英文病例书写范文

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1、英文病例书写范文，用得上就投票豉励一下哈MedicalRecordsforAdmissonMedicalNumber:701721GeneralinformationName:LiuSdeAge:EightySex:MaleRace:HanNationality:ChinaAddress:NO.35,DandongRoad,JiefangRvenue,Hankou,Hubei.Tel:857307523Occupation:RetiredMaritalstatus:MarriedDateofadmission:Aug6th,2001Date

2、ofrecord:11Am,Aug6th,2001Complainerofhistory:patient'ssonandwifeReliability:ReliableChiefcomplaint:Upperbellyachetendays,haematemesis,hemafeciaandunconsciousnessforfourhours・Presentillness:Thepatientfeltupperbellyacheabouttendaysago.Hedidn'tpayattentiontoitandthoughthehada

3、tesomethingwrong.At6o'clockthismorninghefaintedandrejectedlotsofbloodandgore・Thenhemafeciabegan.Hisfamilysenthimtoourhospitalandreceivedemergenttreatment.SothepatientwasacceptedbecauseofUuppergastrointestinehemorrhageandexsanguineshock”.Sincethediseasecomingon,thepatientdi

4、dn'turinate.PasthistoryThepatientishealthybefore・Nohistoryofinfectivediseases・Noallergyhistoryoffoodanddrugs.PasthistoryOperativehistory:Neverundergoinganyoperation.Infectioushistory:Nohistoryofsevereinfectiousdisease・Allergichistory:Hewasnotallergictopenicillinorsulfamide

5、・Respiratorysystem:Nohistoryofrespiratorydisease・Qrculatorysystem:Nohistoryofprecordialpain.Alimentarysystem:Nohistoryofregurgitation.Genitourinarysystem:Nohistoryofgenitourinarydisease.Hematopoieticsystem:Nohistoryofanemiaandmucocutaneousbleeding.Endocrinesystem:Noacromeg

6、aly.Noexcessivesweats.Kineticsystem:Nohistoryofconfinementoflimbs.Neuralsystem:Nohistoryofheadacheordizziness・PersonalhistoryHewasborninWuhanonNov19th,1921andalmostalwayslivedinWuhan.Hislivingconditionsweregood・Nobadpersonalhabitsandcustoms・Menstrualhistory:Heisamalepatien

7、t.Obstetricalhistory:NoContraceptivehistory:Notclear.Familyhistory:Hisparentshavebothdeads・PhysicalexaminationT36.5°C,P130/min,R23/min,BP100/60mmHg.Heiswelldevelopedandmoderatelynourished・Activeposition.Hisconsciousnesswasnotclear.Hisfacewascadaverousandtheskinwasnotstaine

8、dyellow.Nocyanosis・Nopigmentation.Noskineruption.Spiderangiomawasnotseen.Nopittingedema・S