英文住院病例模板

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腹痛住院病历书写范文

腹痛住院病历书写范文英文回答：I was admitted to the hospital due to severe abdominal pain. The pain started suddenly and was located in the lower right side of my abdomen. It was a sharp, stabbing pain that intensified with movement. The pain was so intense that I couldn't even stand up straight. I also experienced nausea and vomiting along with the abdominal pain.Upon admission, the doctors conducted a thorough physical examination. They pressed on different areas of my abdomen to assess the tenderness and check for any signs of inflammation. They also ordered various diagnostic tests, including blood tests, ultrasound, and a CT scan.The blood tests showed an elevated white blood cell count, which indicated the presence of infection. The ultrasound and CT scan revealed inflammation and swellingin the appendix, confirming a diagnosis of appendicitis. The doctors explained that appendicitis occurs when the appendix becomes blocked, leading to infection and inflammation.I was immediately scheduled for an appendectomy, which is the surgical removal of the appendix. The surgery was performed laparoscopically, using small incisions and a camera to guide the surgeon. This minimally invasive approach allows for quicker recovery and less scarring.After the surgery, I was closely monitored for any complications. I was given pain medication to manage the post-operative pain and antibiotics to prevent infection. The medical team ensured that I was able to tolerate oral intake and pass gas, which are signs of normal bowel function.I was discharged from the hospital after a few days, once my condition had stabilized. The doctors provided me with detailed instructions for post-operative care, including wound care, pain management, and dietaryrestrictions. They also advised me to gradually resume normal activities and avoid strenuous exercise for a few weeks.中文回答：我因为剧烈的腹痛被送入医院住院治疗。

住院病历英文作文

住院病历英文作文英文：I recently had to be hospitalized for a few days due toa severe case of pneumonia. During my stay, I had to keep a detailed record of my symptoms, medications, and treatments. This record is commonly known as a hospital or medical record.Hospital records are important because they provide a complete history of a patient's medical condition,including diagnoses, treatments, and outcomes. They arealso used to communicate important information between healthcare providers and ensure that patients receive the appropriate care.In my case, my hospital record included information about my vital signs, such as my temperature, blood pressure, and heart rate. It also included details about my symptoms, such as my cough, chest pain, and shortness ofbreath. Additionally, it listed all of the medications Iwas taking and the dosages, as well as any treatments or procedures I received.Overall, my hospital record was a comprehensive document that provided a clear picture of my medical condition during my hospital stay. It was an essential tool for my healthcare team to ensure that I received the best possible care.中文：最近，我因为严重的肺炎住院了几天。

英文病历报告作文模板

英文病历报告作文模板Patient Information- Name: [Patient's Full Name]- Gender: [Male/Female]- Age: [Patient's age]- Date of Admission: [MM/DD/YYYY]Chief ComplaintThe patient presented with [specific symptoms/complaints] which started [duration].History of Present IllnessThe patient reported [detailed description ofsymptoms/complaints]. The symptoms worsened over the past [duration]. The patient experienced [associated symptoms] and tried [any self-medication or home remedies] but noticed no improvement. There was no history of trauma or injury.Past Medical HistoryThe patient has a history of [chronic/acute medical conditions, if any] which includes [specific conditions]. The patient has taken[previous medications/treatments] for these conditions.Social HistoryThe patient has a [specific occupation] and lives in [specific area]. The patient does [specific habits] such as smoking or drinking alcohol [frequency]. There is no significant family medical history.Physical Examination- Vital Signs:- Blood Pressure: [value] mmHg- Heart Rate: [value] bpm- Respiratory Rate: [value] bpm- Temperature: [value]C- General Appearance:The patient appears [general appearance of the patient].- Systemic Examination:- Cardiovascular: [specific findings]- Respiratory: [specific findings]- Gastrointestinal: [specific findings]- Neurological: [specific findings]- Musculoskeletal: [specific findings]Laboratory and Imaging Findings- Blood Test Results:- Complete Blood Count: [values]- Biochemical Profile: [values]- Others: [specific findings]- Imaging:- [Specific imaging tests performed]- Results: [specific findings]DiagnosisAfter evaluating the patient's medical history, physical examination, and laboratory/imaging findings, the following diagnosis was made:[Primary Diagnosis]Treatment and ManagementThe patient was started on [specific treatment plan] which includes [medications, therapies, or procedures]. The patient wasadvised to [specific instructions] and scheduled for [follow-up tests/appointments, if any].Follow-upThe patient will be followed up in [specific time frame] to assess the response to treatment and manage any complications that may arise. The patient was given contact information for any urgent concerns or changes in symptoms.Discussion and ConclusionThis case report highlights the presentation, evaluation, and management of a patient with [specific condition]. The patient's symptoms were appropriately addressed through a systematic approach involving history taking, physical examination, and laboratory/imaging investigations. The provided treatment plan aims to address the underlying cause and improve the patient's overall well-being. Continuous monitoring and follow-up will guide further management decisions.Note: This medical case report is fictional and serves as a template for educational purposes. Any resemblance to actualpatients is purely coincidental.。

