儿科英文病历模板

Nanjing children’s hospital

Medical Records for Admisson

Ward:321 Bed Number:32178 Medical Number: 696235 General information

Name:Son of ***

Sex: Male

Age: 3 h

Birthplace: *** county,Anhui province

Race:Han

Address:***town,***county,Anhu i province Date of admission:3:31pm Oct 16th,2015

Date of record: 3:31pm Oct 16th,2015

Parents Name: father *** Mother ***

Complainer of history: patient’s father

Reliability: Reliable

Chief complaint: Shortness of breath and moaning for 3h Present illness:

The afflicted baby was delivered 3h ago and had instaneous shortness of breath along with obtuse response and moaning.No aspnea or seizure or scream were observed. In local Hospital he received treatment of “naloxone、mezlocillin and Vit K1”, but his symptoms didn’t abate. So the parents took him to our hospital, he was admitted with a diagnosis of “acute respiratory dyspnea syndrome” .Breast feed has not been initiated.He has not vomitted,defecated or urinated since he was born,.

Past history

No history of any kind of disease.

No history of infective diseases. No history of picking front tooth.No history of wiping oral cavity.

Personal history

1.Natal: second birth born,

Gestational age:28 weeks;Multiplets:No;In Vitro fertilization:No

Cause of premature birth:unknown;Time of birth:2015-10-16 11:00

Mode of delivery:spontaneous delivery,born in local hospital Deliverer:practioner;Apgar scale:1min 7’,5min unknown

Resuscitation:No;Birth weight:1350g

The characteristics and volume of amniotic fluid remains unknown,as well as whether there was fetal aspiration of amniotic fluid or meconium.we also have no idea if there was Premature rupture of the amniotic fluid.

Umbilical cord is normal;Jaundice:unknown

2.Nutrition: breast feed has not been initiated.He had no sign

of defecation or vomit.

3.Immunization: B.C.G and hepatitis B vaccine have not been

inoculated after birth;Other vaccination remains unknown. Family history

Father:Name:***;Age:29ys;Vocation:worker;Health

condition:good;Blood type:AB

Mother:Name:***;Age:26ys;Vocaton:peasant;Health

condition:good;Blood type:unknown

Mother’s history of pregnancies and births:2 pregnancies,no abortion;This pregnancy was normal.

Existing siblings: a healthy sister of 2 and half years old

No history of drug allergy or physical contact with pets;No history of drug abuse or venereal disease.

Physical examination

T 34.1℃, P 126/min, R 70/min, BP 54/26mmHg.Weight 1380g. General description

His consciousness is clear;He has Premature appearance,slight cyanosis on the face.He had shortness of breath along with obtuse response and moaning.

Skin and mucosa

There is slight cyanosis of the skin.Elasticity is good. No edema.No sign of dehydration.No jaundice.No dermatoma.No bleeding or rash.

Head

No deformities of the Cranium.Anterior fontanelle 2cm*2cm,skin tensity is flat and soft..Hair is black.No hematoma or edema.Seams at the width of 2mm have not been sealed.

Eye:Bilateral pupils were round and equal in size about 2mm*2mm. Movement was normal.Direct and indirect pupillary reactions to light were sharp.Conjunctiva was not congestive.No discharges were found around the eyes.

Ear:No discharges were found in external auditory canals. No deformity in external auditory canals.Bilateral auricles were