英文病历模板

1、一.患者，李华，男，69岁，退休教师，因心悸一年，加重5个月于1989年6月6日入院。一年前患者健康。1988年5月感到轻微心悸，在工作劳累，快走及上楼时感气短，傍晚下肢浮肿，休息后则减轻。近5个月来，心悸气短明显加重。以致不能行走，亦不能平卧，不得不坐着度过整夜，有时咳嗽，咳少量白色粘液，无血。患者无寒战、发热、胸痛或关节疼痛，排尿正常。系统复习无特殊，1949年曾患“大叶肺炎”，无药物过敏史。个人史：生在西安，曾去过中国南方，但无疫水接触史，抽烟一天10支，1945年结婚，其妻健康，有一女孩亦健康，其父死于胃癌，其母健在。查体：体温36.8，脉搏90次/分，呼吸28次/分，bp23.5/1

2、3.3kpa，发育良好，营养中等，体胖、半卧位，颜面苍白，全身浮肿，神智清楚，查体合作。皮肤无红斑、黄疸、紫瘢。淋巴结未触及。头部、眼、鼻、耳、口正常，但口唇紫绀。颈软，颈静脉无充盈，甲状腺未触及，无细震颤或搏动，气管正中。胸廓两侧对称，呼吸动度对称，无异常浊音区，但在两肺底部可闻一些湿罗音心尖搏动所见，触诊时在第5肋间，距正中线14cm处，无细震颤，心浊音界如图：心率90次/分，律齐，心尖部可闻级柔和的吹风样收缩期杂音，p2a2，无胸膜磨擦音，腹软，无压痛及反跳痛，肝可触及，在肋下2cm，轻度压痛，脾未触及；无移动性浊音，其他正常。右（cm）左（cm）1.52.02.04.03.08.014

3、.014.0正中线至左锁骨中线距离10cm初步诊断：1.高血压心脏病2.度心衰an example of medical case record in englishpatient li hua,mate,69 years old, a retired teacher, was admitted on june 6,1989,because of palpitation for one year and becoming worse in recent 5 months.the patient was quite well until one year before may,1988, he

4、felt slight palpitation and dyspnia during hard work, fast walk , or climbing stairs, there was swelling of legs in the evening but he felt better after having a rest. in recent 5months, palpitation and dyspnia became so serious that he could neither walk nor lie down.he had to sit up during the who

5、le night, sometimes he coughed with small amounts of sputum, but without blood. he had no chill, fever, chest pain or sore joints. the urinating was normal.there was nothing else abnormal in the case history review except a cured lobor pneumonia in 1949. he had no history of drug allergy.personal hi

6、story：the patient was born in xian in 1923. he had been to the south of china but did not contact contaminated water. he smoked a bout 10 cigarettes daily. he got married in 1945. his wife was healthy .they had a daughter who was also healthy. his father died of stomach cancer.his mather was well.ph

7、ysical examination：t.36.8c, p. 96/min, r. 28/min, bp.23.5/13.3kpa. the patient, an old fatty man who developed well and moderately nourished, was lying in bed with a semifallous position. he looked pale and suffered from general edima. he was mentally normal and cooperative in the examination.there

8、was no eruption, no jaundice, no purpura on the skin, and the lymphnodes were not palpable. the head, eyes, nose, ears, mouth were normal while the lips were cyanotic. the neck was soft, there was no venous engorgement. thyroid glands were not palpable, there were no thrill or brunt. the trachea was

9、 in midline. the chest and respiratory movements were symmetrical. there was no abnormal dullness but some moist rales were heard in the base areas of the both lungs. the points of maximal impulse (pmi) were not visible but palpable in the 6thcostal interspace, 14cm form the middle line, there was n

10、o thrill. the cardiac dullness, 14cm from the middle line, there was no thrill. the cardiac dullness were as follows;right （cm）interspacesleft (cm)1.52.02.04.03.08.010.014.0the distance from midsternal line to midclavicular line was 10cm. the heart rate was 96/min, regular. there was a grade soft bl

11、owinglike systolic murmurat the apex,p2a2, but no pericardium friction sound was heard. abdominal wall was soft without tenderness. the liver was palpable 2cm below the costal margin with slight tenderness. the spleen was not palpable and there was no shifting dull ness. the rest was normal.impressi

12、on：disease withdegree heart failuresignature 二. medical record of copd name：liang ya jun occupation: driver sex： male date of admission: jan ,17,2007 age: 70 years old date of record: jan,17,2007 nationality: han narrator of history: himself birth place: beijing level of history: reliable chief comp

