第一篇：口腔科英文病历
Oral and Maxillofacial Surgery Complete Medical History
（Zhang te）
Medical Number: 182786 General information Name: Tao lili Age: Forty eight Sex: Female Race: Han Occupation: worker Nationality: China Marital status: Married Address:NO.138,mawangdui
Rvenue,changsha, Hunan.Tel: 84722500
Date of admission: Jun 20st, 2013 Date of record: 11Am, Jun20st, 2013 Complainer of history: the patient herself
Reliability: Reliable
Chief complaint: lower incisors gingivae mass found for more than 3 month.Present illness: 3 month ago, the patient suddenly found a small mass on lower incisors gingivae.After touching it, she found a mass tendness, She did not get fever ,dizziness, vertigo and headache.the patient didn’t pay attention it.Then the mass became more and more bigger, so the patient she came to our hospital and asked for an operation.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 Wuhan on Nov 19th, 1957 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 3 to 4 days every times and its cycle is about 30 days.Obstetrical history: Pregnacy 3 times, once nature production, abortion twice.Contraceptive history: Not clear.Family history: His parents have both died.Physical examination
T 36.4℃, P 80/min, R 20/min, BP 90/60mmHg.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.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 No.Professional Examination
Oral mucous membrane was smooth, and of no ulcer or erosion.Tongue was in midline.Pharynx was not congestive.Tonsils were not enlarged.Patients with poor oral hygiene has much dental calculus.There are a about 2*2*1.5cm mass on lower incisors(33-41)gingivae.It is tender but not bleed.It can not be moved and its surface is smooth.Corresponding superficial lymph nodes don’t enlarge.Impression: Epulis
Signature: Zhang te
Hospital course record for the first time 2013-6-20 8:50
一、Characteristics of cases：
1.Clinical presentation:Patient was a worker , female, 48 years old.2.lower incisors gingivae mass found for more than 3 month.3.No special past history.4.Physical examination showed no abnormity in lung, heart and abdoman.Information about her oral can be seen above.5.Shorting of investigation information.6.Temperature is36.5℃, pulse 80, respirations 20, blood pressure 90/60.二、Examination to discuss diagnostic basis：1.lower incisors gingivae mass found for more than 3 month。2.She did not get fever ,dizziness, vertigo and headache.There are a about 2*2*1.5cm mass on lower incisors(33-41)gingivae.It is tender but not bleed.There are a about 2*2*1.5cm mass on lower incisors(33-41)gingivae.It is tender but not bleed.differential diagnosis：Gingival carcinoma：Except fast growth, it can appear local canker, pain, involving related to teeth.ADMITTING DIAGNOSIS:Epulis
三、Case classification：A
四、Treatment plan：1.To improve the routine inspection.2.Whole mouth clean governance.3.Optional operation.Xu yuguo
