英文病历模版

1、Name： _ Sex： _ Age: _ Nation： _ Birth Place: _ Marital Status：_Work-organization Occupation: _Living Address & Tel: _Date of admission: _Date of history taken:_ Informant:_Chief Complaint： _History of Present Illness: _Past History：General Health Status： 1。good 2.moderate 3。poorDisease history:

2、（if any, please write down the date of onset， brief diagnostic and therapeutic course, and the results。)Respiratory system：1. None 2。Repeated pharyngeal pain 3。chronic cough 4.expectoration： 5。 Hemoptysis 6.asthma 7。dyspnea 8.chest pain_Circulatory system:1。None 2.Palpitation 3.exertional dyspnea 4。

3、.cyanosis 5。hemoptysis 6。Edema of lower extremities 7.chest pain 8。syncope 9。hypertension _Digestive system: 1。None 2。Anorexia 3。dysphagia 4.sour regurgitation 5。eructation 6。nausea 7。Emesis 8.melena 9.abdominal pain 10.diarrhea 11。hematemesis 12.Hematochezia 13。jaundice _Urinary system： 1。None 2.Lu

4、mbar pain 3.urinary frequency 4。urinary urgency 5。dysuria 6。oliguria 7。polyuria 8。retention of urine 9。incontinence of urine 10。hematuria 11.Pyuria 12。nocturia 13.puffy face _Hematopoietic system： 1。None 2.Fatigue 3。dizziness 4.gingival hemorrhage 5.epistaxis 6.subcutaneous hemorrhage _Metabolic and

5、 endocrine system: 1.None 2。Bulimia 3。anorexia 4.hot intolerance 5。cold intolerance 6。hyperhidrosis 7.Polydipsia 8.amenorrhea 9。tremor of hands 10。character change 11.Marked obesity 12.marked emaciation 13。hirsutism 14.alopecia 15。Hyperpigmentation 16.sexual function change_Neurological system：1。Non

6、e 2.Dizziness 3.headache 4.paresthesia 5。hypomnesis 6. Visual disturbance 7。Insomnia 8。somnolence 9.syncope 10.convulsion 11。Disturbance of consciousness 12.paralysis 13. vertigo _Reproductive system:1。None 2.others_Musculoskeletal system：1.None 2。Migrating arthralgia 3.arthralgia 4.artrcocele 5。art

7、hremia 6.Dysarthrosis 7。myalgia 8.muscular atrophy _Infectious Disease： 1.None 2。Typhoid fever 3。Dysentery 4。Malaria 4.Schistosomiasis 4.Leptospirosis 7。Tuberculosis 8.Epidemic hemorrhagic fever 9.others_Vaccine inoculation：1。None 2。Yes 3。Not clearVaccine detail _Trauma and/or operation history： Ope

8、rations：1.None 2。Yes Operation details：_ Traumas:1。None 2。Yes Trauma details:_Blood transfusion history：1。None 2.Yes ( 1。Whole blood 2。Plasma 3。Ingredient transfusion） Blood type:_ Transfusion time:_ Transfusion reaction 1.None 2.Yes Clinic manifestation:_Allergic history： 1.None 2.Yes 3.Not clearal

9、lergen：_clinical manifestation:_Personal history：Custom living address:_Resident history in endemic disease area:_Smoking: 1。No 2.Yes Average _pieces per day； about_years Giving-up 1。No 2.Yes (Time:_)Drinking: 1.No 2。YesAverage _grams per day； about _years Giving-up 1。No 2。Yes(Time：_）Drug abuse：1。No

10、 2。Yes Drug names：_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 fi

11、ne Details： _Menstrual history：Menarchal age: _ Duration _day Interval _daysLast menstrual period： _ Menopausal age: _years oldAmount of flow： 1。small 2. moderate 3。 large Dysmenorrheal： 1。 presence 2。absence Menstrual irregularity 1。 No 2。YesFamily history: (especially pay attention to the infectio

12、us 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 anterior statement was agreed by the informant。 Signature of informant: Datetime： Physical ExaminationVital signs： Temperature:_0C Blood pre

13、ssure：_/_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.cachexiaFacial expression： 1。normal 2.acute 3。chronic other_Habitus: 1。asthenic type 2.sthenic type 3

14、.ortho-thenic typePosition: 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_Skin and mucosa:Color: 1。normal 2。pale 3.redness 4.cyanosis 5.jaundice 6.pigm

15、entationSkin 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: normal cold warm dry moist dehydration Liver palmar ： 1.no 2。yes Spider angioma (loc

16、ation:_） Others： _Lymph nodes: enlargement of superficial lymph node： 1. no 2.yesDescription: _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：_ scl

17、era:_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。l

18、eft 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 Stuffy 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.

19、others：_ Gum :1。normal 2。abnormal （Description_） Tonsil：_Pharynx：_ Sound: 1.normal 2。hoarseness 3.others：_ Neck: Neck rigidity 1.no 2.yes （_transvers fingers)Carotid artery: 1。normal pulsation 2.increased pulsation 3。marked distentionTrachea location: 1。middle 2。deviation (1。leftward_2。rightward_）He

20、patojugular vein reflux: 1. negative 2。positive Thyroid： 1.normal 2.enlarged _ 3。bruit （1.no 2.yes _) 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： res

21、piratory 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：_low

22、er border of lung： （detailed percussion in respiratory disease) midclavicular line ： R:_intercostae L:_intercostaemidaxillary line: R:_intercostae L：_intercostaescapular line： R：_intercostae L:_intercostaemovement of lower borders：R：_cmL:_cm Auscultation： Breathing sound ： 1。normal 2.abnormal _ Rale

23、s：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。

24、no 2。yes（location:_ phase：_） Percussion： relative dullness border: 1。normal 2.abnormal Right（cm)Anterior midlineLeft（cm)IIIIIIVV（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.

25、S4 4。 opening snap P2_ A2_Pericardial friction sound:1。no 2.yes Murmur: 1.no 2.yes （location_phase_ quality_intensity_ transmission_ 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.pul

26、se deficit 7.Pistol shot sound 8。Duroziez signAbdomen： Inspection： Shape： 1。normal 2。protuberance 3.scaphoid 4.frogbelly 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