染雾英文病历书写：疼痛 篇一
Title: Patient's Pain Assessment and Management
Date: [Date of assessment]
Patient Information:
Name: [Patient's full name]
Age: [Patient's age]
Gender: [Patient's gender]
Medical Record Number: [Patient's medical record number]
Chief Complaint:
The patient presents with severe pain in the lower back.
History of Present Illness:
The patient reports that the pain started two days ago after lifting heavy objects. The pain is constant and radiates down to the right leg. The patient rates the pain intensity as 8 out of 10 on the pain scale. The pain is aggravated by movement and relieved partially by rest. The patient has also noticed numbness and tingling in the right leg.
Review of Systems:
The patient denies any other significant symptoms such as fever, chills, weakness, or loss of appetite.
Past Medical History:
The patient has a history of chronic lower back pain and has previously undergone physical therapy for the same.
Medications:
1. Ibuprofen 400mg, as needed for pain relief.
Physical Examination:
On examination, the patient appears to be in discomfort due to pain. Vital signs are stable. There is tenderness on palpation over the lower back, and straight leg raise test elicits pain in the right leg. Motor strength and sensation are reduced in the right leg.
Assessment:
Based on the patient's history and physical examination findings, the patient is diagnosed with acute exacerbation of chronic lower back pain with possible nerve root involvement.
Plan:
1. Prescribe oral prednisone 20mg once daily for 5 days to reduce inflammation.
2. Order a lumbar spine X-ray to rule out any structural abnormalities.
3. Refer the patient to a spine specialist for further evaluation and possible intervention.
4. Instruct the patient to continue taking ibuprofen as needed for pain relief.
5. Recommend rest, avoidance of heavy lifting, and application of heat or cold packs to the affected area.
Follow-up:
The patient will return for a follow-up appointment in one week to assess the response to treatment and discuss further management options.
英文病历书写：疼痛 篇二
Title: Patient's Pain Assessment and Management
Date: [Date of assessment]
Patient Information:
Name: [Patient's full name]
Age: [Patient's age]
Gender: [Patient's gender]
Medical Record Number: [Patient's medical record number]
Chief Complaint:
The patient complains of persistent headache and facial pain.
History of Present Illness:
The patient reports experiencing frequent headaches for the past month. The pain is described as throbbing and localized to the frontal area. The intensity varies from mild to moderate, and it worsens with prolonged screen time or exposure to bright lights. The patient also describes experiencing facial pain on the same side as the headache. The pain is not associated with any nasal congestion or discharge.
Review of Systems:
The patient denies any other significant symptoms such as fever, visual disturbances, or changes in appetite.
Past Medical History:
The patient has a history of migraines and has been prescribed sumatriptan for acute attacks.
Medications:
1. Sumatriptan 50mg, as needed for migraines.
Physical Examination:
On examination, vital signs are within normal limits. There are no signs of neurological deficits. Examination of the head and neck does not reveal any abnormalities.
Assessment:
Based on the patient's history and physical examination findings, the patient is diagnosed with chronic tension-type headache with associated facial pain.
Plan:
1. Recommend lifestyle modifications such as stress reduction techniques, regular exercise, and adequate sleep.
2. Instruct the patient to keep a headache diary to identify trigger factors.
3. Prescribe amitriptyline 25mg at bedtime for prophylactic management of chronic headaches.
4. Advise the patient to take sumatriptan as needed for acute migraine attacks.
5. Educate the patient about the importance of maintaining a regular sleep schedule and avoiding known trigger factors.
6. Schedule a follow-up appointment in four weeks to assess the response to treatment and make any necessary adjustments.
Follow-up:
The patient will return for a follow-up appointment in four weeks to evaluate the effectiveness of the prescribed treatment and discuss further management options if needed.
英文病历书写：疼痛 篇三
英文病历书写：疼痛
以下是小编带来的英文病历书写：疼痛，欢迎阅读，更多相关内容尽在cnfla学习网。
(1)当上楼梯时，突然痛了起来，并且持续不止。
The pain came on suddenly while walking up the stairs and it was persistent.
疼痛的发生
感觉疼痛 feel (have; suffer from) a pain; pain is felt in ; feel painful
头痛 have a headache; be troubled with a headache; feel a pain in one's head
患剧烈头痛 have a nasty (bad) headache
时常头痛 be subject (a martyr) to headaches
有撞击似的两侧性头痛 have bilateral pounding headaches
头痛逐渐地变为频发(较不严重) headaches gradually become more frequent (less severe)
ex1:咀嚼时，有偶发的、暂时的、不可言状的疼痛或敏感。
There is occasional， transient， nondescript pain， or sensibility during mastication.
ex2:该齿对于压迫作痛，且有钝麻如咬的`疼痛。
The tooth became sore to pressure and there is a dull gnawing pain.