英文完全病历模板-详细版

Admission RecordName：* Nativity: * district, * citySex:male Race: HanAge:55 Date of admission:2020-09-07 14:30 Marital status: be married Date of record:2020-09-07 15:23 Occupation:teacher Complainer:patient himself Medical record Number: * Reliability: reliablePresent address: NO*, building*, * village,* district, *city, *provinceChief complaint: cough and sputum for more than 6 years, worsening for 2 weeksHistory of present illness: The patient complained of having paroxysmal cough and sputum 6 years ago. At that time, he was diagnosed as “COPD” in another hospital and no regular treatment was applied. Cough and sputum worsened and were accompanied by tachypnea 2 weeks ago with no inducing factors. Small amounts of white and mucous sputum were hard to cough up. Compared to daytime, tachypnea worsened in the night or when sputum can’t be cough up. The patient can’t lie flat at the night because of prominent tachypnea and prefer a high pillow. He had no fever, no chest pain, no dizziness, no diarrhea, no abdominal pain, no obvious decrease of activity tolerance. On 20*-0*-*, the patient went to *Hospital for medical consultation. CT lung imaging indicated: lesion accompanied by calcification in the superior segment, the inferior lobe of the right lung, the possibility of obsolete tuberculosis; emphysema, bullae formation and sporadic inflammation of bilateral lung; calcified lesion in the inferior lobe of the left lung; arteriosclerosis of coronary artery.Pulmonary function tests indicated:d obstructive ventilation dysfunction; bronchial dilation test was negative2.moderate decrease of diffusion function, lung volume, residual volume and the ratio of lungvolume; residual volume were normalThe patient was diagnosed as “AECOPD” and prescribed cefoxitin to anti-infection for a week, Budesonide and Formoterol to relieve bronchial muscular spasm and asthma,amb roxol to dilute sputum, and traditional Chinese medicine (specific doses were unknown).The patient was discharged from the hospital after symptoms of cough and sputum slightly relieved with a prescription of using Moxifloxacin outside the hospital for 1 week. Cough and sputum were still existing, thus the patient came to our hospital for further treatment and the outpatient department admitted him in the hospital with “COPD”. His mental status, appetite, sleep, voiding, and stool were normal. No obvious decrease or increase of weight.Past history: The patient was diagnosed as type 2 diabetes 1 years ago and take Saxagliptin (5mg po qd) without regularly monitoring the levels of blood sugar. The patient denies hepatitis, tuberculosis, malaria, hypertension, mental illness, and cardiovascular diseases. Denies surgical procedures, trauma, transfusion, food allergy and drug allergy. The history of preventive inoculation is not quite clear.Personal history: The patient was born in *district, * city and have lived in * since birth. He denies water contact in the schistosome epidemic area. Smoking 10 cigarettes a day for 20 years and have stopped for half a month. Denies excessive drinking and contact with toxics.Marital history: Married at age of 27 and have two daughters. Both the mate and daughters are healthy.Family history: Denies familial hereditary diseases.Physical ExaminationT: 36.5℃ P：77bpm R: 21 breaths/min BP：148/85mmHgGeneral condition：normally developed, well-nourished, normal facies, alert, active position, cooperation is goodSkin and mucosa: no jaundiceSuperficial lymph nodes: no enlargementHead organs: normal shape of headEyes:no edema of eyelids; no exophthalmos; eyeballs move freely; no bleeding spots of conjunctiva; no sclera jaundice; cornea clear; pupils round, symmetrical in size and acutely reactive to light.Ears: no deformity of auricle; no purulent secretion of the external canals; no tenderness over mastoidsNose: normal shape; good ventilation;no nasal ale flap; no tenderness over nasal sinus; Mouth: no cyanosis of lips; no bleeding spots of mouth mucosa; no tremor of tongue; glossy tongue in midline; no pharynx hyperemia; no enlarged tonsils seen and no suppurative excretions; Neck: supple without rigidity, symmetrical; no cervical venous distension; Hepatojugular reflux is negative; no vascular murmur; trachea in midline; no enlargement of thyroid glandChest: symmetrical; no deformity of thoraxLung:Inspection：equal breathing movement on two sidesPalpation: no difference of vocal fremitus over two sides;Percussion: resonance over both lungs;Auscultation: decreased breath sounds over both lungs; no dry or moist rales audible; no pleural friction rubsHeart:Inspection: no pericardial protuberance; Apex beat seen 0.5cm within left mid-clavicular at fifth intercostal space;Palpation: no thrill felt;Percussion: normal dullness of heart bordersAuscultation: heart rate 78bpm; rhythm regular; normal intensity of heart sounds; no murmurs or pericardial friction sound audiblePeripheral vascular sign: no water-hammer pulse; no pistol shot sound; no Duroziez’s murmur; no capillary pulsation sign; no visible pulsation of carotid arteryAbdomen:Inspection: no dilated veins; no abnormal intestinal and peristaltic waves seenPalpation: no tenderness or rebounding tenderness; abdominal wall flat and soft; liver and spleen not palpable; Murphy's sign is negativePercussion: no shifting dullness; no percussion tenderness over the liver and kidney regionAuscultation: normal bowel sounds.External genitalia: uncheckedSpine: normal spinal curvature without deformities; normal movementsExtremities: no clubbed fingers(toes); no redness and swelling of joints; no edema over both legs; no pigmentation of skins of legsNeurological system: normal muscle tone and myodynamia; normal abdominal and bicipital muscular reflex; normal patellar and heel-tap reflex; Babinski sign(-);Kerning sign(-) ; Brudzinski sign(-)Laboratory DataKey Laboratory results including CT imaging and pulmonary function test have been detailed in the part of history of present illness.Abstract*, male, 55 years old. Admitted to our hospital with the chief complaint of cough and sputum for more than 6 years, worsening for 2 weeks. Cough and sputum worsened and were accompanied by tachypnea 2 weeks ago. The patient can’t lie flat in the night because of prominent tachypnea and prefer a high pillow.Physical Examination: T: 36.5℃,P: 77bpm, R: 21 breaths per minute, BP:148/85mmHg. Decreased breath sounds over both lungs; no dry or moist rales audible.Laboratory data: CT lung imaging indicates: lesion accompanied by calcification in superior segment, inferior lobe of right lung, possibility of obsolete tuberculosis; emphysema, bullae formation and sporadic inflammation of bilateral lung; calcified lesion in inferior lobe of left lung. Pulmonary function tests indicate: mild obstructive ventilation dysfunction, bronchial dilation test was negative moderate decrease of diffusion function.Primary Diagnosis:1.AECOPD2.Type 2 Diabetes3.Primary Hypertension Doctor’s Signature:。

