传染科英文病历模板

传染科英文病历模板

Medical Records for Admisson

Medical Number: 733735

General information

Name: Chen Dong yin

Age: Forty-four

Sex: Female

Race: Han

Nationality: China

Address: NO.11, Macao Road,

Whhan, Hubei. Tel: 8260504

Occupation: Peasant Marital status: Married Date of admission: July 6th, 2002 Date of record: 3pm, July 6th, 2002 Complainer of history: the patient herself Reliability: Reliable

Chief complaint: Intertia and Dyspepsia for about decades days.

Present illness:

The patient felt dyspepsia, intertia, nausea and vomiting after her taking some traditional Chinese medicine orally for her headache about ten days ago. She didn’t get a fever. The color of her urine is normal. The physical examination show no tenderness or reboundtenderness. The patient was examined at another hospital, the results show “HBV(+), the function of the liver is abnormal. So the patient came to our hospital and was accepted as “chronic hepatitis B”.

Since the disease coming on, the patient’s mind and appetite is not as good as normal. Her sleeping, stool and urine

are normal but her physical strength is a bit decline. Past history

The patient is healthy before.

No history of hepatitis. No allergy history of food and drugs. Past history

Operative history: Deligation of ovidut at 1985.

传染科英文病历模板

Infectious history: No history of severe infectious disease. Allergic history: He 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

He was born in Wuhan on Nov 19th, 1957 and almost always lived in Wuhan. His living conditions were good. No bad personal habits and customs.

Menstrual history: The first time when she was 14. Lasting 4 days every times and its cycle is about 28 days. The latest time was at march,1999.

Obstetrical history: Pregnacy 2 times, both nature production. Contraceptive history: Amenorrhea already.

Family history: His parents are both alive.

Physical examination

T 36.5℃, P 63/min, R 16/min, BP 105/60mmHg. She is well developed and moderately nourished. Active position. His consciousness was clear. His face and 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 found enlarged.

Head

Cranium: Hair was black and white, well distributed. No deformities. No scars. No masses. No tenderness.

传染科英文病历模板

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 there were not ulcer can be seen. Tongue was in midline. Pharynx was 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.

Lungs: Respiratory movement was bilaterally symmetric with the frequency of 16/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

传染科英文病历模板

normal. Heart sounds were strong and no splitting. Rate 63/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 or rebound tenderness on abdomen or renal region. Liver and spleen was untouched. No masses. Fluidthrill negative. Shifting dullness negative. Borhorygmus not heard. 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

Examination of the hepatitis B: HBsAg(+), HBeAb(+), HBcAb(+); Function of the liver: STB: 27μmol/L, ALT: 352U/L .

History summary

1. Patient was female, 44 years old.

2. Intertia and Dyspepsia for about decade days.

3. No special past history.

4. Physical examination: T 37.5℃, P 63/min, R 16/min, BP 105/60mmHg Spider angioma was not seen. No pitting edema. No abdominal wall varicosis. Gastralintestinal type or peristalses were not seen. There was not …… 此处隐藏：3904字，全部文档内容请下载后查看。喜欢就下载吧 ……