如何写好英文病历及内外妇儿例文.docx
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如何写好英文病历及内外妇儿例文.docx
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如何写好英文病历及内外妇儿例文
英文病历书写范例
内科CASE1
外科CASE3
儿科CASE5
妇科CASE7
如何写好一份英文病历10
英文病历书写系列一12
内科CASE
MedicalRecordsforAdmisson
MedicalNumber:
701721
Generalinformation
Name:
LiuSide
Age:
Eighty
Sex:
Male
Race:
Han
Nationality:
China
Address:
NO.35,DandongRoad,JiefangRvenue,Hankou,Hubei.Tel:
857307523
Occupation:
Retired
Maritalstatus:
Married
Dateofadmission:
Aug6th,2001
Dateofrecord:
11Am,Aug6th,2001
Complainerofhistory:
patient’ssonandwife
Reliability:
Reliable
Chiefcomplaint:
Upperbellyachetendays,haematemesis,hemafeciaandunconsciousnessforfourhours.
Presentillness:
Thepatientfeltupperbellyacheabouttendaysago.Hedidn’tpayattentiontoitandthoughthehadatesomethingwrong.At6o’clockthismorninghefaintedandrejectedlotsofbloodandgore.Thenhemafeciabegan.Hisfamilysenthimtoourhospitalandreceivedemergenttreatment.Sothepatientwasacceptedbecauseof“uppergastrointestinehemorrhageandexsanguineshock”.
Sincethediseasecomingon,thepatientdidn’turinate.
Pasthistory
Thepatientishealthybefore.
Nohistoryofinfectivediseases.Noallergyhistoryoffoodanddrugs.
Pasthistory
Operativehistory:
Neverundergoinganyoperation.
Infectioushistory:
Nohistoryofsevereinfectiousdisease.
Allergichistory:
Hewasnotallergictopenicillinorsulfamide.
Respiratorysystem:
Nohistoryofrespiratorydisease.
Circulatorysystem:
Nohistoryofprecordialpain.
Alimentarysystem:
Nohistoryofregurgitation.
Genitourinarysystem:
Nohistoryofgenitourinarydisease.
Hematopoieticsystem:
Nohistoryofanemiaandmucocutaneousbleeding.
Endocrinesystem:
Noacromegaly.Noexcessivesweats.
Kineticsystem:
Nohistoryofconfinementoflimbs.
Neuralsystem:
Nohistoryofheadacheordizziness.
Personalhistory
HewasborninWuhanonNov19th,1921andalmostalwayslivedinWuhan.Hislivingconditionsweregood.Nobadpersonalhabitsandcustoms.
Menstrualhistory:
Heisamalepatient.
Obstetricalhistory:
No
Contraceptivehistory:
Notclear.
Familyhistory:
Hisparentshavebothdeads.
Physicalexamination
T36.5℃,P130/min,R23/min,BP100/60mmHg.Heiswelldevelopedandmoderatelynourished.Activeposition.Hisconsciousnesswasnotclear.Hisfacewascadaverousandtheskinwasnotstainedyellow.Nocyanosis.Nopigmentation.Noskineruption.Spiderangiomawasnotseen.Nopittingedema.Superficiallymphnodeswerenotfoundenlarged.
Head
Cranium:
Hairwasblackandwhite,welldistributed.Nodeformities.Noscars.Nomasses.Notenderness.
Ear:
Bilateralauriclesweresymmetricandofnomasses.Nodischargeswerefoundinexternalauditorycanals.Notendernessinmastoidarea.Auditoryacuitywasnormal.
Nose:
Noabnormaldischargeswerefoundinvetibulumnasi.Septumnasiwasinmidline.Nonaresflaring.Notendernessinnasalsinuses.
Eye:
Bilateraleyelidswerenotswelling.Noptosis.Noentropion.Conjunctivawasnotcongestive.Sclerawasanicteric.Eyeballswerenotprojectedordepressed.Movementwasnormal.Bilateralpupilswereroundandequalinsize.Directandindirectpupillaryreactionstolightwereexistent.
