儿科英文病历模板.doc

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1、Nanjingchildren’shospitalMedicalRecordsforAdmissonWard:321BedNumber:32178MedicalNumber:GeneralinformationName:Sonof***Sex:MaleAge:3hBirthplace:***county,AnhuiprovinceRace:HanAddress:***town,***county,AnhuiprovinceDateofadmission:3:31pmOct16th,2015Dateofrecord:3:31

2、pmOct16th,2015ParentsName:father***Mother***Complainerofhistory:patient’sfatherReliability:ReliableChiefcomplaint:Shortnessofbreathandmoaningfor3hPresentillness:Theafflictedbabywasdelivered3hagoandhadinstaneousshortnessofbreathalongwithobtuseresponseandmoaning.Noa

3、spneaorseizureorscreamwereobserved.InlocalHospitalhereceivedtreatmentof“naloxone、mezlocillinandVitK1”,buthissymptomsdidn’tabate.Sotheparentstookhimtoourhospital,hewasadmittedwithadiagnosisof“acuterespiratorydyspneasyndrome”.Breastfeedhasnotbeeninitiated.Hehasnotvo

4、mitted,defecatedorurinatedsincehewasborn,.PasthistoryNohistoryofanykindofdisease.Nohistoryofinfectivediseases.Nohistoryofpickingfronttooth.Nohistoryofwipingoralcavity.Personalhistory1.Natal:secondbirthborn,Gestationalage:28weeks;Multiplets:No;InVitrofertilization:

5、NoCauseofprematurebirth:unknown;Timeofbirth:2015-10-1611:00Modeofdelivery:spontaneousdelivery,borninlocalhospitalDeliverer:practioner;Apgarscale:1min7’,5minunknownResuscitation:No;Birthweight:1350gThecharacteristicsandvolumeofamnioticfluidremainsunknown,aswellaswh

6、ethertherewasfetalaspirationofamnioticfluidormeconium.wealsohavenoideaiftherewasPrematureruptureoftheamnioticfluid.Umbilicalcordisnormal;Jaundice:unknown2.Nutrition:breastfeedhasnotbeeninitiated.Hehadnosignofdefecationorvomit.3.Immunization:B.C.GandhepatitisBvacci

7、nehavenotbeeninoculatedafterbirth;Othervaccinationremainsunknown.FamilyhistoryFather:Name:***;Age:29ys;Vocation:worker;Healthcondition:good;Bloodtype:ABMother:Name:***;Age:26ys;Vocaton:peasant;Healthcondition:good;Bloodtype:unknownMother’shistoryofpregnanciesandbi

8、rths:2pregnancies,noabortion;Thispregnancywasnormal.Existingsiblings:ahealthysisterof2andhalfyearsoldNohistoryofdrugallergyorphysicalcontactwithpets;Noh