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1、.MedicalRecordsforAdmissonGeneralinformation精选word范本!.Name:DuxuechunAge:52Sex:MaleRace:HanNationality:ChinaAddress:Room.479,Building.11,StationnorthRoad,Changsha,Hunan.Occupation:managerMaritalstatus:MarriedDateofadmission:Dec17th,2014,16:00Dateofrecord:Dec18th,2014,15:32
2、Complainerofhistory:DuxuechunReliability:Reliable精选word范本!.Chiefcomplaint:Coughandexpectorationforonemonth,andshortnessofbreathaftertheeventforhalfamonth.Presentillness:Thepatientfeltitchythroatandcoughedinmid-November2014aftercatchingacold.Itisaparoxysmalcoughrelievedatn
3、ightandoccurredrepeatedlyinamoderatedegreeusuallywithwhitefrothysputumeasilycoughed.Hedidn’thavefever,chesttightnessandpainandshortnessofbreath.AftertakingmedicinefromChinesemedicinepractitioners,hefeltshortnessofbreathespeciallywhenhewentupstairsandwalkedfast.Othersympto
4、msstillexisted.OnDec13th,2014,thepatientcametoouroutpatientandwasdiagnosed“lunginfectionwithtuberculosis”.DuringDec14thtoDec16th,2014,thepatientwenttoChestHospitalofHunanprovinceandwasdiagnosedfungalinfectionsandAlveolarproteinosis.Nowtoseekfurthertherapythepatientwasacce
5、ptedtoourdepartmentbecauseof“unknownoflungdisease”.Sinceonset,herappetitewasgood,andbothherspiritednessandphysicalenergyaregood.Defecationandurinationarenormal.PasthistoryThepatientishealthybefore.精选word范本!.Nohistoryofoperativediseases.Nohistoryofinfectivediseases.Noaller
6、gyhistoryoffoodanddrugs.SystemreviewRespiratorysystem:Nohistoryofrespiratorydisease.Circulatorysystem:Nohistoryofprecordialpain.Alimentarysystem:Nohistoryofregurgitation.Genitourinarysystem:Nohistoryofgenitourinarydisease.Hematopoieticsystem:Nohistoryofanemiaandmucocutane
7、ousbleeding.Endocrinesystem:Noacromegaly.Noexcessivesweats.Kineticsystem:Nohistoryofconfinementoflimbs.Neuralsystem:Nohistoryofheadacheordizziness.PersonalhistoryHewasborninHunanandalmostalwayslivedthere.Hislivingconditionsweregood.Nobadpersonalhabitsandcustoms.Quittingsm
8、oking10yearsandhaveregularlife.Obstetricalhistory:Hemarriedat26,hadadaughter.Hisdaughterandwifea