊檢查知情同意書(按頁數次序順排) 十
一、特殊治療知情同意書(按頁數次序順排) 十
二、、會診記錄(按頁數次序順排) 十
三、病危(重)通知書
十四、患者知情同意、溝通記錄、授權委托書 十
五、輔助檢查報告單
1、病理資料(按日期先后順序排)
2、血、尿、糞常規檢驗報告單(按日期先后順排，自上而下貼于專用紙左邊線上)
3、臨床化學、免疫、微生物及其他檢驗報告單(按日期先后順排，自上而下貼于專用紙左邊線上)
4、醫學影像檢查資料(按分類及日期先后順排)
5、其他檢查資料
十六、、體溫單(按頁數次序倒排) 十
七、長期醫囑單(按頁數次序倒排) 十
八、臨時醫囑單(按頁數次序倒排)
十九、病危(病重)患者護理記錄(按頁數次序倒排) 二
十、ICU記錄單、各類監測記錄單(按頁數次序倒排) 二十
一、特殊治療記錄單(按頁數次序倒排) 二十
二、死亡患者的門診病歷