Hospital records 2013-6-21 The patient was hospitalized on this morning.with suddenly found a small mass on lower incisors gingivae 3 month ago.transparent mild redness, lining color is normal, Patients usually in good health.Blood, urine, dung routine has been sent, liver and kidney function checklist to fill in, check the doctor's advice already open.Pathological biopsy for the diseased tissue has been sent.Xu yuguo 2013-6-23 This morning Pro.zhang visits, the diagnosis and treatment of put forward the following opinions:Pathological biopsy result has shown Epulis.All investigation is normal.According to the clinical manifestations of it ,this disease The disease can be diagnosed with Epulis.Gum tumor resection Can be imposed immediately.Preoperative should be whole mouth clean governance.surgery will be done at eight on tomorrow morning.Zhang te/ Xu yuguo
2013-6-24 Preoperative SUMMARY Patient was a worker , female, 48 years old.lower incisors gingivae mass found for more than 3 month.No special past history.Physical examination showed no abnormity in lung, heart and abdoman.Information about her oral can be seen above.All investigation is normal.whole teeth have been cleaned.Surgical treatment plan:(1)pastoperative biopsy to determine the tumor nature;(2)Complete removal of the tumor and spread of the periodontal membrane, teeth and gums.(3)a mandibular defect should still depending on the nature of the tumor and then make a decision whether to immediately bone graft, but should be ready to immediately bone graft.(4)preoperative for teeth cleaning and use of antibiotics.Xu yuguo 2013-6-25 8:15
Operation records
Make Routine local anesthesia on the patient supine, disinfection and shop towels according to Maxillofacial surgery routine.lump completely and spread of the periodontal membrane, and gums been removed with electricity knife.hydrogen peroxide and saline flush incision.Mass was sent to Pathological biopsy.The patient went back the ward safetyly at 9:30 , The surgery was over.Zhang te
2013-6-26
Pastoperative records
T 36.5℃, P 80/min, R 23/min, BP 100/60mmHg.Patients feel the wound and teeth pain is severe, the wound near swollen gums, jaw was covered with a little fake.Continue to Analgesic, anti-inflammatory.Pay attention to maintain oral hygiene.Patients require to dischange tomorrow, he Would be approved to agree with.Zhang te
DISCHARGE RECORD
DATE OF ADMISSION: Jun 20st, 2013 DATE OF DISCHARGE: Jun 26st, 2013 Number of days in hospital:6 Days
ADMITTING DIAGNOSIS: Epulis
