英文病例模板

Medical Records for Admission
Medical Number: 701721 General information
Name:Liu Side
Age: Eighty
Sex: Male
Race:Han
Nationality:China
Address: NO.**, Dandong Road, Jiefang Rvenue, Hankou, Hubei. Tel: ****** Occupation: Retired
Marital status: Married
Date of admission: Aug 6th, 2001
Date of record: 11Am, Aug 6th, 2001 Complainer of history: patient’s son and wife Reliability: Reliable
Chief complaint: Upper abdominal pain for ten days, hematemesis, hematochezia and unconsciousness for four hours.
Present illness:
The patient felt upper abdominal pain for about ten days ago. He didn’t pay attention to it and thought he had ate something wrong. At 6 o’clock this morning he fainted and rejected lots of blood and gore. Then hemafecia began. His family sent him to our hospital and received emergent treatment. So the patient was accepted as “upper gastrointestine hemorrhage and hemorrhagic shock”.
Since the disease coming on, the patient didn’t urinate.
Past history
The patient is healthy before.
No history of infective diseases. No allergy history of food and drugs. Personal history
He was born in Wuhan on Nov 19th, 1921 and almost always lived in Wuhan. His living conditions were good. No bad personal habits and customs.
Family history: His parents have both deads.
Physical examination
T 36.5℃, P 130/min, R 23/min, BP 100/60mmHg. He was well developed and moderately nourished. Active position. His consciousness was not clear. His face was pale and the skin was not stained yellow. No cyanosis. No pigmentation. No skin eruption. Spider angioma was not seen. Superficial lymph nodes were not found enlarged. Respiratory movement was bilaterally symmetric with the frequency of 23/min. No pleural friction fremitus. Resonance was heard during percussion. No abnormal breath sound was heard. No wheezes. No rales. Border of the heart was normal. Heart sounds were strong and no splitting. Rate 150/min. Cardiac rhythm was not regular. No pathological murmurs. Abdomen was flat and soft. No bulge or depression. No abdominal wall varices. Gastralintestinal type or peristalses were not seen. Tenderness was obvious around the navel and in upper abdoman. There was not rebound tenderness on abdomen or renal region. Liver and spleen was untouched. No masses. Shifting dullness negative. No vascular murmurs. No edema.
Physiological reflexes were existent without any pathological ones.
Investigation
Blood-Rt: Hb 69g/L RBC 2.70×1012/L WBC 1.1×109/L PLT 120×109/L
History summary
1.Patient was male, 80 years old
2.Upper bellyache ten days, haematemesis, hemafecia and unconsciousness for four hours.
3.No special past history.
4.Physical examination: T 37.5℃, P 130/min, R 23/min, BP 100/60mmHg Superficial lymph nodes were not found enlarged. Heart rate was 150/min. Cardiac rhythm was not regular. Tenderness was obvious around the navel and in upper abdomen. No rebound tenderness. Liver and spleen was untouched. No masses. Shifting dullness negative. No other positive signs.
5.investigation information:
Blood-Rt: Hb 69g/L RBC 2.70×1012/L WBC 1.1×109/L PLT 120×109/L
Impression: upper gastrointestine hemorrhage
hemorrhagic shock
Signature: He Lin。