Mouth:
Oralmucousmembranewasnotsmooth,andtherewereulcercanbeseen.Tonguewasinmidline.Pharynxwascongestive.Tonsilswerenotenlarged.
Neck:
Symmetricandofnodeformities.Nomasses.Thyroidwasnotenlarged.Tracheawasinmidline.
Chest
Chestwall:
Veinscouldnotbeseeneasily.Nosubcutaneousemphysema.Intercostalspacewasneithernarrowednorwidened.Notenderness.
Thorax:
Symmetricbilaterally.Nodeformities.
Breast:
Symmetricbilaterally.
Lungs:
Respiratorymovementwasbilaterallysymmetricwiththefrequencyof23/min.thoracicexpansionandtactilefremitusweresymmetricbilaterally.Nopleuralfrictionfremitus.Resonancewasheardduringpercussion.Noabnormalbreathsoundwasheard.Nowheezes.Norales.
Heart:
Nobulgeandnoabnormalimpulseorthrillsinprecordialarea.Thepointofmaximumimpulsewasin5thleftintercostalspaceinsideofthemidclavicularlineandnotdiffuse.Nopericardialfrictionsound.Borderoftheheartwasnormal.Heartsoundswerestrongandnosplitting.Rate150/min.Cardiacrhythmwasnotregular.Nopathologicalmurmurs.
Abdomen:
Flatandsoft.Nobulgeordepression.Noabdominalwallvaricosis.Gastralintestinaltypeorperistalseswerenotseen.Tendernesswasobviousaroundthenavelandinupperabdoman.Therewasnotreboundtendernessonabdomenorrenalregion.Liverandspleenwasuntouched.Nomasses.Fluidthrillnegative.Shiftingdullnessnegative.Borhorygmusnotheard.Novascularmurmurs.
Extremities:
Noarticularswelling.Freemovementsofalllimbs.
Neuralsystem:
Physiologicalreflexeswereexistentwithoutanypathologicalones.
Genitourinarysystem:
Notexamed.
Rectum:
notexaned
Investigation
Blood-Rt:
Hb69g/LRBC2.70T/LWBC1.1G/LPLT120G/L
Historysummary
1.Patientwasmale,80yearsold
2.Upperbellyachetendays,haematemesis,hemafeciaandunconsciousnessforfourhours.
3.Nospecialpasthistory.
4.Physicalexamination:
T37.5℃,P130/min,R23/min,BP100/60mmHgSuperficiallymphnodeswerenotfoundenlarged.Noabdominalwallvaricosis.Gastralintestinaltypeorperistalseswerenotseen.Tendernesswasobviousaroundthenavelandinupperabdoman.Therewasnotreboundtendernessonabdomenorrenalregion.Liverandspleenwasuntouched.Nomasses.Fluidthrillnegative.Shiftingdullnessnegative.Borhorygmusnotheard.Novascularmurmurs.Nootherpositivesigns.
5.investigationinformation:
Blood-Rt:
Hb69g/LRBC2.80T/LWBC1.1G/LPLT120G/L
Impression:
uppergastrointestinehemorrhage
Exsanguineshock
外科CASE
MedicalNumber:
682786
Generalinformation
Name:
WangRunzhen
Age:
Fortythree
Sex:
Female
Race:
Han
Occupation:
Teacher
Nationality:
China
Maritalstatus:
Married
Address:
NO.38,HangkongRoad,JiefangRvenue,Hankou,Hubei.Tel:
82422500
Dateofadmission:
Jan11st,2001
Dateofrecord:
11Am,Jan11st,2001
Complainerofhistory:
thepatientherself
Reliability:
Reliable
Chiefcomplaint:
Rightbreastmassfoundformorethanhalfamonth.
Presentillness:
Halfamonthago,thepatientsuddenlyfeltpaininherrightchestwhensheputupherhand.Aftertouchingit,shefoundamassinherrightbreast,butnotendness,andthepatientdidn’tpayattentionit.Thenthepainbecamemoreandmoreserious,sothepatientwenttotumourhospitalandreceivedapathologycentesis.Herdiagnosiswasbreastcancer.Thenshecametoourhospitalandaskedforanoperation.
