英文病历模版

1、Division: _ Ward: _ Bed: _ Case No. _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.good2.mo

2、derate3.poorDisease history:(if any, please write down the date of onset, brief diagnostic and therapeutic course, and the results.)I3.urinary frequency 4.urinary urgency 5.dysuria6.oliguria 7.polyuria 8.retention of urine 9.incontinence of urine10.hematuria 11.Pyuria 12.nocturia 13.puffy face_Hemat

3、opoietic system:1.None2.Fatigue 3.dizziness 4.gingival hemorrhage 5.epistaxis6.subcutaneous hemorrhage_Division: _ Ward: _ Bed: _ Case No. _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.None2.P

4、alpitation3.exertional dyspnea 4.cyanosis5.hemoptysis6.Edema of lower extremities 7.chest pain 8.syncope 9.hypertension_Digestive system:1.None2.Anorexia3.dysphagia4.sour regurgitation5.eructation6.nausea 7.Emesis8.melena9.abdominal pain 10.diarrhea11.hematemesis 12.Hematochezia 13.jaundice_Urinary

5、system:1.None2.Lumbar painMetabolic and endocrine system:1.None2.Bulimia3.anorexia4.hot intolerance5.cold intolerance6.hyperhidrosis7.Polydipsia8.amenorrhea9.tremor of hands10.character change11.Marked obesity12.marked emaciation13.hirsutism14.alopecia15.Hyperpigmentation16.sexual function change_Ne

6、urological system:1.None2.Dizziness3.headache 4.paresthesia 5.hypomnesis6. Visual disturbance7.Insomnia8.somnolence9.syncope10.convulsion11.Disturbance of consciousness12.paralysis13.vertigo_Reproductive system:1.None2.others_Musculoskeletal system:1.None2.Migrating arthralgia3.arthralgia4.artrcocel

7、e5.arthremia6.Dysarthrosis7.myalgia8.muscular atrophy_Infectious Disease:II2.Yes (Time:_)3.Ingredient transfusion)Division: _ Ward: _ Bed: _ Case No. _1.None2.Typhoid fever3.Dysentery4.Malaria 4.Schistosomiasis4.Leptospirosis7.Tuberculosis8.Epidemic hemorrhagic fever9.others_Vaccine inoculation:1.No

8、ne2.Yes3.Not clearVaccine detail _Trauma and/or operation history:Operations:1.None2.YesOperation details:_Traumas:1.None2.YesTrauma details:_Blood transfusion history:1.None2.Yes ( 1.Whole blood 2.PlasmaBlood type:_ Transfusion time:_Transfusion reaction1.None2.YesClinic manifestation:_Allergic his

9、tory:1.None2.Yes3.Not clearallergen:_clinical manifestation:_Personal history:Custom living address:_Resident history in endemic disease area:_Smoking:1.No2.YesAverage _pieces per day; about_yearsGiving-up 1.NoDrinking:1.No2.YesAverage _grams per day; about _yearsGiving-up 1.No2.Yes(Time:_)Drug abus

10、e:1.No 2.YesDrug names:_Marital and obstetrical history:Married age:_years oldPregnancy_timesLabor _timesIIIDivision: _ Ward: _ Bed: _ Case No. _(1.Natural labor: _times2.Operative labor: _times3.Natural abortion: _times4.Artificial abortion: _times5.Premature labor:_times 6.stillbirth_times)Health

11、status of the Mate:1.Well2.Not fineDetails: _Menstrual history:Menarchal age:_Duration_dayInterval_daysLast menstrual period:_Menopausal age:_years oldAmount of flow:1.small2. moderate3. largeDysmenorrheal:1. presence 2.absence Menstrual irregularity1. No 2.YesFamily history:(especially pay attentio

12、n to the infectious and hereditary diseaserelated to the present illness)Father: 1.healthy2.ill:_3.deceased cause: _Mother:1.healthy2.ill:_3.deceased cause: _Others:_The anterior statement was agreed by the informant.Signature of informant:Datetime:PhysicalExaminationVital signs:Temperature:_ 0CBloo