BRIEF HISTORY PATIENT name :Tao lili , AGE: 48 3 month ago, the patient suddenly found a small mass on lower incisors gingivae.After touching it, she found a mass tendness, She did not get fever ,dizziness, vertigo and headache.the patient didn’t pay attention it.Then the mass became more and more bigger.REVIEW OF SYSTEM She has had no headache, fever, chills, diarrhea, chest pain, palpitations, dyspnea, cough, hemoptysis, dysuria, hematuria or ankle edema.PAST MEDICAL HISTORY She has had no previous surgery, accidents or childhood illness.SOCIAL HISTORY: She has no history of excessive alcohol or tobacco use.FAMILY HISTORY She has no family history of cardiovascular, respiratary and gastrointestinal diseases.PHYSICAL EXAMINATION Temperature is36.5℃, pulse 80, respirations 20, blood pressure 90/60.General: Plump girl in no apparent distress.HEENT: She has no scalp lesions.Her pupils are equally round and reactive to light and accommodation.Extraocular movements are intact.Sclerae are anicteric.Oropharynx is clear.There is no thyromegaly.There is no cervical or supraclvicular lymphadenopathy.Cardiovascular: Regular rate and rhythm, normal S1, S2.Chest: Clear to auscultation bilateral.Abdomen: Bowel sounds present, no hepatosplenomagaly.Extremities: There is no cyanosis, clubbing or edema.Neurologic: Cranial nerves II-XII are intact.Motor examination is 5/5 in the bilateral upper and lower extremities.Sensory, cerebellar and gait are normal.HOSPITAL COURSE The patient was admitted.The patient was resect the gums tumor and improved.The patient was discharged in stable condition.DISCHARGE DIAGNOSIS Epulis
DISCHANGE INSTRCTIONS: To pay attention to rest, strengthen nutrition, keep the anti-inflammatory for three days.To maintain oral hygiene.To review on a regular basis.PROGNOSIS Good.No medications needed after discharge.The patient is to follow up with Dr.xu in one week.Zhang te/ Xu yuguo
第二篇：口腔科病历书写要求及范文
口腔科病历书写要求及范文
一、病史
病案记录一般要求，已详见一般病历及普通外科病历，但须注意以下各项：
1.儿童时期的营养状及有关不良习惯。
2.口腔卫生情况、疾病史、手术史及治疗经过。
3.家族史 询问患者直系亲属中是否有人患过癌、糖尿病、结核病，先天性畸形等疾病。
二、体格检查
应详述专科检查，即口腔及颌面部情况，应分述：
1.牙齿
(1)牙齿部位的记录符号 以十字形线条将上下左右四区的牙齿，依照牙位排列顺序，自前至后，用数字代表，分别记载于各区内。恒牙用阿拉伯数字代表，乳牙用罗马数字代表。见下表。
(2)形态、数目、色泽及位置 注意牙齿形态、大小，有无畸形，有无缺牙及多生牙;色泽是否正常;有无拥挤、稀疏、错位、倾斜、阻生等情况。
(3)松动度 正常生理性松动度不计度数，大于生理性松动度而不超过1mm者为Ⅰ°，松坳度相当于1～2mm者为Ⅱ°，松动度大于2mm者为Ⅲ°，异常松动至上下浮动者为Ⅳ°。
(4)牙体缺损及病变 记录病变名称、牙位、范围及程度等，必要时进行温度、电活力或局部麻醉试验，以查明病变部位及性质。
(5)修复情况 有无充填物、人造冠、固定桥及托牙等，注意其密合度，有无继发性病变。
(6)咬合关系 记录正常、反、锁(跨)、超、深复、对刃、开及低间隙等。
(7)缺牙情况 缺牙数目位置，拔牙创口愈合情况。
2.牙龈
(1)形态、色泽及坚韧度 注意有无炎症、溃烂、肿胀、坏死、增生、萎缩、瘘管，色泽是否正常，是否易出血。
(2)盲袋情况 盲袋分为龈袋及牙周袋(骨上袋、骨下袋)两种，记录其部位及范围，并测量其深度，以mm计算，盲袋内有无分泌物。
(3)牙石 分为龈上及龈下两类，注意其部位及程度，龈上牙石可分为少量(+)，中等量(++)，大量(+++)(牙石多或面亦附有者)。
3.唇及粘膜 注意有无色泽、形态异常，有无疱疹、皲裂、脱屑、角化、充血、出血、溃疡、糜烂、结痂、硬结、畸形等，记录其部位、大小及范围。
4.舌 注意舌体大小、颜色，有无硬结、溃疡、肿块、印迹，是否松软、肿胀，有无舌苔及其颜色、厚薄，舌背有无裂纹、角化，乳头有无异常，舌的运动及感觉功能有无障碍，舌系带是否过短。
5.腭 注意有无瘘管、充血、角化、糜烂、溃疡、肿块、畸形等，软腭运动有无障碍。
6.涎腺及其导管 有否肿胀、压痛、阻塞、充血、溢脓、外瘘等。
7.淋巴结 注意耳前、耳后、颊、颏下、颌下及颈部各组淋巴结的数目、大小、硬度、活动度、压痛等。
8.面部 观察表情、外形是否对称，有无畸形、缺损、肿胀、瘢痕、瘘管、颜色改变，查明痛区及麻木区(可拍照片或绘简图说明)。
9.颌骨 分别检查上、下颌骨的外形，两侧是否对称，有无畸形、肿大、压痛、缺损及不连接等，注意咬合及开口情况。
10.颞下颌关节 注意形态及运动情况，有无压痛、弹响，并以两侧作对比。张口受限时，其程度以张口时上下切牙切缘相距的厘米数表明。
姓名:**
性别:**
年龄:**
主诉:右上后牙冷刺激痛夜间痛3日
现病史:右上后牙近三日来遇冷水剧烈疼痛,夜间痛加剧,故来我院就诊.既往史:无
检查:右上第一磨牙远中龋坏深还牙本质层, 探诊(++),叩诊(-)，冷热诊(+++)，牙周正常无牙石,牙龈颜色正常,牙齿松动,其余牙正常,口腔卫生良好,X光可见右上第一磨牙远中龋坏接近髓腔.诊断:急性牙髓炎
治疗计划:开髓引流,行牙髓治疗
