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ID:51926134
大小:34.50 KB
页数:5页
时间:2020-03-19
《英文病历书写范例(内科).doc》由会员上传分享,免费在线阅读,更多相关内容在行业资料-天天文库。
1、MedicalRecordsforAdmissonMedicalNumber:701721GeneralinformationName:LiuSideAge: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’tpayattentiont
3、oitandthoughthehadatesomethingwrong.At6o’clockthismorninghefaintedandrejectedlotsofbloodandgore.Thenhemafeciabegan.Hisfamilysenthimtoourhospitalandreceivedemergenttreatment.Sothepatientwasacceptedbecauseof“uppergastrointestinehemorrhageandexsanguineshock
4、”.Sincethediseasecomingon,thepatientdidn’turinate.PasthistoryThepatientishealthybefore.Nohistoryofinfectivediseases.Noallergyhistoryoffoodanddrugs.PasthistoryOperativehistory:Neverundergoinganyoperation.Infectioushistory:Nohistoryofsevereinfectiousdiseas
5、e.Allergichistory:Hewasnotallergictopenicillinorsulfamide.Respiratorysystem:Nohistoryofrespiratorydisease.Circulatorysystem:Nohistoryofprecordialpain.Alimentarysystem:Nohistoryofregurgitation.Genitourinarysystem:Nohistoryofgenitourinarydisease.Hematopoie
6、ticsystem:Nohistoryofanemiaandmucocutaneousbleeding.Endocrinesystem:Noacromegaly.Noexcessivesweats.Kineticsystem:Nohistoryofconfinementoflimbs.Neuralsystem:Nohistoryofheadacheordizziness.PersonalhistoryHewasborninWuhanonNov19th,1921andalmostalwayslivedin
7、Wuhan.Hislivingconditionsweregood.Nobadpersonalhabitsandcustoms.Menstrualhistory:Heisamalepatient.Obstetricalhistory:NoContraceptivehistory:Notclear.Familyhistory:Hisparentshavebothdeads.PhysicalexaminationT36.5℃,P130/min,R23/min,BP100/60mmHg.Heiswelldev
8、elopedandmoderatelynourished.Activeposition.Hisconsciousnesswasnotclear.Hisfacewascadaverousandtheskinwasnotstainedyellow.Nocyanosis.Nopigmentation.Noskineruption.Spiderangiomawasnotseen.Nopittingedema.Superficiallymphnode
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