13、d pressure:_/_mmHgPulse: _ bpm (1.regular2.irregular_)Respiration:_bpm (1.regular 2.irregular_)General conditions:Development:1.Normal2.Hypoplasia3.HyperplasiaNutrition: 1.good2.moderate3.poor4.cachexiaFacial expression:1.normal 2.acute 3.chronic other_Habitus:1.asthenic type 2.sthenic type3.ortho-t

14、henic typePosition:1.active 2.positive pulsive 4.other_Consciousness:1.clear2.somnolence3.confusion4.stupor 5.slight coma6.mediate coma7.deep coma 8.deliriumCooperation:1Yes2.NoGait:1.normal 2.abnormal_Skin and mucosa:Color:1.normal 2.pale 3.redness 4.cyanosis 5.jaundice 6.pigmentationIVDivision: _

15、Ward: _ Bed: _ Case No. _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:normalcoldwarmdrymoistdehydrationLiver palmar :1.no2.yesSpider angioma

16、(location:_)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:_sclera

17、:_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.r

18、ight 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. Eurodontia4.others:_Gum :

19、1.normal 2.abnormal (Description_)Tonsil:_Pharynx:_Sound: 1.normal 2.hoarseness 3.others:_Neck:Neck rigidity1.no 2.yes (_transvers fingers)Carotid artery:1.normal pulsation2.increased pulsation 3.marked distentionTrachea location:1.middle2.deviation (1.leftward_2.rightward_)Hepatojugular vein reflux

20、:1. negative 2.positiveThyroid:1.normal 2.enlarged _ 3.bruit (1.no 2.yes _)Chest:VDivision: _ Ward: _ Bed: _ Case No. _Chest wall:1.normal 2.barrel chest 3.prominence or retraction:( left_right_Precordial prominence_)Percussion pain over sternum1.No 2.YesBreast:1.Normal 2.abnormal _Lung: Inspection:

21、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 bor

22、der of lung: (detailed percussion in respiratory disease)midclavicular line : R:_intercostaeL:_intercostaemidaxillary line:R:_intercostaeL:_intercostaescapularline:R:_intercostaeL:_intercostaemovement of lower borders:R:_cmL:_cmAuscultation:Breathing sound : 1.normal 2.abnormal _Rales:1.no 2.yes_Hea

23、rt: Inspection:Apical pulsation: 1.normal 2.unseen 3.increase 4.diffuseSubxiphoid pulsation: 1.no2.yesLocation of apex beat: 1.normal2.shift (_ intercosta,distance away from left MCL_cm)Palpation:Apical pulsation:1.normal 2.lifting apex impulse 3.negativepulsationThrill:1.no 2.yes(location:_ phase:_

24、)Percussion:relative dullness border: 1.normal 2.abnormalRight(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.no2.S 33.S 44. opening snapP2_ A 2_Pericardi

25、al friction sound:1.no 2.yesMurmur: 1.no 2.yes (location_phase_quality_intensity_ transmission_effects of position_effects of respiration_Peripheral vascular signs:VIDivision: _ Ward: _ Bed: _ Case No. _1.None2.paradoxical pulse3.pulsus alternans 4. Water hammer pulse5.capillary pulsation6.pulse def

26、icit7.Pistol shot sound8.Duroziez signAbdomen:Inspection:Shape: 1.normal 2.protuberance 3.scaphoid4.frog-bellyGastric pattern 1.no 2.yesIntestinal pattern 1.no 2.yesAbdominal vein varicosis 1.no 2.yes(direction:_ )Operation scar1.no 2.yes _Palpation:1.soft2. tensive (location:_)Tenderness: 1.no 2.yes(location:_)Rebound tenderness:1.no 2.yes(location:_)Fluctuation:1.present2.abscentSuccussion splash: 1.negative2.positiveLiver:_Gallbladder: _Murphy sign:_Spleen:_Kidneys:_Abdominal mass:_Others:_Percussion:L