处理:局麻下开髓,除冠髓,双氧水冲洗,生理盐水冲洗,CP氧化锌丁香油暂封.医嘱:一周复诊
医生签名:
****年**月**日
慢性牙周炎主诉：下前牙处常有脓液溢出一月余。
现病史：患者近一年来时常牙龈刷牙时出血，有口臭。近一月来下前牙处有脓溢出要求诊治。
既往史：询问患者否认重大疾患史(无高血压心脏病史)否认血液疾病史。
检查：右下1 2左下1 2排列不齐，牙石2度 ,牙龈红肿,轻探出血,牙周袋深约4-5mm,内有脓液,探之根面粗糙有牙石。松动1度。X线检查水平吸收达根长1/3左右。
诊断：右下1 2左下1 2成人牙周炎(慢性牙周炎)
鉴别诊断：牙龈炎 牙龈炎有牙龈炎症，无牙周袋形成，无牙槽骨吸收，无牙齿松动等典型牙周炎临床表现。
治疗计划：
1.进行彻底的洁治，刮治局部刺激物，双氧水冲洗，上碘甘油。
2.进行口腔卫生宣教，让患者正确掌握刷牙的方法。
3.一个月后在酌情进行下前牙翻瓣术，以消除牙周袋。
4.术后定期复查，维护疗效。
急性化脓性根尖周炎
主诉：患者因左下牙肿痛三天就诊。
现病史：患者左下牙有龋洞数年，无不适感，三天前嚼觉食物后疼痛，开始嚼觉轻疼痛，今疼痛渐加重伴肿来诊。
既往史：询问否认重大疾患史。
检查：左下6龋深及髓，无探痛;松动3度;叩痛+++，根尖部红肿，扪痛，有波动感;左侧面颊部水肿;体温38度。余牙检查无特殊情况。
诊断：左下6急性化脓性根尖周炎(骨膜下脓肿)
鉴别诊断：急性牙髓炎其疼痛特征为自发性，自发性剧痛，不能定位，叩 —，温度刺激引起长时间剧痛。
治疗计划：
1.开髓引流，局麻下切开排脓，缓解症状。
2.症状消退后行根管治疗术，然后永久充填。
3.必要时作保护冠修复
边缘性牙龈炎
主诉：患者因下前牙出血一周要求诊治。
现病史：患者近一段时间来刷牙及咀嚼食物容易出血，至今有一周左右，现要求诊治。，既往史：患者否认重大疾病史(无高血压，心脏病，肝炎，血液疾病史)
检查：下切牙颈部牙石1度沉积，牙龈充血发红，质地松软，边缘厚钝，龈乳头圆钝，肥大面光亮，龈沟深度3mm，轻探出血，无附着丧失。
诊断：下切牙边缘性龈炎。
鉴别诊断：1，早期牙周炎，有牙周袋，牙槽骨吸收;2，血液病，应与全身性疾病鉴别如白血病，血小板减少性紫癜等;3，坏死性龈炎，虽以牙龈出血为主要症状，但其牙龈边缘坏死如虫蚀状，坏死区出现灰褐色假膜，伴有疼痛和特殊的腐败臭味;4，爱滋病相关的龈炎。
治疗计划：1，去除病因，洁治术;2，药物治疗，双氧水冲洗，上碘甘油;3，维护治疗，掌握正确刷牙的方法，定期洁治，保持口腔卫生。
深龋
主诉：患者右下牙进食物常有嵌塞痛一周。
现病史：患者发现龋洞有数月，近一周来进食物常有嵌塞痛有一周要求诊治。
既往史：患者否认有牙痛史和其他不良疾患。
检查：右下6牙合面较大龋洞，有大量腐质，边缘不规则，颜色黑褐色，质地松软，探诊有轻度酸痛，达牙本质深层，叩诊(—)，冷热诊反映同对照牙。但如刺激进入龋洞时有明显酸痛感刺激去除后疼痛立即消失。
鉴别诊断：1.可复性牙髓炎 主要依据牙髓活力测试反映,可复性牙髓炎遇到温度刺激会出现短暂的一过性疼痛，刺激去除疼痛持续片刻即消失。而深龋只要刺激不进入龋洞就不会出现激发痛。
2.慢性闭锁性牙髓炎 自发性隐痛，急性发作，晚期有叩诊不适，机械去腐反应迟钝，牙髓活力测试迟钝。而深龋无叩诊不适，无自发痛，牙髓活力正常。去净腐质时极其敏感。
治疗计划：常规去龋，备洞，消毒，干燥，垫底(常规三层垫底)，永久充填。
慢性根尖囊肿
主诉：患者右上牙食物嵌塞数年余要求诊治。
现病史：右上牙发现龋洞数年，曾有疼痛过，经常有食物嵌塞，现要求诊治。
既往史：患者有牙疼痛史，无其他重大疾患史。
检查：右上4牙合面龋坏，探诊(—)，冷热诊(—)，叩(—)，牙龈处有一瘘道，牙齿无松动，X线：根尖大面积阴影，圆形，周边有一层骨白线包饶，根尖位于阴影之中。
诊断：右上4根尖囊肿
鉴别诊断：与慢性根尖肉芽肿相鉴别 1。无牙龈瘘管
2.X示：根尖周透引区为圆形，边界清楚。
与慢性根尖脓肿相鉴别 1。牙体有疾患，牙髓坏死，有瘘管。
2.X示根尖病变不规则，边界不清。
治疗计划：常规开髓，拔 髓、无痛、根管治疗、充填。三个月后，瘘道未消失，阴影未缩小，行囊肿除切除术及根尖切除术。三个月复诊。
上牙列缺损
主诉：左上有一牙已拔除半年余要求修复。
现病史：左上有一牙龋坏数年已剩残根，半年前已拔除，现已影响吃饭要求修复。
既往史： 曾今有牙痛史，其他否认重大疾患史。
检查：左上6 缺失，左上5 7良好稳固、无龋咬牙合关系正常。
诊断：左上牙列 缺损
治疗计划：建议固定桥修复(金属烤瓷桥)
有瘘型慢性根尖周炎
主诉：患者右上后牙反复肿痛，牙龈起脓包6 个月要求诊治。
现病史：一年前右上后牙曾有冷热痛史，曾在外院治疗过，一月前进食时将治疗过的牙咬断。
既往史：有牙疼痛史，否认重大疾患史。
检查：右上5 残根，根管外露，探不通，叩(—)。右上4 颈部锲状缺损并发深龋，探已穿髓，无反应，冷热测无反映，叩(+)，松动1度。X两根尖周均有透射影像，直径0.5 *0.5cm。自牙龈瘘管口插入牙胶尖，再拍X片，显示诊断丝指向右上4根处边界不清且不规则的透影区。
诊断：右上4慢性根尖脓肿(有瘘型)
鉴别诊断：
1，与右上5慢性根尖周炎鉴别：
诊断丝片显示：瘘管并非来自右上5
2，与慢性根尖肉芽肿鉴别：
(1)，牙龈无瘘管。(2)，X线片显示：根尖周透影区为圆形，边界较清楚。
3，与根尖囊肿鉴别：
(1)X线片显示：根尖周圆形透影区周围被一圆滑清晰的骨白线包绕;
(2)开髓后可有黄色清亮液体溢出，涂片镜检可见胆固醇结晶。
治疗设计;
(1)右上4根管治疗，充填颊颈部缺损，观察根尖病变的修复情况后考虑修复;
(2)右上5拔除后义齿修复。
牙震荡
主诉：上前牙因撞击疼痛1小时。
现病史：一小时前患者因打蓝球时不甚撞击至上前牙，感觉患牙有伸长感，咬合痛来院就诊。
既往史：否认有牙痛史和其他疾患史。
检查：右上1 牙冠完整，轻度松动，龈缘少量出血，叩(+)。冷热诊反应迟钝，X：未见根折情况，牙周膜间隙轻度增宽。
诊断：右上1 牙震荡
治疗计划：患牙调牙合，松牙固定，该牙修息，定期复查做牙髓活力测试，如牙变色及时做根管治疗。
上颌牙列缺失
主诉：上颌牙因松动已全部拔除三月余要求修复。
现病史：患者牙齿松动已数年，三个月前已逐步拔除，现要求修复。
既往史：有牙痛史，牙周病史，其他无重大疾患史。
检查：下颌牙个别牙已缺失，其余轻度松动，牙根暴露。上颌牙已缺失，牙槽骨、牙槽脊愈合良好。
诊断：上颌牙列缺失
治疗计划：上颌半口活动修复。
急性牙髓炎
主诉：左下牙后牙自发痛3 天，昨晚起阵发性加剧，现因剧痛就诊。
现病史：患者因一周前咀嚼食物嵌塞痛，后逐渐冷热激发性疼痛，时痛时停，近三天来 自发性阵发性疼痛，夜间特别痛，有时放射至颞部，现因剧痛难忍就诊。
既往史：否认以往有牙痛史和其他疾患史。
检查：左下6 邻面深龋近髓，洞底有大量软化牙本质，探痛明显，叩(—)，冷热诊疼痛剧烈，且持续较长时间。
诊断：左下6 急性牙髓炎
