{J}英文病历模版507

1、英文病历模版Name:Sex:Age:Nation:Birth Place:Marital Status:Work-orga nizatio n & Occupatio n:Livi ng Address & Tel:. Date of admission:Date of history taken:Informant:.Chief Complaint:.History ofPresentIllness:Past History:General Health Status:1good2.moderate3.poorDisease history(f any, please write dow

2、n the date of on set, brief diag no stic and therapeuticcourse, and the results.)Respiratory system:1. None 2.Repeatedpharyngealpain 3.chronic cough 4.expectoratio-n:5. Hemoptysis 6.asthma 7.dyspnea 8.chest painCirculatory system:1.N one2.Palpitatio n 3.exerti onal dysp nea 4.cya no sis 5.hemoptysis

3、英文病历模版6. Edema of lower extremities 7.chest pain 8.syncope 9.hypertensio.nDigestive system:1.None 2.Anorexia 3.dysphagia 4.sour regurgitation 5.eructation 6.nausea7. Emesis 8.melena 9.abdominal pain 10.diarrhea 11.hematemesis 12.Hematochezia13.jaundice .Urinary system:1.None 2.Lumbar pain 3.urinary

4、frequency 4.urinary urgency 5.dysuria 6.oliguria 7.polyuria8. 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 hemorrha. geMetabolic and endocrine system:1.N

5、one 2.Bulimia 3.anorexia 4.hot intolerance 5.coldintolerance .6.hyperhidrosis7.Polydipsia 8.amenorrhea9. tremor of hands 10.characterchange 11.Marked obesity 12.marked emaciation13.hirsutism14.alopecia.15.Hyperpigmentation 16.sexual function changeNeurological system:1.None 2.Dizziness 3.headache 4.

6、paresthesia 5.hypomnesis 6.Visual disturbance7.Insomnia 8.somnolence 9.syncope 10.convulsion 11.Disturbance of consciousness 12.paralysis 13. vertigo .Reproductive system:1.None 2.othersMusculoskeletal system:1.None 2.Migrating arthralgia 3.arthralgia 4.artrcocele 5.arthremia .6.Dysarthrosis 7.myalg

7、ia 8.muscular atrophyInfectious 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.Yes3.Not clearVaccine detail . _Trauma and/or operation history: Operations:1.None 2.YesOperation d

8、etails:. _Traumas:英文病历模版1.None 2.YesTrauma details:. _Blood transfusion history:1.None 2.Yes ( 1.Whole blood 2.Plasma 3.Ingredient transfusion). Blood type: Transfusion time:.Transfusion reaction1.None 2.Yes Clinic manifestation:Allergic history:1.None 2.Yes 3.Not clear allergen:. _clinical manifest

9、ation:._Personal history:Custom living address_:. _Resident history in endemic disease are_a_:._Smoking:1.No 2.YesAverage _pieces per day; about_yearsGiving-up 1.No 2.Yes (Time:. )Drinking: 1.No 2.YesAverage _grams per day; about _yearsGiving-up 1.No 2.Yes(Time:. )Drug abuse:1.No 2.YesDrug names:Mar

10、ital and obstetrical history:Married age: years old Pregnancytimes .Labor times(1.Natural labor: times 2.Operative labor: times.3. Natural abortion:times4.Artificial abortion:times .5.Premature labor:times 6.stillbirthtimes. )Health status of the Mate:1.Well 2.Not fineDetails:. _Menstrual history:Me

11、narchal age:DurationdayInterval days.Last menstrual period:Menopausal age:years old.Amount of flow:1.small 2. moderate3. largeDysmenorrheal:1. presence 2.absencMeenstrual irregularity 1. No 2.Yes.Family history:(especially pay attention to the infectious and hereditary disease related to the present

12、 illness).Father: 1.healthy 2.ill:3.deceased cause: . _Mother :1.healthy 2.ill: 3.deceased cause: ._英文病历模版Others:.The an terior stateme nt was agreed by the in formant.Sig nature of in forma nt:Datetime:Physical ExaminationVital signs:mmHg .)Temperature:CBlood pressure:丿Pulse：bpm (.regular 2.irregul

13、arRespiration:bpm (.regular 2.irregularGeneral conditions:Developmentl.Normal 2.Hypoplasia 3.HyperplasiaNutrition: l.good 2.moderate 3.poor 4.cachexiaFacial expressionl .no rmal 2.acute 3.chr onic other.Habitus: l.asthe nic type2.sthe nic type 3.ortho-the nic typePosition l.active 2.positive pulsive

14、 4.other.Consciousness:clear2.so mnolence 3.c on fusi on 4.stupor 5.slight coma 6.mediate coma7.deep coma 8.deliriumCooperation: 1Yes 2.No Gait:.normal 2.abnormalSkin and mucosa:Color: 1.no rmal 2.pale 3.red ness 4.cya no sis 5.ja un dice 6.pigme ntatio nSkin eruption:1.No 2.Yes(type:distributi on:_