13、laint: cough with productive of sputum for 30 years, wheeze for 10 years, and got worse for 3 days. history of present illness: 30 years ago after exposure to cold weather, the patient suffered from a cough, with purulent sputum, without fever、fatigue、night sweats、hemoptysis. with the anti-infection

14、 therapy, he was cured. since then he was often recurrent 2-3 times every year after catching a cold or having pulmonary infection. 20 years ago, he was diagnosed the chronic bronchitis, and he had to be admitted 1-2 times 1 year for the therapy. 10 years ago, he felt shortness of breath, particular

15、ly after sports ,and 5 years ago, he began edema in his legs and feet. 3 days ago, he felt worse without any reson. he coughed all night, couldnt lie down during sleep, sometimes with dyspnea. the sputa was sticky and purulent. but no fever. he took the oral ampicillin and aminophylline by himself ,

16、but they didnt work. then he came to emergency department of tiantan hospital. the results of blood routine was: wbc:12500/mm3, n:82.3%. the x-ray of lung: the veins of 2 pumonarys are coarse and irregular, right-lower pulmonary arterial trunk 15mmhg, cardiac apex being globular appearance and more

17、elevated and emphysema. he was given some drugs of anti-infection, but the effect is not good. to be well treated, he was incharged of acute episode of copd.these days, he felt weakness, poor of appetite, the urine and stool are normal, his weight did not change. past history:he has had hypertension

18、 for 30 years, dm for 4-5 years . 1986: myocardial infarction, full recovery / no subsequent investigation. social history: smoking for 50 years ,the amount is about half a cigarette case per day. never drink. born and lives in beijing, never been to area of pestilence. married for 45 years with 2 c

19、hildren and both of them are healthy. family history: no family history of chronic disease and genetic disease. review of systems respiratory system: same as the history of present illness. gastrointestinal tract: no current indigestion. no vomiting/ dysphagia/ diarrhea/ constipation/ abdominal pain

20、. cardiovascular system: no current chest pain. no palpitation/loss of consciousness.genitourinary system: no urinary systems. nervous system: no headache/ syncope/ vertigo/ balance problem. no dizziness/ limb weakness/ sensory loss. no disturbance of vision/ hearing/ smell/ speech. musculoskeletal

21、system: no joint pain/ stiffness/ extremity pain/ decreased range of motion. no disability. allergies history: penicillin-skin rash physical examinationt: 37.2 r: 24bpm p: 101bpm bp: 110/60mmhg general: well. no anemic looking. consciousness is clear. his action is free . skin: no petechiae, purpura

22、, anlcteric. no cutaneas lesions or rashes. his feet is degree edema . nodes: surface nodes unpalpable. eyes: conjunctive normal.no icterus, hemorrhage. lids without lesions. pupils equal, round and react to light and accommodation. neck: supple, trachea midline. thyroid not enlarged and without nod

23、ules. jugular veins flat. venous pulses normal. chest: tubbish chest contour. no catfale, pain. lungs: inspection:respiration equal,24bpm,rhythm regular. palpation:with symmetrical full expansion.no thrills. percussion:no percussion dullness. auscultation: coarse. sometimes there are moist and dry r

24、ales in both lungs. there is no sounds of pleural friction. heart: inspection: no visible lifts. palpation:rate:101bpm. rhythm is regular. no lifts thrills,heaves. percussion: heart border normal as follows: right(cm) rib left(cm) 2 2 2 4.5 3 6 8 mcl=8cm auscultation: rate:101bpm,rhythm is irregular

25、, p 2 a 2. no splitting of heart sound.no cardiac murmurs or pericardial sound. abdomen: inspection:no scars or visible masses.venous pattern normal. palpation: soft, no pain, mass, thill or fluid wave. liver and spleen not palpable. percussion:liver sonant normal. auscultation:bowel sound 3bpm.no b

26、ruit. nerve: higher function normal. cranial nerves-: normal. upper and lower limbs: power, tone, coordination, sensation all normal. laboratory and diagnostic tests blood routing: wbc 12500/mm3, n 82.2%. arterial blood-gas : ph 7.35 po2 58mmhg pco2 70mmhg be 5mmol/l. x-ray: the veins of 2 pumonarys

