呼吸科英文病历范文

呼吸科英文病历范文
ENGLISHCASE700756(Respiratory department)
----------------------------Name: Liyuzhen `Age:42 yearsSex: FemaleRace: HanOccupation: Free occupationNationality: ChinaMarried status: married Addre: Qianjing Road No.16, Wuhan Hankou.
thDate of admiion: July 26, 2001
thDate of record: July 26, 2001
Present illne:
Two days ago the patient suddenly started to cough and feel
Her spirit,sleep,appetite were normal.stool and urine were
normal, too.
----------------------------PastHistory:
General health status: normal
Operation history: thyroidectomy.
Infection history: No history of tuberculosis or hepatitis.Allergic history: allergic to a lot of drugs such as sulfanilamideTraumatic history: No traumatic history
----------------------------Systemreview
Respiratorysystem: No history of repeated pharyngodynia, chroniccough, expectoration, hemoptysis, asthma, dyspneaor chest pain.
Circulation system: No history of palpitation, hemoptysis, legsedema, short breath after sports, hypertension,precordium pain or faintne.
Digestive system: No history of low appetite, sour regurgitation,belching, nausea, vomiting, abdominal distension,abdominal pain, constipation, diarrhea, hemaptysis,melena, hematochezia or jaundice.
Urinary system: No history of lumbago, frequency of urination,urgency of urination, odynuria, dysuria, bloodyurine, polyuria or facial edema
Hematopoietic system: No history of acratia, dizzine, gingival
bleeding, nasal bleeding, subcutaneous bleeding
or ostealgia.
Endocrine system: No history of appetite change, sweating, chilly
exceive thirst, polyuria, hands tremor, character alternation, obesity, emaciation, hair change, pig- mentation or amenorrhea.
Kinetic system: No history of wandering arthritis, joint pain, red swelling of joint, joint deformity, muscle pain
or myophagism.
Neural system: No history of dizzine ,headache, vertigo, in- somnia, disturbance of consciousne, tremor, conv-
ulsion, paralysis or abnormal sensation.--------------------------- Personal History:
She was born in Hubei.She never smokes and
Drinks.No exposurehistory to toxic substances,
and infected water.Her menstruation was normal.
LMP:23/7,2001----------------------------
Family History:
Her parents are living and well.No congenital
disease in her family.---------------------------- PhysicalExamination
Vital signs:T 36.6`C , P 80/min, R 22/min, BP120/80mmHg. General inspection: The patient is a well developed, well nou- rished adult female apparently in no acute distre,
pleasant and cooperative.
Skin:Normally free of eruption or unusual pigmentation. Lymphnodes: There are no swelling of lymphnodes. Head: Normal skull.No baldne, noscars.
Eyes: No ptosis.Extraocular normal.Conjuctiva normal.The Pupils are round, regular, and react to light and ac-
Ears: Externally normal.Canals clear.The drums normal.
Nose: No abnormalities noted.
Mouth and throat: lips red, tongue red.Alveolar ridges normal. Tonsils atrophil and uninfected.
Neck: No adenopathy.Thyroid palpable,but not enlarged.No Abnormal pulsations.Trachea in middle.
Chest and lung: Normal contour.Breast normal.Expansion equal. Fremitus normal.No unusual areas of dullne.Diaphr-
agmatic position and excursion normal.No abnormal br-
eath sound.No moist rales heard.No audible pleural fric-
ion.There are lots of rhonchi rales and whoop can be heard thHeart: P.M.I 0.5cm to left of midolavicular line in 5 inter- Space.Forceful apex beat.No thrills.No pathologic
heart murmur.Heart beat 80 and rhythm is normal. Abdomen: Flat abdomen.Good muscle tone.No distension.No v- isible peristalsis.No rigidity.No ma palpable.
Tenderne (-), rebound tenderne (-).Liver and spleen
are not palpable.Shifting dullne (-).Bowl sounds
normal.Systolic blowing murmur can be heard at the
right side of the navel.
Extremities: No joint disease.Muscle strength normal.No ab- normal motion.Thumb sign(+).Wrist sign(+).
Neural system:Knee jerk (-).Achilles jerk (-).
Babinski sign (-).Oppenheim sign (-).
Chaddock sign (-).Conda sign (-).
Hoffmann sign (-).
Neck tetany (-)Kernig sign (-).
Brudzinski sign (-).
Genitourinary system: Normal.
Rectum: No tenderne------
Out-patient department data:
No----------------------------
Historysummary
1).Li Yuzhen, female, 42y.
2).Cough and dyspnea for 2 days
3).PE: T 36.6`C, P 80/min, R 22/min, BP120/80mmHg.superficial nodes were not palpable.Normal vision.Upper palate haunch-
-uped.HR: 80bpm, rhythm is normal.There are lots of rho-
nchi rales and whoop can be heard .Flat abdomen, Tenderne (-),rebound tenderne (-).Liver and spleen are not pal-
pable.Shifting dullne (-).Bowl sounds normal..
4).Outpatient data: see above.
----------------------------
Impreion: Bronchial asthma
Signature:He Lin 95-10033
《英文病历.doc》。