应急救援队患者入院记录中英文对照

Name:Department:bednumber:hospitalnumber:Ward:InternationalEmergencyMedicalTeamMedicalrecordsInpatientSheetPersonalInformationNameName:Occupation:GenderGender::ageAge:AddressAddress:MarriageMaritalStatus:Forhistory:Reliability:placeofbirth:Admissiontime:yearmonthdayTimeMinuteNationality:recordtime:yearmonthdayTimeMinuteMedicalHistoryandPhysicalExamChiefComplaint:HistoryofPresentIllness:PastHistoryPastHistory:Generacondition:GoodFairPoorHistoryofthedisease:NoneHaveHistorydiseases:NoneHaveVaccinationhistory:HistoryofTrauma&Surgery:Surgery:OperationnameandtimeTrauma:PleaseindicationthesituationandtimeTransfusionhistory:nobloodtransfusiontimeTransfusionreactionDrugallergyhistory:noallergiesReviewofSystem:Respiratorysystemdyspnea,hemoptysis,chroniccoughandsputum,chestpain,nightsweatsCirculatorysystempalpitations,shortnessofbreath,lowerextremityedema,precordialpain,highbloodpressure,syncopeDigestiveappetiteacidregurgitationbelching,nauseaandvomiting,abdominaldistension,abdominalpainconstipationdiarrheavomitingbloodinthestoolmelenajaundiceGenitourinarysystemlumbagourinaryurgencyanddysuriadysurianocturiahematuriaurineabnormalgenitalitchingandedemagenitalulcersHematopoieticsystemfatiguedizzinesssubcutaneousbleedinggumsbleedingnosebleedingpainEndocrineandmetabolicsystemsbulimia,anorexia,chills,sweating,heatintolerancepolydipsiaandpolyuriatremorhandschangeofcharactersignificantweightlossinobesesignificantlyincreasedhairlossofhairpigmentationchangesinsexualfunctionamenorrheaMusculoskeletalSystemmigratoryarthralgiaswellingofjointsjointsdeformedmusclepainmuscleatrophyNervoussystem,memoryloss,dizziness,headache,dizzinesssyncope,visualdisturbances,insomniaunconsciousnessconvulsionstremorparalysis,paresthesiaPersonalhistory:regularresidenceHistoryofexposuretocontaminatedwaterSmoking:NoYesaverageCigarettes/day,timeYears,quitsmoking:NoItistimeDrinkinghistory:NoYesaverageG(two)/day,timeYears,alcohol:NoTimeMenstrualhistory:Obstetricalhistory:Familyhistory:PhysicalT℃PBeats/minRBeats/minBPmmHgGeneral:Development:NormalPoorExtraordinaryNutrition:GoodMediumbadCachexiaheightcmWeightkgImpression:comfortableOtherCooperation:YesNoambulatory:PositiveForceinabilitysuperpowertypeGait:NormalisnotnormalPosition:automaticposturalpassivepositionMind:clearDrowsinessdrowsinessblurredlightcomamoderatecomadeepcomadeliriumSkinandmucousmembranes:Color:NormalpaleFlushingCyanosisJaundicePigmentationotherRash:NoYesSubcutaneoushemorrhage:NoYesPalmar:NoYesSpider:NoYesotherLymph:superficiallymphnodes:noneHaveHead:HairDistribution:NormalabnormalotherEye:NormalAbnormalPupil:otherlargeandroundrange(leftmmRightmm)lightreflex:NormalabnormalEar:externalauditorycanalabnormalsecretions:NoYesMastoidtenderness:NoneHaveHearingimpairment:NoYesNose:noseflap:noabnormalsecretions:NoYesSinustenderness:NoneHaveOral:Lips:normalabnormalMucosa:NormalAbnormalTongue:normalabnormalGear:normalabnormalGums:normalabnormalTonsil:NormalAbnormalPharynx:NormalAbnormalNeck:stiffneck:NoneHaveMandibularfromsternumcmJugularvein:notrevealfillingengorgementCarotid:pulsenormalpulseincreasedpulseweakenedLiverjugularvenoussign:negativepositiveneckbruit:NoYesTrachea:middledeviation(left/right)Thyroid:normalabnormalChest:thorax:NormaldeformityBreast:NormalAbnormalSternumpercussionpain:NoYesLung:visualexamination:breathingexercises:normalabnormalPalpation:fremitus:NormalAbnormalPleuralfrictionsense:NoYesPercussion:normalabnormalvoicelessAuscultation:breathsounds:normalabnormalRales:NoYesVoiceconduction:normalabnormalPleuralfrictionrub:NoYesHeart:visualexamination:precordialbulge:NoYesApexbeat:normalabnormalApexbeatposition:NormalShift(awayfromthecenterlinewithintheleftsubclaviancmoutercm)Palpation:apexbeat:normalliftingofthenegativepulseTremor:NoYesPericardialfrictionsense:NoYesPercussion:Relativecardiacdullness:normalabnormalrightIntercostalleftIIIIIIVV(Anteriormidlinefromclavicularlinecm)Auscultation:heartrateBeats/minheartrate:neatArrhythmiaAbsolutemissingPrematurebeat:NoneHavePCG:NormalAbnormalMurmur:NoYes(conductionpropertiesofstrengthduringthesitefactors)Pericardialfrictionrub:NoYesAndotherperipheralvascularsign:NoYesAbdomen:visualexamination:Shape:NormalBulgingDepressedSurgicalscar:NoYesPalpation:softwholeabdominalmuscletensionTenderness:NoYesRebound:NoYesAbdominalmass:NoYesLiver:nottouchedtouchedribscmxiphoidcmtexturesurfaceedgetendernessGallbladder:Murphysign:negativepositiveOthersSpleen:untouchedtouchKidneys:notpalpabletouchPercussion:liverdullness:normalabnormalAuscultation:bowelsounds:NormalHyperthyroidismWeakenDisappeargurgling:NoYesAnal:NochecknormalabnormalGenitalia:notexaminednormalabnormalSpine:NormalabnormaldeformityLimbs:NormalabnormalJointswellingJointstiffnessClubbing(toe)OslerknotJanewayknotMuscleatrophyotherNervousSystem:abdominalreflexMuscletensionMuscleBicepsreflexKneetendonreflexesAchillestendonreflexHoffmannlevyBabinskisignKerninglevyotherSpecialistsituationAuxiliaryexaminationImportantoutpatientandhospitalauxiliaryexaminationresults(includinginspectionitems,medicalinstitutions,name,date,result)Medicalsummaryinitialdiagnosis: