心内科英文病历模板.doc

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1、MedicalRecordsforAdmissonMedicalNumber:701721GeneralinformationName:LiuSideAge:EightySex:MaleRace:HanNationality:ChinaAddress:NO.35,DandongRoad,JiefangRvenue,Hankou,Hubei.Tel:857307523Occupation:RetiredMaritalstatus:MarriedDateofadmission:Aug6th,2001Dateofrecord:11Am,Aug6th,2001C

2、omplainerofhistory:patient’ssonandwifeReliability:ReliableChiefcomplaint:Upperbellyachetendays,haematemesis,hemafeciaandunconsciousnessforfourhours.Presentillness:Thepatientfeltupperbellyacheabouttendaysago.Hedidn’tpayattentiontoitandthoughthehadatesomethingwrong.At6o’clockthismo

3、rninghefaintedandrejectedlotsofbloodandgore.Thenhemafeciabegan.Hisfamilysenthimtoourhospitalandreceivedemergenttreatment.Sothepatientwasacceptedbecauseof“uppergastrointestinehemorrhageandexsanguineshock”.Sincethediseasecomingon,thepatientdidn’turinate.PasthistoryThepatientishealt

4、hybefore.Nohistoryofinfectivediseases.Noallergyhistoryoffoodanddrugs.PasthistoryOperativehistory:Neverundergoinganyoperation.Infectioushistory:Nohistoryofsevereinfectiousdisease.Allergichistory:Hewasnotallergictopenicillinorsulfamide.Respiratorysystem:Nohistoryofrespiratorydiseas

5、e.Circulatorysystem:Nohistoryofprecordialpain.Alimentarysystem:Nohistoryofregurgitation.Genitourinarysystem:Nohistoryofgenitourinarydisease.Hematopoieticsystem:Nohistoryofanemiaandmucocutaneousbleeding.Endocrinesystem:Noacromegaly.Noexcessivesweats.Kineticsystem:Nohistoryofconfin

6、ementoflimbs.Neuralsystem:Nohistoryofheadacheordizziness.PersonalhistoryHewasborninWuhanonNov19th,1921andalmostalwayslivedinWuhan.Hislivingconditionsweregood.Nobadpersonalhabitsandcustoms.Menstrualhistory:Heisamalepatient.Obstetricalhistory:NoContraceptivehistory:Notclear.Familyh

7、istory:Hisparentshavebothdeads.PhysicalexaminationT36.5℃,P130/min,R23/min,BP100/60mmHg.Heiswelldevelopedandmoderatelynourished.Activeposition.Hisconsciousnesswasnotclear.Hisfacewascadaverousandtheskinwasnotstainedyellow.Nocyanosis.Nopigmentation.Noskineruption.Spiderangiomawasnot

8、seen.Nopittingedema.Superficiallymphnode