英文病历范文.docx

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1、英文病历范文Name(姓名):zhangsanOccupation(职业):teacher(教师)Gender(性别):female(女)Address(通讯地址):No167,BeilishiRoad,Beijing(mou路167号)ge(年龄):30yearsold(30岁)Timeadmission(入院日期):2014-2-1417:00Nationality(民族):Han(汉)Timerecording(病史采集日期):2014-2-1417:00Birthplace(出生地):Beijing(北京)ReIiabiIity(可信度):ReIiabIe(可靠)Maritalstat

2、us(婚姻状况):married(已婚)Historyoffer(病史陈述者):herself(患者本人)Chiefcomplaint(主诉):Palpitationsfortwentyyearsandchills,fever,dyspneaandedemaoftheankleforhalfamonth心悸持续20年,寒战、发热、呼吸困难及踝部水肿15天Presentillness(现病史):Abouttwentyyearsago,thepatientsufferedforthefirsttimefrompalpitationswhichoccurredaftershehaddonevigor

3、ousphysicalexercise,andwhichhavebeengraduallyworseningeversince.Tenyearsago,shebegantoexperiencedyspneawhilegoingupstairsordoingwork;therefore,shehadsoughtmedicaltreatment.cardiacmurmurwassubsequentlydiscoveredandadiagnosisofheartdiseasewasgiven,whichwasnottreated.Nevertheless,shehadbeencapableofdoi

4、nglightworkuntilhalfamonthago,whenshecaughtabadcold,whichwasaccompaniedbychills,coughnon-productiveofsputum.Inthelastfewdays,herconditionhasbeenaggravatedbyepigastricdistention,nausea,vomitingandedemaoftheankles;shewasthusunabletoliesupine.Palpitationsanddyspneawerefurtheraggravatedatthesametime.For

5、thisreason,shehadtocometothehospitalfortreatment.患者于20年前因剧烈运动开始出现从心悸症状,并逐渐恶化。于10年前开始出现上楼后及劳累后发作性呼吸困难,因此求医,遂查出心脏杂音,诊断为冠心病心脏病,未做治疗。此后仍可从事轻体力活动。15天前患重感冒,伴寒战、咳嗽无痰。近几日病情加重,出现脱腹胀满、恶心、呕吐和脚踝水肿,不能平卧,心悸和呼吸困难进一步加剧,为求诊治来我院就诊。Inthecourseofherillness,shehashadanorexiaandoliguriawithoutabnormalbowelmotions;shehasn

6、ottakendigoxinoritsequivalent;andshehasnotsufferedfromparoxysmalnocturnalasthma.发病以来,患者食欲下降、少尿,大便通畅。无地高辛类药物服用史。不伴阵发性夜间哮喘。Pasthistory(既往史):Priormajorillnessandinjuries:shehasoftenhadIaryngalgiaandArthralgiasinceherchildhood.疾病和外伤史:自幼年经常喉痛和关节痛。Prioroperations(手术史):Noprioroperations(无手术史)。Priorhospital

7、izations(住院史):Nopriorhospitalizations(无住院史)。Allergies(过敏史):Nofood,medications,chemicalsallergy(无食物、药物及化学品过敏史)。AgeappropriateimmunizationStatUS(免疫接种史):Unknown(不详)。Reviewofsystems(系统回顾):Respiratorysystem:Deniedhemoptysis,asthma,bronchitis,orthopnea,emphysema.呼吸系统:无咯血、哮喘、支气管炎、端坐呼吸和肺气肿。Cardiovascularsys

8、tem:Deniedparoxysmalnocturnaldyspnea,orthopnea,edema,butchestpain,palpitations.心血管系统:无夜间阵发性呼吸困难、端坐呼吸、水肿,有胸痛、心悸。Gastrointestinalsystem:Deniedrectalbleeding,vomitingblood,blacktarrystools,abdominalpain,jaundice,hepatitis,diarrhea,changeinbowelhabits,constipation.消化系统:无直肠出血、吐血、柏油样便、腹痛、黄疸、肝炎、腹泻、排便习惯改变、便

