非手术科室住院志英文病历模板(修改版)

Division Ward Bed Case No I HUAZHONG UNIVERSITY OF SCIENCE AND TECHNOLOGY TONGJI MEDICAL COLLEGE ACCESSORY TONGJI HOSPITAL Hospitalization Records for None operation Division Division Ward Bed Case No Name Sex Age Nation Birth Place Marital Status Work organization about years Giving up 1 No 2 Yes Time Drinking 1 No 2 Yes Average grams per day about years Giving up 1 No 2 Yes Time Drug abuse 1 No 2 Yes Drug names Division Ward Bed Case No IV Marital and obstetrical history Married age years old Pregnancy times Labor times 1 Natural labor times 2 Operative labor times 3 Natural abortion times 4 Artificial abortion times 5 Premature labor times 6 stillbirth times Health status of the Mate 1 Well 2 Not fine Details Menstrual history Menarchal age Duration day Interval days Last menstrual period Menopausal age years old Amount of flow 1 small 2 moderate 3 large Dysmenorrheal 1 presence 2 absence Menstrual irregularity 1 No 2 Yes Family history especially pay attention to the infectious and hereditary disease related to the present illness Father 1 healthy 2 ill 3 deceased cause Mother 1 healthy 2 ill 3 deceased cause Others The statement above was agreed by the informant Signature of theinformant Date Physical Examination Vital signs Temperature 0C Blood pressure mmHg Pulse bpm 1 regular 2 irregular Respiration bpm 1 regular 2 irregular General conditions Development 1 Normal 2 Hypoplasia 3 Hyperplasia Nutrition 1 good 2 moderate 3 poor 4 cachexia Facial expression 1 normal 2 acute 3 chronic other Habitus 1 asthenic type 2 sthenic type 3 ortho thenic type Position 1 active 2 positive pulsive 4 other Consciousness 1 clear 2 somnolence 3 confusion 4 stupor 5 slight coma 6 mediate coma 7 deep coma 8 delirium Cooperation 1Yes 2 No Gait 1 normal 2 abnormal Division Ward Bed Case No V Skin and mucosa Color 1 normal 2 pale 3 redness 4 cyanosis 5 jaundice 6 pigmentation Skin eruption 1 No 2 Yes type distribution Subcutaneous bleeding 1 no 2 yes type distribution Edema 1 no 2 yes location and degree Hair 1 normal 2 abnormal details Temperature and moisture 1 normal 2 cold 3 warm 4 dry 5 moist dehydration Liver palmar 1 no 2 yes Spider angioma location Others Lymph nodes enlargement of superficial lymph node 1 no 2 yes Description Head Skull size 1 normal 2 abnormal description Skull shape 1 normal 2 abnormal description Hair distribution 1 normal 2 abnormal description Others Eye exophthalmos eyelid conjunctiva sclera Cornea Pupil 1 equally round and in size 2 unequal R mm L mm Pupil reflex 1 normal 2 delayed R s L s 3 absent R L others Ear Auricle 1 normal 2 desformation description Discharge of external auditory canal 1 no 2 yes 1 left 2 right quality Mastoid tenderness 1 no 2 yes 1 left 2 right quality Disturbance of auditory acuity 1 no 2 yes 1 left 2 right description Nose Flaring of alae nasi 1 no 2 yes Discharge 1 no 2 yes quality Tenderness over paranasal sinuses 1 no 2 yes location Mouth Lip Mucosa Tongue Teeth 1 normal 2 Agomphiasis 3 Eurodontia 4 others Gum 1 normal 2 abnormal Description Tonsil Pharynx Sound 1 normal 2 hoarseness 3 others Neck Neck rigidity 1 no 2 yes distance between jaw and sternum transvers fingers Carotid artery 1 normal pulsation 2 increased pulsation 3 marked distention Trachea location 1 middle 2 deviation 1 leftward 2 rightward Hepatojugular vein reflux 1 negative 2 positive Thyroid 1 normal 2 enlarged 3 bruit 1 no 2 yes Division Ward Bed Case No VI Chest Chest wall 1 normal 2 barrel chest 3 prominence or retraction left right Precordial prominence Percussion pain over sternum 1 No 2 Yes Breast 1 Normal 2 abnormal Lung Inspection respiratory movement 1 normal 2 abnormal Palpation vocal tactile fremitus 1 normal 2 abnormal pleural rubbing sensation 1 no 2 yes Subcutaneous crepitus sensation 1 no 2 yes Percussion 1 resonance 2 Hyperresonance location 3 Flatness location 4 dullness location 5 tympany location lower border of lung detailed percussion in respiratory disease midclavicular line R intercostae L intercostae midaxillary line R intercostae L intercostae scapular line R intercostae L intercostae movement of lower borders R cmL cm Auscultation Breathing sound 1 normal 2 abnormal Rales 1 no 2 yes Heart Inspection Apical pulsation 1 normal 2 unseen 3 increase 4 diffuse Subxiphoid pulsation 1 no 2 yes Location of apex beat 1 normal 2 shift intercosta distance away from left MCL cm Palpation Apical pulsation 1 normal 2 lifting apex impulse 3 negative pulsation Thrill 1 no 2 yes location phase Percussion relative dullness border 1 normal 2 abnormal Right cm Anterior midlineLeft cm II III IV V Distance between Anterior Medline and left MCL cm Auscultation Heart rate bpm Rhythm 1 regular 2 irregular Heart sound 1 normal 2 abnormal Extra sound 1 no 2 S3 3 S4 4 opening snap P2 A2 Pericardial friction sound 1 no 2 yes Murmur 1 no 2 yes location phase quality intensity transmission Division Ward Bed Case No VII effects of position effects of respiration Peripheral vascular signs 1 None 2 paradoxical pulse 3 pulsus alternans 4 Water hammer pulse 5 capillary pulsation 6 pulse deficit 7 Pistol shot sound 8 Duroziez sign Abdomen Inspection Shape 1 normal 2 protuberance 3 scaphoid 4 frog belly Gastric pattern 1 no 2 yes Intestinal pattern 1 no 2 yes Abdominal vein varicosis 1 no 2 yes direction Operation scar1 no 2 yes Palpation 1 soft 2 tensive location Tenderness 1 no 2 yes location Rebound tenderness 1 no 2 yes location Fluctuation 1 present 2 abscent Succussion splash 1 negative 2 positive Liver Gallbladder Murphy sign Spleen Kidneys Abdominal mass Others Percussion Liver dullness border 1 normal 2 decreased 3 absent Upper hepatic border Right Midclavicular Line Intercosta Shift dullness 1 negative 2 positive Ascites degree Pain on percussion in costovertebral area 1 negative 2 positve Aus