英文病历模板.doc

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1、MedicalRecordsforAdmissonMedicalNumber:GeneralinformationName:CaiChunwangAge:47yDateofbirth:1965.2.16Sex:maleRace:HanNationality:ChinaMarriage:marriedOccupation:workerIdentificationNo.:Address:Huanggangcity,HubeiPhoneNo.:Complainerofhistory:CaiChunwangReliability:HimselfDateofrecord:2

2、013.2.27Chiefcomplaint:Pancytopeniafor2yearPresentillness:ThepatientfoundPancytopeniaat2011,andheusedtobeinhospitaltotakeaphysicalexaminationwhichwasconsideredintoMyelodysplasticsyndromewithalargeprobability.Thepatienthadreexaminedhemogram,withobviouspancytopenia.Sohegotintothehospita

3、ltodotheBonemarrowcytologyandImmunetyping,whichshowedthatMDShadaggravatedintoAML.Now,hehasnoanybleedingspotintheskin,withoutheadache、melena、stomachacheandsoon.Theclinicmadeit“AML”tobetreatedinhospital.Duringtheperiodoftheillness,hismentalstateisbad,withafairappetiteandsleep.Thestoolan

4、durinationarebothnormal,withahyposthenia.Weightisthesameasbefore.Pasthistory:generalsituationisbadSystemreview:Respiratorysystem:No.Circulatorysystem:NoAlimentarysystem:NoGenitourinarysystem:NoHematopoieticsystem:NoEndocrinesystem:NoKineticsystem:NoNeuralsystem:NoInfectioushistory:Den

5、iedAllergichistory:.NoOperativehistory:Hewasonceoperatedonancholecystectomy.Taumahistory:Denied.Historyofallergy:Denied.Historyofpreventiveinoculation]:thenationalplanforvaccinationPersonalhistoryMenstrualhistory:MaleObstetricalhistory:NoMarriage:marriedonce.Familyhistory:Hisfatherand

6、motherarealiveandhealthy.Deniesgeneticandinfectiousdiseasesinhisfamily.PhysicalexaminationT37℃,P95/min,R20/min,BP124/78mmHg.Heiswelldevelopedandmoderatelynourished.Activeposition.Theskinwasnotstainedyellow.Cyanosis.Nopigmentation.Noskineruption.Spiderangiomawasnotseen.Nopittingedema.S

7、uperficiallymphnodeswerenotfoundenlargedinhisneck.HeadCranium:size:normallargesmalldeformity.Nocoxycephalysquaredskulldeformingskull.Notendernessmasssunk.Ear:Auricleisnormal.Noexcretionsofexternalauditorycanal.NoTendernessofmastoid.Nose:Shapeisnormal.Nonosalalaflapobsructionexcretions

8、nasal