15、)Subcutaneousbleedingi:. no 2.yes (type:distributio n:_)Edema:1. no 2.yes ( locatio n and degree_)Hair: 1.no rmal 2.ab no rmal(details_)Temperature and moisture:no rmal cold warm dry moist dehydrati on Liver palmar : 1.no 2.yesSpider angioma(location:)Others:.Lymph nodesenlargement of superficial ly

16、mph node:1. no 2.yesDescripti on:.Head:Skull sizel. no rmal 2.ab no rmal (descripti on:_)Skull shapel. no rmal 2.ab no rmal(descripti on:_)Hair distribution :1. no rmal 2.ab no rmal(descripti on:_)Others:Eye: exophthalmos:eyelid:conjunctiva:sclera:Cornea:.Pupil: l.equally round and in size 2.un equa

17、l (Rmm Lmm)Pupil reflex: l.normal 2.delayed (Rs Ls ) 3.abse nt (RL)others:英文病历模版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 auditoryacuity:1.no2.ye

18、s(1.left 2.right description:).Nose:Flaring of alae nasi :1.no 2.yesStuffy discharge 1.no 2.yes(quality. )Tenderness over paranasal sinuses:1.no 2.yes (location:._)Mouth: LipMucosaTongue. _Teeth:1.normal 2.Agomphiasis 3.Eurodontia 4.others:.Gum:1.normal2. abnormal(Description)Tonsil:_Pharynx:.Sound:

19、 1.normal 2.hoarseness3.others:. _Neck:Neck rigidity 1.no 2.yes (transvers fingers. )Carotid artery: 1.normal pulsation 2.increased pulsation 3.marked distention.Trachea location:1.middle 2.deviation (1.leftward2.rightward).Hepatojugular vein reflux:1.negative 2.positiveThyroid: 1.normal 2.enlarged

20、3.bruit (1.no 2.yes ._)Chest:Chest wall:1.normal 2.barrel chest 3.prominence or retraction:(leftrightPrecordial prominence. )Percussion pain over sternum1.No 2.YesBreast: 1.Normal 2.abnormal . _Lung:Inspection: respiratory movement 1.normal 2.abnormal. _Palpation: vocal tactile fremitus:1.normal 2.a

21、bnormal pleural rubbing sensation:1.no2.yes._Subcutaneous crepitus sensation:1.no 2.yes. _Percussion:1.resonance 2.Hyperresonance&location3Flatness&location4. dullness& location:5.tympany&location:.lower border of lung: (detailed percussion in respiratory disease.)midclavicular line : R:intercostae

22、L:intercostae.midaxillary line: R:intercostaeL:intercosta.escapular line: R:intercostaeL:intercosta.emovement of lower borders:R:cmL:cm.Auscultation:Breathing sound : 1.normal 2.abnormal . _Rales:1.no 2.yesHeart: Inspection:Apical pulsation: 1.normal 2.unseen 3.increase 4.diffuse Subxiphoid pulsatio

23、n: 1.no 2.yes.Location of apex beat: 1.normal 2.shift ( intercosta,.distance away from left MCLcm)Palpation:英文病历模版Apical pulsation:1. normal 2.lifting apex impulse 3.negative pulsationThrill:1.no 2.yes(location:phase:)-Percussion:elative dull ness border: 1.no rmal 2.ab no rmalRight(cm)An terior mid

24、li neLeft(cm)IIIIIIVV(Dista nee betwee n An terior Medli ne and left MCLcm)Auscultation Heart rate:bpm Rhythm:1.regular 2.irregular -Heart sound: 1.no rmal 2.abnormal.44.ope ning snapP2APericardial frictio n soun d:1. no 2.yesMurmur: 1.no 2.yes (locationphasequalityintensitytran smissi oneffects of

25、position effects ofrespirationPeripheral vascular signs1.N one2.paradoxical pulse 3.pulsus alter nans 4. Water hammer pulse 5.capillarypulsatio n 6.pulse deficit 7.Pistol shot sound 8.Duroziez sig nAbdomen:Inspection: Shape: 1.normal 2.protuberanee 3.scaphoid 4.frog-belly.Gastric pattern 1. no 2.yes

26、In test inal pattern 1. no 2.yesAbdomi nal ve in varicosis 1.no 2.yes(direction:)Operati on scarl. no 2.yes.Palpation:1.soft 2. ten sive(locati on:_)Tendern ess:1. no 2.yes(locati on:_)Rebo und tendern ess:1. no 2.yes(locati on:_)Fluctuati on:l.prese nt2.absce ntSuccussi on splash: 1.n egative2.positiveLiver:.Gallbladder:Murphy sign:Spleen:Kidneys:.Abdomi nal mass:.Others:.PercussionLiver d