鉴别诊断：龈乳头炎 疼痛为持续性胀痛，对温度测试仅为敏感，不发生激发疼痛，对疼痛能定位，患处龈乳头红肿，触痛。
三 叉神经痛 它有板击点，很少有夜间发作。
急性上颌窦炎 疼痛为持续性胀痛，患侧的上颌前磨牙和磨牙可同时受累均有疼痛，但无牙体疾患;上颌窦有压痛，同时 有头痛，鼻塞，脓涕等上呼吸道症状。
治疗计划：应急治疗 开髓引流 缓解患牙急性症状。好转后作根管治疗。充填后做保护冠修复。
智齿冠周炎
主诉：左下磨牙后区胀痛，咀嚼、吞咽时疼痛加重来诊。
现病史：患者一周前感觉左下磨牙区不适，近两天来感觉胀痛明显，咀嚼、吞咽时疼痛加重，有张口不适来院就诊。
既往史：有牙疼痛史，否认重大疾患史。
检查：左侧面部稍肿，颌下淋巴结有压痛，张口轻度受限，左下8 牙周牙龈红肿，探诊易出血，可探到阻生的左下 8，有脓液溢出。X检查：左下8近中低位阻生，融合根，左下7 远中邻面未见龋坏。
诊断：左下8 冠周炎
鉴别诊断：1.颌智齿冠周炎合并面颊瘘或下颌第一磨牙颊侧瘘时，可被误认为第一磨牙的炎症。
2.与下第二磨牙远中颈部龋引起的牙髓炎或牙槽脓肿相鉴别。
3.应与第三磨牙区牙龈的恶性肿瘤相鉴别。
治疗计划：局部治疗 3%双氧水冲洗，上碘甘油。如形成脓肿及时切开引流。
全身治疗 抗生素应用及全身支持疗法。
待炎症消退后切除盲袋或拔除阻生齿.
第三篇：口腔科常用英文术语
口腔科常用英文术语
1.My tooth is aching again.（我的牙又疼了。）
2.One of my teeth is trouble me.(我有一颗牙疼。)
3.I have got anawful toothach.It kept me awake the whole night.（我的牙很疼，整晚未眠）
4.One of my incisors is loose and aching.（我的一颗门牙松动而且疼。）
5.This tooth on the lower jaw is sensitive to heat and hot.（下颌的这颗牙对冷热很敏感。）
6.I think one of the back ones at the top is giving most of trouble.（我觉得上排有一个后牙疼的最厉害。）
7.I suffer pain when my teeth are exposed to heat.（我的牙碰到热时感到疼痛。）
8.There are several painful spots in my mouth，and salty and sour things make it sting.（我嘴里有几块地方疼，咸的和酸的都蜇着疼。）
9.I have a burning and thickening sensation in my mouth.（我嘴里有灼热和增厚的感觉。）
10.He has pain in his teeth or jaw.(他的牙齿和下巴疼痛。)
11.He has some problems with his teeth.(他牙齿有问题。)
12.The tooth hurts only when he bites down on it.(他咬东西时，牙齿就痛。)
13.His gums are red and swollen.(他的牙床红肿。)
14.His tongue is red and sore all over.(他的舌头到处红和痛。)
15.His breath smells bad and he has a foul taste in his mouth.(他口里有怪味。)
16.His gums do bleed.(他牙床有出血。)
17.He has some sore swellings on his gum or jaw.(他的牙床和下巴肿痛。)
18.He has sore places on or around the lip.(他的嘴唇和周围都很痛。)
19.There are cracks at the corners of his mouth.(他的嘴巴角落破了。)
20.There are some discolored areas inside on his tongue.(他舌头里边有些地方颜色怪怪的。)
1.What can I do for you？你有什么事？
2．May I help you？我能帮你什么忙？
3．Please take a seat！/please sit down！请坐下．
4．Wait a moment，please．请等一等．
5．Sorry to have kept you waiting.对不起让你久等了．
6．It is not serious．病情不严重．
7．Don't worry．/There is nothing to worry about.不必顾虑。
8．You need a thorough examination．你需要做一个全面检查．
9．You will have to stay in hospital for sevral days．你需要在医院里住几夭． /We think that you had better be hospitalized我们认为你最好住进医院来。
10． You should stay in bed for a few days.你需要卧床几天．
11． You can keep on working．/You can carry on with your work.可以继续工作。
12． You should be very careful for a week or two这一两周内，你需要很注意。
13.Try to relax and keep calm．尽量放松保持镇静。
14． You'll soon be all right．你很快就会好起来的．
15． 1'm sure this medicine will help you a great deal．这药对你肯定会很有效的．
16． Feeling well again is a rather slow process，I'm afraid.恐怕痊愈将是一个很慢的过程．
17． You will have to wait for twenty minutes．你需要等20分钟．
18．Complete recovery will take a rather long time．彻底恢复需要一段很长的时间。
19． You will have to come here for periodical check-ups．你需要定期来门诊检查．
20． If you feel worse，please come back to the clinic right away.要是你觉着病加重了，就请马上来门诊。
How are you,sir?
