病例汇报英文模板

检查PE，诊断 imp，处理 Rx 。

初诊病人病历中应含五有一签名：（主诉、病史、体检、初步诊断、处理意见和医师签名），其中病史应包括现病史、既征史、以及与疾病有关的个人史，婚姻、月经、生育史，家族史等。

复诊病人应重点记述前次就诊后各项诊疗结果和病情演变情况，体检时可有所侧重，对上次的阳性发现应重复检查，并注意新发现的体征，补充必要的辅助检查及特殊检查，三次不能确诊的患者，接诊医师应请上级医师诊视，与上次不同的疾病，一律按初诊病人书写门诊病历。

扩展资料：

注意事项：

病历不但要认真记录，还要记录重要的内容，诸如患者家属不接受手术、是否考虑手术家属再商议、由于经济原因不考虑靶向治疗等等。

临床治疗要充分尊重家属和患者的个人意愿，特别是肿瘤。

家属在多家医院就诊后所叙述的事情会由于各种原因而不全面，一定了解清楚，不要轻易指责其他医院医生的诊治。

书写病历可能会有误，但不要涂改或事后更改，保持原始记录，有误之处在下一次病历中进行补充说明和修正。

保存好原始病历记录对医院和患者都有益处。

参考资料来源：百度百科-病历

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That patients with a year ago because of leg injuries led to play basketball for more than three months ago to play basketball again leg sprain, arthritis has now become, rainy day would be unbearable pain, mobility A format for the English leg of the cases Good point format, at a glance, is that patients should not be a long walk Three months before the case reads as follows, treatments include: (1) not do any work to rest, rest, so that in the condition to allow patients, their activities are not over-weight, the damp cold, avoid sedentary, told the patient to lose weight in order to reduce weight. (2) exercise in order to take the initiative mainly of non-weight-bearing activities, to enhance muscle strength for the first practice, and then gradually increase the range of motion exercises. (3) physical therapy: relief of pain and muscle spasms, improve blood circulation and reduce swelling, can be hot, preferably hot and humid enough, hot bath, hot bath can be effective. (4) the application of anti-inflammatory painkillers, commonly used in anti-inflammatory pain, aspirin compound, security Tesson. Ibuprofen used in recent years, cases of non-Pula, tea-chip S & P, Fenbid, Fu Lin He, and so on.