27、 are coarse and irregular, right-lower pulmonary arterial trunk 15mmhg, cardiac apex being globular appearance and more elevated and emphysema. summary 70-year-old male smoker with a family history and previous history of chronic bronchitis, presents with 20-year history of cough, sputum, wheeze and

28、 got worse for 3-day, which is unrelieved by ampicillin and aminophylline. on examination, there are moist and dry rales in both lungs. blood routing: wbc 12500/mm3, n 82.2%. x-ray: the veins of 2 pumonarys are coarse and irregular, right-lower pulmonary arterial trunk 15mmhg, cardiac apex being glo

29、bular appearance and more elevated and emphysema.the most likely diagnosis is an acute episode of copd(chronic obstructive pulmonary disease). diagnosis: acute episode stage of copd(chronic obstructive pulmonary disease) chronic bronchitis obstructive emphysema chronic pulmonary heart disease decomp

30、ensation stage of cardiac and lung functions type 2 respiratory failure coronary heart disease old myocardial infarction sinus heart rate heart border normal cardiac function 2 classic hypertension 3 classic 2 type diabetes mellitus 三name: liu side age: eightysex: malerace: hannationality: chinaaddr

31、ess: no.35, dandong road, jiefang rvenue, hankou, hubei. tel: 857307523occupation: retiredmarital status: marrieddate of admission: aug 6th, 2001date of record: 11am, aug 6th, 2001complainer of history: patients son and wifereliability: reliablechief complaint: upper bellyache ten days, haematemesis

32、, hemafecia and unconsciousness for four hours.present illness: the patient felt upper bellyache about ten days ago. he didnt pay attention to it and thought he had ate something wrong. at 6 oclock this morning he fainted and rejected lots of blood and gore. then hemafecia began. his family sent him

33、 to our hospital and received emergent treatment. so the patient was accepted because of “upper gastrointestine hemorrhage and exsanguine shock”.since the disease coming on, the patient didnt urinate. past historythe patient is healthy before.no history of infective diseases. no allergy history of f

34、ood and drugs. past historyoperative history: never undergoing any operation.infectious history: no history of severe infectious disease.allergic history: he was not allergic to penicillin or sulfamide.respiratory system: no history of respiratory disease. circulatory system: no history of precordia

35、l pain.alimentary system: no history of regurgitation.genitourinary system: no history of genitourinary disease.hematopoietic system: no history of anemia and mucocutaneous bleeding.endocrine system: no acromegaly. no excessive sweats. kinetic system: no history of confinement of limbs.neural system

36、: no history of headache or dizziness.personal historyhe was born in wuhan on nov 19th, 1921 and almost always lived in wuhan. his living conditions were good. no bad personal habits and customs.menstrual history: he is a male patient.obstetrical history: nocontraceptive history: not clear.family hi

37、story: his parents have both deads.physical examinationt 36.5, p 130/min, r 23/min, bp 100/60mmhg. he is well developed and moderately nourished. active position. his consciousness was not clear. his face was cadaverous and the skin was not stained yellow. no cyanosis. no pigmentation. no skin erupt

38、ion. spider angioma was not seen. no pitting edema. superficial lymph nodes were not found enlarged.headcranium: hair was black and white, well distributed. no deformities. no scars. no masses. no tenderness.ear: bilateral auricles were symmetric and of no masses. no discharges were found in externa

39、l auditory canals. no tenderness in mastoid area. auditory acuity was normal.nose: no abnormal discharges were found in vetibulum nasi. septum nasi was in midline. no nares flaring. no tenderness in nasal sinuses.eye: bilateral eyelids were not swelling. no ptosis. no entropion. conjunctiva was not

40、congestive. sclera was anicteric. eyeballs were not projected or depressed. movement was normal. bilateral pupils were round and equal in size. direct and indirect pupillary reactions to light were existent.mouth: oral mucous membrane was not smooth, and there were ulcer can be seen. tongue was in m

41、idline. pharynx was congestive. tonsils were not enlarged. neck: symmetric and of no deformities. no masses. thyroid was not enlarged. trachea was in midline.chestchestwall: veins could not be seen easily. no subcutaneous emphysema. intercostal space was neither narrowed nor widened. no tenderness.t

42、horax: symmetric bilaterally. no deformities.breast: symmetric bilaterally.lungs: respiratory movement was bilaterally symmetric with the frequency of 23/min. thoracic expansion and tactile fremitus were symmetric bilaterally. no pleural friction fremitus. resonance was heard during percussion. no a

43、bnormal breath sound was heard. no wheezes. no rales.heart: no bulge and no abnormal impulse or thrills in precordial area. the point of maximum impulse was in 5th left intercostal space inside of the mid clavicular line and not diffuse. no pericardial friction sound. border of the heart was normal.