2、Are you all right,madam?
3、How are you feeling now,madam? What seems to be your problem,sir? What seems to be wrong/the matter with you? Is there anything wrong with you? What's happened to you?
What's up? What are you suffering from? Are you having any discomfort?
What seems to be your trouble?/What's troubling you? What hurt you?
What ails you? How are you keeping?
1病人在右下颌的大臼齿，有一放射透过性的病变。
The patient has a radiolucent lesion below the molar teeth in the right mandible.2他因口底下左下颌处疼痛和肿胀有72小时而受检。
He was examined with a 72-hour complaint of pain and swelling under the left jaw in the floor of the mouth
3右侧颊部粘膜下，有带痛的肿胀。There is a tender swelling beneath the right buccal mucosa.4在右下齿龈上 on the right lower gingiva
5在下颌右角处 at the right angle of the mandible
6不能开口 inability to open the mouth
7把口张开到最大限度并无困难 have no difficulty in opening one＇s mouth to its full extent
8口内大干，以致病人咀嚼和吞下食物，都有困难。
The mouth is so dry that it is difficulty for the patient to masticate and swallow food.9在上腭有一个无痛性的肿胀。There is a painless swelling in the roof of the mouth.10在上星期肿块大了起来 mass was growing larger during last week
-肿块大小未变 the sizes remained stationary
11拔牙后，他流了10天的血。He bled for 10 days following the extraction of a tooth-12牙痛频发 continual bouts of toothache
13-一阵阵剧烈的牙痛 the pangs of a toothache
14咀嚼时，有偶发的、暂时的、不可言状的疼痛或敏感。
There is occasional, transient, nondescrpit pain, or sensibility during mastication.15该齿对于压迫作痛，且有钝麻如咬的疼痛。
The tooth became sroe to pressure and there is a dull gnawing pain
16疼痛未停止 the pain did no ease 17疼痛减轻了 the pain became lighter
口唇 Lips: 对称 symmetry, 颜色color, 湿润度moisture, 紫绀 cyanosis, 疱疹 herpes.粘膜 Mucosa: 颜色 color, 色素沉着 pigmentation, 溃疡 ulceration.齿龈 Gums: 齿龈脓漏pyorrhea, 出血 bleeding, 齿龈炎gingivitis, 齿龈肿胀swelling of gums.舌 Tongue: 颜色 color, 乳头萎缩 papillary atrophy, 溃疡ulceration, 扁斜deviation, 运动 movement, 舌苔coating.牙齿 Teeth:无齿的 edentulous, 牙齿数目 number present, 口腔卫生欠佳或良好 hygiene poor or good, 牙根 roots, 齿髓炎pulpitis, 假牙false teeth, 龋齿 caries, 失去的牙齿missing teeth, 修补牙齿 dental repair(牙冠crowns, 装桥术bridgework, 镶嵌inlay, 充填filling)口臭 Halitosis(fetor oris;foul or bad breath)
