- 皮肤科病例怎么写
- 有个病历需要翻译，可是医生的字体太潦草，很多地方看不清楚，急需帮助 谢谢大家~
- 关于病历的英文书写
- 文言文“病在皮肤无常者取以馋针于病所.肤白勿取病在分肉间取以员针……泻于井荥分输取以四时”如何翻译？
皮肤科病例怎么写
我治疗过会指甲的病历给你抄过来！
R1 经检查脚指甲患有甲藓，本人要求治疗
双足指2，3，4指灰色变厚，中间隆起．
诊断：＊＊＊
R2 普诊
完了，会指甲也属于皮肤科的，希望对你有帮助！
一名因上嘴唇疖肿2天，伴高烧、头痛而前来急诊的男性青年患者，经体格检查：体温39.5℃，左上唇、眼周围组织红肿、触痛，鼻唇沟外侧有1.5cm直径的红肿硬块，在硬疖和硬块的皮肤表面均有多个小脓点。经追问病史，原来他在两天前左上唇长了一个小疮，发痒不适，即用手指挤压小疮，疮口流出黄水，当时似乎好了些，但当天晚上，就出现了上述症状。医生根据病史和检查结果，诊断为上唇疖肿并发海绵窦血栓性静脉炎。经抗感染治疗后病愈。
因为口腔颌面部的血管丰富，构成深、浅两个静脉网，互相吻合，但没有静脉瓣，血液既可以向心回流，也可离心反流。因此，面部尤其是两侧口角至鼻根部位，即被医学上称之为“危险三角区”，在这个部位发生感染（如疖、痈等）后，若随意搔抓、挤压、挑破、热敷及意外损伤等，都可导致炎症迅速扩散。因为挤压疖、痈时，可使脓液和静脉内含细菌的栓子进入颅内海绵窦，引起颅内海绵窦血栓性静脉炎，严重时可危及生命。
当面部尤其“危险三角区”发生疖肿，早期可用2％碘酊涂抹患处，连续数次，保持局部清洁，疖肿通常可逐渐消散；如疖肿增大，周围红肿或唇痈初起，这时局部应外敷中药，常用的有二味拔毒散、玉露散或地丁草等，敷在疖顶周围，每日2次至3次，可促使炎症消退；如系唇痈，可在硬性浸润区敷用六合丹；若脓头溃破，或有脓栓形成时，局部应加用高渗盐水纱布持续湿敷，以利引流；如脓栓阻塞，引流不畅时，可在破溃孔处加用少量化腐丹，以促使坏死组织溶解，脓栓液化脱出。
有个病历需要翻译，可是医生的字体太潦草，很多地方看不清楚，急需帮助 谢谢大家~
患者本人提供： 患者自行可入病房，要求作精神检查 整体：此为检测指标…… 心律齐，无杂音 精神检查：意识清楚，自行可入病房 年貌相当，定向力完整，表情自然，交流通畅，情感反应适切，未引出相关感知觉障碍、思维障碍，粗测智力正常，社会功能良好。 既往史：否认“高血压”,"糖尿病“，”肺结核“病史。 旦畅测堆爻瞪诧缺超画家族史：无阳性家族史。 诊断： 目前无精神病状态
关于病历的英文书写
A Sample of Complete History
PATIENT'S NAME: Mary Swan
CHART NUMBER: 660518
DATE OF BIRTH:10-5-1993
SEX: Female
DATE OF ADMISSION: 10-12-2000
DATE OF DISCHARGE: 10-15-2000
Final Discharge Summary
Chief Complaint:
Coughing, wheezing with difficult respirations.
Present Illness:
This is the first John Hopkins Hospital admission for this seven-year-old female with a history of asthma since the age of 3 who had never been hospitalized for asthma before and had been perfectly well until three days prior to admission when the patient development shortness of breath and was unresponsive to Tedral or cough medicine.
The wheezing progressed and the child was taken to John Hopkins Hospital Emergency Room where the child was given epinephrine and oxygen. She was sent home. The patient was brought back to the ER three hours later was admitted.
Past History:
The child was a product of an 8.5-month gestation. The mother had toxemia of pregnancy. Immunizations: All. Feeding: Good. Allergies: Chocolate, dog hair, tomatoes.
Family History:
The mother is 37, alive and well. The father is 45, alive and well. Two sibs, one brother and one sister, alive and well. The family was not positive for asthma, diabetes, etc.
Review of Systems:
Negative except for occasional conjunctivitis and asthma.
Physical Examination on Admission:
The physical examination revealed a well-developed and well-nourished female, age 7, with a pulse of 96, respiratory rate of 42 and temperature of 101.0℉. She was in a mist tent at the time of examination.
Funduscopic examination revealed normal fundi with flat discs. Nose and throat were somewhat injected, particularly the posterior pharynx. The carotids were palpable and equal. Ears were clear. Thyroid not palpable. The examination of the chest revealed bilateral inspiratory and expiratory wheezes. Breath sounds were decreased in the left anterior lung field. The heart was normal. Abdomen was soft and symmetrical, no palpable liver, kidney, or spleen. The bowel sounds were normal. Pelvic: Normal female child. Rectal deferred. Extremities negative.
Impression:
Bronchial asthma, and pharyngitis.
Laboratory Data:
The white count on admission was 13,600 with hgb of 13.0. Differential revealed 64 segs and 35 lymphs with 3 Eos. Adequate platelets. Sputum culture and sensitivity revealed Alpha hemolytic streptococcus sensitive to Penicillin. Chest x-ray on admission showed hyperaeration and prominent bronchovascular markings. The child was started on procaine Penicillin 600,000 unites IM q.d in accordance with the culture and sensitivity of the sputum.
Hospital Course:
The child was given Penicillin IM as stated above. Ten drops of Isuprel were added to the respirator every 2 hours. The patient improved steadily. She took her diet well. She was discharged on 10-15-2000 in good condition.
Operation procedure: none
Condition on discharge: Improved
Diagnosis: Asthma. Pharyngitis. Possible right upper lobs pneumonia.
文言文“病在皮肤无常者取以馋针于病所.肤白勿取病在分肉间取以员针……泻于井荥分输取以四时”如何翻译？
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风邪在皮肤变幻无常的病人，用馋针（九针的一种）针刺于风邪的所在之处。但皮肤白的则不要这样。这样的病人风邪患在分肉之间，要用员针，。。。。。按照季节的不同，在井或荥穴位用泻的针法来泻。