44、 heart sounds were strong and no splitting. rate 150/min. cardiac rhythm was not regular. no pathological murmurs.abdomen: flat and soft. no bulge or depression. no abdominal wall varicosis. gastralintestinal type or peristalses were not seen. tenderness was obvious around the navel and in upper abd

45、oman. there was not rebound tenderness on abdomen or renal region. liver and spleen was untouched. no masses. fluidthrill negative. shifting dullness negative. borhorygmus not heard. no vascular murmurs.extremities: no articular swelling. free movements of all limbs.neural system: physiological refl

46、exes were existent without any pathological ones.genitourinary system: not examed.rectum: not exanedinvestigationblood-rt: hb 69g/l rbc 2.70t/l wbc 1. 1g/l plt 120g/lhistory summary1. patient was male, 80 years old2. upper bellyache ten days, haematemesis, hemafecia and unconsciousness for four hour

47、s. 3. no special past history.4. physical examination: t 37.5, p 130/min, r 23/min, bp 100/60mmhg superficial lymph nodes were not found enlarged. no abdominal wall varicosis. gastralintestinal type or peristalses were not seen. tenderness was obvious around the navel and in upper abdoman. there was

48、 not rebound tenderness on abdomen or renal region. liver and spleen was untouched. no masses. fluidthrill negative. shifting dullness negative. borhorygmus not heard. no vascular murmurs. no other positive signs.5. investigation information: blood-rt: hb 69g/l rbc 2.80t/l wbc 1.1g/l plt 120g/l impr

49、ession: upper gastrointestine hemorrhage exsanguine shock四患者，李华，男，69岁，退休教师，因心悸一年，加重5个月于1989年6月6日入院。一年前患者健康。1988年5月感到轻微心悸，在工作劳累，快走及上楼时感气短，傍晚下肢浮肿，休息后则减轻。近5个月来，心悸气短明显加重。以致不能行走，亦不能平卧，不得不坐着度过整夜，有时咳嗽，咳少量白色粘液，无血。患者无寒战、发热、胸痛或关节疼痛，排尿正常。系统复习无特殊，1949年曾患“大叶肺炎”，无药物过敏史。个人史：生在西安，曾去过中国南方，但无疫水接触史，抽烟一天10支，1945年结婚，其妻健

50、康，有一女孩亦健康，其父死于胃癌，其母健在。查体：体温36.8，脉搏90次/分，呼吸28次/分，bp23.5/13.3kpa，发育良好，营养中等，体胖、半卧位，颜面苍白，全身浮肿，神智清楚，查体合作。皮肤无红斑、黄疸、紫瘢。淋巴结未触及。头部、眼、鼻、耳、口正常，但口唇紫绀。颈软，颈静脉无充盈，甲状腺未触及，无细震颤或搏动，气管正中。胸廓两侧对称，呼吸动度对称，无异常浊音区，但在两肺底部可闻一些湿罗音。心尖搏动所见，触诊时在第5肋间，距正中线14cm处，无细震颤，心浊音界如图：心率90次/分，律齐，心尖部可闻级柔和的吹风样收缩期杂音，p2a2，无胸膜磨擦音，腹软，无压痛及反跳痛，肝可触及，在肋

51、下2cm，轻度压痛，脾未触及；无移动性浊音，其他正常。右（cm）左（cm）1.52.02.04.03.08.014.014.0正中线至左锁骨中线距离10cm初步诊断：1.高血压心脏病2.度心衰an example of medical case record in englishpatient li hua,mate,69 years old, a retired teacher, was admitted on june 6,1989,because of palpitation for one year and becoming worse in recent 5 months.the p

52、atient was quite well until one year before may,1988, he felt slight palpitation and dyspnia during hard work, fast walk , or climbing stairs, there was swelling of legs in the evening but he felt better after having a rest. in recent 5months, palpitation and dyspnia became so serious that he could

53、neither walk nor lie down.he had to sit up during the whole night, sometimes he coughed with small amounts of sputum, but without blood. he had no chill, fever, chest pain or sore joints. the urinating was normal.there was nothing else abnormal in the case history review except a cured lobor pneumonia in 1949. he had no history of drug allergy.personal history：the patient was born in xian in 1923. he had been to the s