第四篇：口腔科病历的规范书写
口腔科病历的规范书写.txt﹃根网线''尽赚了多少人的青春い有时候感动的就是身边微不足道的小事。﹎破碎不是最残酷的 最残酷的是踩着这些碎片却假装不疼痛 固执的寻找﹎将来就算我遇见再怎么完美的人,都有一个缺点,他不是你,_____下辈子要做男生，娶一个像我这样的女生。口腔科病历的规范书写.txt世上有三种人：一是良心被狗吃了的人，二是良心没被狗吃的人，三是良心连狗都不吃的人。︶﹋丶爱情是个梦，而我却睡过了头﹌口腔科病历的规范书写
第一节 口腔科病历书写的重点要求
1． 一般资料及病史
（一）常规资料
包括姓名、性别、年龄、民族、职业、出生地等。这些项目对每一个患者都是不可缺少的，它们于疾病的诊断、治疗均有密切关系。
1、年龄：青少年性牙周炎好发于年轻人，而口腔癌多见于老年人。
2、性别：白斑多见于男性，而播散性红斑狼疮主要是女性患者。
3、民族：由于长期生活环境不同，患者体质及对疾病的感受性也不同，例如藏族的患龋率较汉族低。又如牙骨质瘤常见于黑种人。
4、职业和劳动条件：有些疾病与职业有关，例如汞中毒、铅中毒、牙齿酸蚀症等。
5、出生地、成长地或久居地：某些地区由于饮水及食物种类关系，可以影响牙疾病的发生。例如饮水中含氟量过高会引起斑釉症；因食物中缺乏维生素C等营养成分，而使牙龈炎或牙周炎特别严重。
（二）主诉
用患者的语言，简明扼要地记录。例如：“一周来左上后牙遇冷热痛”，“左舌缘溃烂已3个月”。
（三）现病史
包括与主诉有关的自觉症状与检查结果。例如：“左舌缘溃烂已3个月，溃疡逐渐扩大，有自发痛。检查时溃疡大小为1.5cmx1cm，边缘不整，有到悬，低面不平，有无数小结节，表面被覆污秽黄色假膜，基底不硬”等等。在本栏内不要记录所有的口腔情况，因为这样不仅浪费时间，而且还容易遗漏。
（四）既往史
既往史包括的内容见前述章节，在本栏内应将有关的重要部分记录下来。例如：“一年前患过浸润性肺结核”，“注射链霉素时发生过敏性休克”等。
（五）家族史
家族中若有类似患者的疾病，应记录在本栏。
一、一般体格检查
1、皮肤：皮肤表面有无皮疹和皮下脂肪。
2、淋巴结：重点检查头颈部淋巴结，因口腔颌面部恶性肿瘤如发生头颈部淋巴结转移，对治疗方法的选择和预后的估计都非常重要。当颌颈部淋巴结肿大，凝为淋巴系统恶性肿瘤或嗜酸性淋巴肉芽肿等与全身淋巴系统有关的疾病时，应对全身各组淋巴结作详细记录。
3、头部：口腔颌面部与头颅相邻。口腔颌面部的损伤、肿瘤或类肿瘤疾病，如骨纤维结构不良、浆细胞瘤等，均可累及头部。先天性口腔颌面部畸形的病人，要注意有无伴发头颅的畸形。
4、眼：包括眼距、眼睑闭合，眼球运动，结膜，瞳孔大小、形状，对光反射以及视力等，口腔颌面部的炎症，并发眶周蜂窝组织炎、海绵窦血栓性静脉炎时，上颌骨高位骨折或颌面部损伤并发颅脑损伤时，翼腭凹区肿瘤并侵犯眶内或球后时，均可导致视力、瞳孔、对光反射和眼球运动等改变。白塞氏综合征、口眼干燥综合征等，眼部病变本身就为其中的一组症
状。
5、耳：颅中凹骨折，常有脑脊液耳漏、外耳道流血。
6、鼻：鼻腔有无阻塞、异常分泌物及其性状（血性、脓性或清亮等），对上颌窦肿瘤、前颅凹损伤和前牙区的颌骨肿瘤等的判断，有较大的参考价值。
7、咽喉；对腭裂病人应检查和记录扁桃体及增殖体情况。
三、专科检查
口腔专科检查，包括颌面部、口腔软组织、颞颌关节、涎腺、上下班颈部和牙体、牙周组织等内容。应根据主诉，有选择地、顺序地先口外后口内逐项检查记录，以免遗漏，尽量做到全面细致。有关鉴别诊断的重要阴性项目亦应记录。
（一）颌面部
视诊：颜面表情与意识神态。颜面表情变化既是某些口腔疾病的表征，又是各种全身疾病的反应。颌面部损伤病人，如出现意识和神志变化，常提示合并颅脑损伤。
观察颜面及上颈部是否对称，面上、中、下三部的正、侧比例是否协调，有无脓肿、肿块、瘘管、畸形或缺损。如有肿块或肿胀，应注明准确的部位和所涉及的周围解剖界限以及与周围组织器官的关系和对功能影响等。
面颈部皮肤之色泽、皱纹和弹性的改变，对某些疾病的诊断很有帮助，如神秘纤维瘤、血管瘤、恶性黑色素瘤、白斑病、硬皮病等，均可出现皮肤色素及弹性的改变，在检查及记录时应加以注意。
触诊：在视诊的基础上进一步对病变区进行检查，以了解病变区皮肤温度、硬度和弹性，病变范围和深度，有无压痛、波动感等。对口底及颌下区病变应记录双手对口内外联合触诊的情况。如有肿块，应注意其质地、边界、肿块直径大小、活动度以及与深部组织和皮肤的关系。有无异常搏动及压缩等。
颌面骨的检查，应注意其大小、对称性、有无膨隆或缺损。对于骨肿块应检查骨质膨隆或增生的范围，骨面有无台阶状改变及异常活动等。
探诊：颌面部有瘘管、窦道时，应进行探诊检查，了解其深度、方向，是否贯通口腔，能否触及粗糙骨面或可移动的死骨块、异物等。必要时楞在瘘管内注入染色剂（如亚蓝）或行瘘道造影，以进一步明确其走向。
（二）口腔软组织