Sinceonset,herappetitewasgood,andbothherspiritednessandphysicalenergyarenormal.Defecationandurinationarenormal,too.
Pasthistory
Operativehistory:
Neverundergoinganyoperation.
Infectioushistory:
Nohistoryofsevereinfectiousdisease.
Allergichistory:
Shewasnotallergictopenicillinorsulfamide.
Respiratorysystem:
Nohistoryofrespiratorydisease.
Circulatorysystem:
Nohistoryofprecordialpain.
Alimentarysystem:
Nohistoryofregurgitation.
Genitourinarysystem:
Nohistoryofgenitourinarydisease.
Hematopoieticsystem:
Nohistoryofanemiaandmucocutaneousbleeding.
Endocrinesystem:
Noacromegaly.Noexcessivesweats.
Kineticsystem:
Nohistoryofconfinementoflimbs.
Neuralsystem:
Nohistoryofheadacheordizziness.
Personalhistory
ShewasborninWuhanonNov19th,1957andalmostalwayslivedinWuhan.Shegraduatedfromseniorhighschool.Herlivingconditionsweregood.Nobadpersonalhabitsandcustoms.
Menstrualhistory:
Thefirsttimewhenshewas14.Lasting3to4dayseverytimesanditscycleisabout30days.
Obstetricalhistory:
Pregnacy3times,oncenatureproduction,abortiontwice.
Contraceptivehistory:
Notclear.
Familyhistory:
Hisparentshavebothdied.
Physicalexamination
T36.4℃,P80/min,R20/min,BP90/60mmHg.Sheiswelldevelopedandmoderatelynourished.Activeposition.Theskinwasnotstainedyellow.Nocyanosis.Nopigmentation.Noskineruption.Spiderangiomawasnotseen.Nopittingedema.Superficiallymphnodeswerenotenlarged.
Head
Cranium:
Hairwasblackandwelldistributed.Nodeformities.Noscars.Nomasses.Notenderness.
Ear:
Bilateralauriclesweresymmetricandofnomasses.Nodischargeswerefoundinexternalauditorycanals.Notendernessinmastoidarea.Auditoryacuitywasnormal.
Nose:
Noabnormaldischargeswerefoundinvetibulumnasi.Septumnasiwasinmidline.Nonaresflaring.Notendernessinnasalsinuses.
Eye:
Bilateraleyelidswerenotswelling.Noptosis.Noentropion.Conjunctivawasnotcongestive.Sclerawasanicteric.Eyeballswerenotprojectedordepressed.Movementwasnormal.Bilateralpupilswereroundandequalinsize.Directandindirectpupillaryreactionstolightwereexistent.
Mouth:
Oralmucousmembranewassmooth,andofnoulcerorerosion.Tonguewasinmidline.Pharynxwasnotcongestive.Tonsilswerenotenlarged.
Neck:
Symmetricandofnodeformities.Nomasses.Thyroidwasnotenlarged.Tracheawasinmidline.
Chest
Chestwall:
Veinscouldnotbeseeneasily.Nosubcutaneousemphysema.Intercostalspacewasneithernarrowednorwidened.Notenderness.
Thorax:
Symmetricbilaterally.Nodeformities.
Breast:
Symmetricbilaterally.Neithernipplesnorskinwereretracted.Elasticitywasfine.
Lungs:
Respiratorymovementwasbila
儿科CASE
MedicalRecordsforAdmisson
MedicalNumber:
696235
Generalinformation
Name:
ZhangYi
Age:
thirteen
Sex:
Female
Race:
Han
Nationality:
China
Address:
NO.23,YunchunRoad,JiefangRvenue,Hankou,Hubei.Tel:
85763723
ParentsName:
fatherZhangHesheng
MotherYangChiulian
Dateofadmission:
May8th,2001
Dateofrecord:
11Am,May8th,2001
Complainerofhistory:
patient’smother
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