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1、原版英文病历范文(皮肤科英文病历)来源：医学全在线更新：2009-11-2医学英语论坛NoteforJaneDoeon4/8/03-Chart2646ChiefComplaint(1/1):This19yearoldfemalepresentstodaycomplainingofacnefromcontinuallywashingarea,frequentphoneusesothereceiverrubsonfaceandoralcontraceptiveuse.Location:Sheindicatestheproblemlocationisthechin,righttempleandlef
2、ttemplelocally.Severity:Severityofconditionisworsening.Menses:Onset:13yearsold.Interval:22-27days.Duration:4-6days.Flow:light.Complications:none.Allergies:Patientadmitsallergiestopenicillinresultingindifficultybreathing.MedicationHistory:PatientiscurrentlytakingAlesse-28,20mcg-0.10mgtabletusagestart
3、edon08/07/2001medicationwasprescribedbyObstetrician-GynecologistA.PastMedicalHistory:FemaleReproductiveHx:(+)birthcontrolpilluse,ChildhoodIllnesses:(+)chickenpox,(+)measles.PastSurgicalHistory:Noprevioussurgeries.FamilyHistory:Patientadmitsafamilyhistoryofanxiety,stressdisorderassociatedwithmother.S
4、ocialHistory:PatientadmitscaffeineuseSheconsumes3-5servingsperday,PatientadmitsalcoholuseDrinkingisdescribedassocial,Patientadmitsgooddiethabits,Patientadmitsexercisingregularly,PatientdeniesSTDhistory.ReviewofSystems:Integumentary:(+)periodicreddeningofface,(+)acneproblems,Allergic/Immunologic:(-)a
5、llergicorimmunologicsymptoms,ConstitutionalSymptoms:(-)constitutionalsymptomssuchasfever,headache,nausea,dizziness.PhysicalExam:Patientisa19yearoldfemalewhoappearspleasant,innoapparentdistress,hergivenage,welldeveloped,wellnourishedandwithgoodattentiontohygieneandbodyhabitus.Skin:Examinationofscalps
6、howsnoabnormalities.Hairgrowthanddistributionisnormal.Inspectionofskinoutsideofaffectedarearevealsnoabnormalities.Palpationofskinshowsnoabnormalities.Inspectionofeccrineandapocrineglandsshowsnoevidenceofhyperidrosis,chromidrosisorbromhidrosis.Faceshowskeratoticpapule.Impression:Acnevulgaris.Plan:Rec
7、ommendedtreatmentisantibiotictherapy.Janereceivedextensivecounselingaboutacne.Sheunderstandsacnetreatmentisusuallylong-term.Returntoclinicin4week(s).PatientInstructions:Patientreceivedliteratureregard