口腔软组织的检查应包括口唇、颊、腭、舌及口底等部位。
唇颊：唇红的颜色和弹性，有无鳞屑、皲裂，与皮肤的界限是否清楚整齐。两侧口角是否对称，有无唇部过度紧张或增大。颊部腮腺导管开口处有无红肿，导管有无条束状改变。唇颊部黏膜有无色泽异常、表面糜烂及溃疡。对黏膜溃疡，应认真检查记录其数目、大小、部位、形态、表面假膜的性质，基底部有无浸润性硬结，有无明显触痛，触之是否易出血等。需要时，应对腮腺导管作探诊检查。
腭：注意硬腭、软腭、悬雍垂、舌腭弓等处的黏膜有无病损、畸形缺损或瘘管等。对肿块或肿胀属性质的病损，应进行触诊，以判别甚性质和范围。对有重鼻音者或腭裂语音，而腭部未发现有缺损的患者，应检查软腭、舌腭弓、咽腭弓的运动，有无肌肉瘫痪或腭咽闭合不等。对发生于硬腭中央之骨性肿块，应与腭隆突鉴别。
舌：注意观察舌体、舌根、舌背及舌腹的黏膜及乳头形态，舌的大小等，注意舌系带位置，舌向上、向前运动是否受限或偏向一侧。对舌肌病变及溃疡应行触诊，以了解病变所在的范围、硬度、浸润等情况。舌部的恶性肿瘤还应记录其前后位置及与中线的关系。舌的疾患可分发育性、创伤性、内分泌性和肿瘤性等，在检查时应注意鉴别。对某些舌病，必需进行舌味觉功能检查。
口底：指舌腹以下和两侧下颌骨体之间的口腔底部。口底检查同样要注意黏膜的色泽、有无糜烂或溃疡等情况。颌下腺导管开口处有无红肿及异常分泌物、溢脓。触诊应双手口内外同时进行，注意口底区有无肿块或硬结，颌下腺导管有无条束状改变，是否触及导管内结石。口底的软性肿胀，可为囊肿或脉管性肿瘤所致；硬而固定的肿块，可因舌下腺炎症或肿瘤引起。近期的硬结和肿胀，伴有炎症和触痛者，要注意牙齿、牙周的感染情况。舌下腺的肿瘤，常以恶性多见，必要时应结合z组织病理学检查。
（三）涎腺
涎腺的检查系指对三对涎腺的检查，其中以腮腺及颌下腺为主。腮腺大部分位于颌后凹内。注意观察两侧是否对称，触诊治时应同时检查腮腺和颌下腺的导管，注意涎液的分泌情况。对腮腺的触诊，切勿用手指夹住腮腺提拉，以免将腺体误认为肿块。如有肿块，应记录其大小、质地、活动度、压痛等情况。必要时应行涎腺分泌功能的检查。
（四）颞下颌关节
颞下颌关节之髁状突颈部为下颌骨的生长发育中心，对颞颌关节检查时，应注意颜面下1/3左右两侧是否对称、协调，有无明显缩短或增长，颏部中点是否居中。必要时应对下颌角、下颌支、下颌体的大小、长度用尺测量，并左右两侧比较。
（1）颞颌关节的检查以触诊为主，应注意髁状突的活动度，有无消失或过度活动、弹响及摩擦感。明确弹响与张闭口的关系。关节区有无压痛及肿物等。
（2）咀嚼肌检查应进行双侧肌肉质地、收缩强度对比与肌肉疼痛、张闭口关系的检查。
（3）下颌运动应注意开口型是否正常，前后及侧向运动两侧是否对称、协调。下颌前伸时下前牙中线有无偏斜。下颌运动时有无疼痛，张口有无受限。若张口受限，应记录其张口度，一般分为三度：
轻度张口受限——上、下切牙切缘间距仅可置入二横指，约2~3cm。
中度张口受限——上、下切牙切缘间距仅可置入一横指，约1~2cm。
重度张口受限——上、下切牙切缘间距不到一横指，约在1cm以内。
在下颌作任何方向运动时，均需注意有无弹响，并观察其弹响发生的时间、性质、次数。必要时，可辅以听诊器协助。
（五）[补]关系检查
牙和[补]状态的异常与颞颌关节疾病有密切关系，颞下颌关节病变，可导致牙、[补]关系异常。对[补]关系的检查，应注[补]曲线、[补]面有无磨损、是否有创伤等，异常[补]关系情况存在，还应注意牙列缺失及修复情况。对某些颌骨正畸的病人、[补]关系尤其应有准确、仔细的记录。
（六）牙齿及牙周检查
牙齿和牙周的病变，与某些颌面部疾病有着密切的关系。牙源性肿瘤常可伴有牙齿数目的减少。牙髓的病变可引起颌骨的囊肿。而某些口腔软组织和颌骨的病变，其早期症状可能是牙齿的松动、移位等。
颌骨损伤的病人，对位于骨折线上的牙齿，如处理不当，可影响颌骨骨折的愈合。因此在牙体牙周的检查过程中，应注意以下几点：
（1）牙齿的数目、形态、排列和接触关系，有无龋坏和变色等到。
（2）牙龈有无充血、肿胀、增生、糜烂、萎缩和坏死，龈黏膜有无瘘管和溃疡。
（3）牙齿龋洞的部位、深浅，有无穿髓、探痛等，可探及牙周袋的深浅。
（4）患牙有无明显叩痛，根尖区是否有压痛。
（5）牙齿有松动的临床评估：颊舌向松动为1度，颊舌向及近远中向松动为2度，颊舌、近远中向及垂直向松动为3度。
（七）口腔颌面颈畸形检查
有口腔颌面颈部先天性或后天性畸形者，除按口腔专科检查要求外，应参考整形外科病历书
写要求，进行检查及记录。
（八）颈部检查
除观察颈部有无畸形、肿胀或肿块等外，应对病变区仔细确诊，以了解病变的性质、深度及与颈部重要结构的关系。
第五篇：妇科英文病历
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)
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