发生时间
ex1:Epigastric pain comes immediately after meal.
ex2:Colic pain came on and off since yesterday.
ex3:This pain has been relentlessly postprandial， regardless of the character of her meals.
ex4:The joint pains were present mainly at night， with relief during the day.
ex5:The mild frontal headaches were usually present upon awakening， but not severe enough to require analgesics.
ex6:The pain usually commenced within 30 minutes after meals and lasted 1 to 3 hours.
发生原因
ex1:He described the pain as dull and aching， occurring approximately once a week， unrelated to food intake， and radiating to his back.
(2)起初疼痛无变化，但数小时时变成发作性的痛。
The pain initially was steady， but after several hours became episodic.
疼痛的种类
恒常(痛) constant
间歇(痛) intermittent
偶(痛) occasional
急性(痛) acute
钝麻(痛)，闷(痛) dull
搏动性的 throbbing
抽搐(痛)tic
抽(痛) twinge
锐(痛)，急(痛) sharp
刺(射)痛 stabbing ( shooting) pain
钻锥(痛) boring
穿刺(痛) piercing
窜(痛) darting
被咬样的(痛) gnawing
似裂(痛) tearing (splitting)
胀(痛) bursting
刀割样(痛) knife like
痉挛(痛) crampy
拉(痛) dragging
箍(痛) girdle like (constricting)
痛得打滚 writhing
极痛的 excruciating
切割的(痛) lancinating
绞性痛 colic (colicky pain)
剧痛 severe (pungent; intense)
感应痛 referred pain
坠痛 bearing down pain
发生遍身的酸痛 develop diffuse body aching
有剧烈的骨盘痛 have exquisite pelvic pain
牙痛频发 continual bouts of toothache
一阵阵剧烈的牙痛 the pangs of a toothache
带有胸膜炎性状的右胸痛 right sided pain of a pleuritic character
发生阵痛性的疼痛 have labor like pains
ex1:这痛是持续不变的，若刺的剧痛。
The pain was steady， sharp and boring in nature (character).
ex2:该痛和她以前诉过的疼痛一样。
The pain was ide
疼痛再发
pain reappears (relapses); pain breaks out again; a return of the pain
ex1:左乳房下的疼痛时时再发，而不是持续性的。
The pain under the left breast recurred at intervals but was not constant.
ex2:疼痛很少在他晚餐后再发，同时喝牛奶或服用抑酸剂，对于疼痛并无影响。
The pain rarely returned after his evening meal and it was not affected when he ingested milk or antacid.
(3)有时疼痛放射到右下肢后侧，一直到脚部。
At times pain radiates down the back of the right lower extremity to the foot.
疼痛放射
pain radiates ( travels) to …; pain radiating from … to …; radiation of the pain to …
ex1:疼痛放射到腰部周围，躺下时缓和些，站立时加剧。
The pain radiated around toward the groin， relieved by lying down and aggravated
while standing.
ex2:住院那天，他感到疼痛加剧，并且放射到右肩胛和肩部。
On the day of admission he experienced increasingly severe pain with radiation to the right scapular area and shoulders.
(4)这疼痛局限于正中线，因吃力的劳动而加剧。
The pain was confined to the midline and was aggravated by heavy labor.
疼痛部位
疼痛存在于 the pain is limited to; the pain is located (localized; situated) in (or over) ; there is localized pain in …
遍在痛 generalized (general; extensive; unlocalized) pain
ex1:起初，疼痛遍及整个腹部，后来它局限于右上象限。
At first the pain was generalized in the (whole) abdomen; but it subsequently localized to the R.U.Q.
ex2:起于右下腹部的疼痛，不久便局限于左上腹部。
The pain， which began (originated) in the R.L.Q.， soon became localized in the L.U.Q.
疼痛减轻
疼痛减轻 pain is relieved by ， relieve (ease， allay， alleviate， assuage， abate， soothe) the pain， pains decrease (grow less， go down ， fall off)
疼痛减轻了 the pain became lighter
疼痛的严重度减少 the severity of the pain waned
疼痛未停止 the pain did no ease
ex1:疼痛和腹泻都减轻，但自从那时起，他就感觉疲倦和衰弱。
The pain and diarrhea abated， but he felt tired and weak since then.
ex2:胸部痛有时因改变体位而减轻，但只是暂时而已。
The chest pain is sometimes relieved by a change of position， but only temporarily.
疼痛加剧
ex1:虽然没有肋膜带性状，但这痛因深吸气而显著加剧。
The pain was markedly accentuated by deep inspiration， although it was not pleurisy in nature.
ex2:当他在晚上作偏右侧睡时，疼痛最厉害。
The pain is most severe at night when he lies on his right side.