9、秘。Urinarysystem:Deniedpolyuria,dysuria,hematuria,incontinence,urinaryinfections,stones.泌尿系统:无多尿、排尿困难、血尿、尿失禁、尿路感染、尿结石。Hematologicsystem:Deniedanemia,easybruisingorbleeding.血液系统:无贫血、易发瘀斑及出血。Endocrinesystem:Deniedthyroidtrouble,heatorcoldintolerance,excessivesweating,diabetes,excessivethirst,hungerorur

10、ination.内分泌系统:无甲状腺功能异常、恶寒/热、多汗,无糖尿病、口渴、过饥及多尿。Musculoskeletalsystem:Deniedjointpainsorstiffness,arthritis,gout,backpain.Deniedmusclepainsandcramps.肌肉骨骼系统:无关节疼痛或僵硬、关节炎、痛风、背痛。无肌肉疼痛及痉挛。Neurologicalsystem:Deniedseizures,paralysis,localweakness,numbness,tremors,memoryproblems.神经系统:无癫痫发作、肌肉麻痹、局部肢体无力、麻木、震颤及

11、记忆障碍。Personalhistory(个人史):Currentemployment(从事职业):WOrker(工人)Useofdrugs(药物史):Nomedicationsweredailyused(无药物滥用史)Useofalcohol(饮酒史):Nodrinking(无饮酒史)Useoftobacco(吸烟史):Nosmoking(无吸烟史)1.evelofeducation(教育背景):college(本科)Maritalhistory(婚姻史):Shegotmarriedattheageofnineteen.Herhusbandishealthy,andtheirrelation

12、shipisharmony.19岁结婚,配偶身体健康,夫妻关系和谐。MenstrualhistoryandChildbearinghistory(月经史及孕产史):Hermenarchebeganwhenshewasfifteenanditwasregular.Ayearafterhermarriage,shenormallydeliveredababyboy,whoisnowtenyearsoldandhealthy.15岁月经初潮,经期正常。婚后1年内产一男婴,现已10岁,身体健康。Familyhistory(家族史):Healthstatusorcauseofdeathofparents

13、,siblingsandchildren:Allarehealthy.父母、兄弟姐妹和子女健在(或死因无异常)。Specificdiseasesrelatedtoproblemsidentifiedinthechiefcomplaintorhistoryofthepresentillnessand/orsystemreview:None.无与主诉及现病史/系统回顾中相关疾病史(即无心脏病及相关性病史)。Diseasesoffamilymemberswhichmaybehereditaryorplacethepatientatrisk:Nohereditarydiseases.直系家属遗传病史或

14、潜在风险:无家族遗传疾病。Physicalexamination(体格检查)T38P108/minR:24/minBP:12080mmHgNormallydeveloped.Moderatelynourished.Mindclear.Inasemi-sittingposition.Acutelyill-looking,showingdyspnea,slightcyanosisandflushing.Superficiallymphnodesnotpalpable.Nojaundiceonskinorsclera.Pharynxslightlycongested.Necksoftandsuppl

15、e.Tracheainmidline.Nothyroidenlargement,butwithengorgementofjugularveins.Chestnotasymmetrical.Lungsclear.Apexbeatfeltin5thinter-costalspacealongleftmidclavicularline.Heartbeatfluctuatedbetween100/minand108/min,extrasystolesoccurring7-8/min.Arumbling,crescendodiastolicmurmurheardoverapex,ratherlocali

16、zed,andnottransmittedelsewhere.A2equaltoP2.Abdomenflatandsoft.Liverpalpable5cmbelowcostalmarginwithsoftconsistencyandfreefromtenderness.Hepatojugularrefluxpositive.Spleennotfelt.Abdomenfreeofanymassormobiledullness.Notendernessinkidney.Bowelsoundsnotabnormal.Nodeformityofspineorextremities.Markedpittingedemainlowerextremities.Kneejerkspresent.N

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