一般事项 date of admission /marital status /present address /correspondence / occupation
主诉 chief complaints
现病史 present illness / history of present illness
既往史 past medical history
家族史 family history
个人病史 personal history / social history
曾用药物 medications
过敏史 allergies
系统回顾 system review / review of system
体检 physical examination
一般资料 physical data 生理指标physical signs
一般状况或全身状况 general appearance
头眼与耳鼻喉 head ,eyes,ear,nose,throat ,略作heent.
胸部与心肺 CHEST,heart,and lungs
腹部 abodoms
四肢extremities
神经系统nervous system,Neurological,略作CNC或Neuro,
骨骼肌系统 Musculoskeletal
泌尿生殖系统 Genitourinary
化验室资料laboratory data/ studies /diagnosis
血液检查 blood test
化学7项指标 chem.-7
心脑电图 electrocardiogram / electroencephalogram , 略作 EKG/EEG
X线检查与x光片 X-ray examination, x-ray slides,
计算机X线断层扫描与核磁共振扫描资料 computerized x-ray tomography and nuclear magnetic resonance spectroscopy dta. CT AND NMR
其他检查资料 other lab data
印象与诊断 impression and diagnosis
住院治疗情况 hospital course
出院医嘱 discharge instructions / recommendations
出院后用药 discharge medications |