英文病历标准模版

英文病历标准模版Patient ProfileName: Si RuihuaDepartment: ___ Power ___Sex: FemalePresent Address: Electric Power Bureau Age: 80 yearsDate of n: May 17.2003nality: Chinese XinjiangDate of Record: May 17.2003Marital Status: MarriedReliability: Reliablen: Family ___History of Allergy: None reportedChief Complaints___。

breathlessness。

and precordial pain for the last hour。

There were no precipitating factors。

and the fort could not be relieved by rest。

As a result。

she came to the hospital for help。

She did not experience syncope。

cough。

headache。

diarrhea。

or vomiting during the course of the illness。

Her appetite。

sleep。

voiding。

and stool were normal.Medical History___.______。

___ distress。

She had a heart rate of 120 beats per minute and a blood pressure of 160/90 mmHg。

Her respiratory rate was 28 breaths per minute。

and her oxygen n was 90% on room air。

soap英文病历

soap英文病历Patient Information:Name: John SmithAge: 45 yearsGender: MaleDate of Admission: June 5, 2021Date of Discharge: June 10, 2021Chief Complaint:The patient presented with a persistent cough and difficulty breathing for the past week.History of Present Illness:Mr. Smith reports that he developed a cough one week ago, which has progressively worsened. He also complains of shortness of breath, especially during physical activities. He denies any chest pain, fever, or weight loss. The cough is non-productive and is not associated with any sputum or blood. He does not have a history of allergies or recent exposure to respiratory irritants.Past Medical History:The patient has a history of asthma, which is well-controlled with daily use of an inhaler. He had a similar episode of respiratory distress three years ago and was treated with corticosteroids and bronchodilators at that time. He denies any recent hospitalizations or surgeries.Family History:There is no significant family history of respiratory diseases.Social History:Mr. Smith is a non-smoker and does not consume alcohol regularly. He works as an office manager and is not exposed to any occupational hazards. He lives with his wife and two teenage children. He denies any recent travel or contact with sick individuals.Physical Examination:Upon examination, the patient appears in no acute distress. Vital signs are stable with a temperature of 98.6°F (37°C), blood pressure of 120/80 mmHg, heart rate of 80 beats per minute, and respiratory rate of 16 breaths per minute. Auscultation of the lungs reveals bilateral wheezing and decreased breath sounds in the lower lung fields. There is no evidence of cyanosis or clubbing. The cardiovascular and abdominal examinations are within normal limits.Diagnostic Tests:A chest X-ray was ordered to evaluate the patient's respiratory symptoms. The X-ray showed bilateral diffuse patchy infiltrates, consistent with bronchial asthma. Pulmonary function tests were performed, revealing a decreased forced expiratory volume in one second (FEV1) and forced vital capacity (FVC), indicating obstructive lung disease.Assessment and Plan:The patient's symptoms, physical examination findings, and diagnostic test results are consistent with a diagnosis of exacerbation of bronchial asthma. The patient was started on a short course of oral corticosteroids, a short-acting bronchodilator,and an inhaled corticosteroid. He was also provided education regarding trigger avoidance and proper inhaler technique. Close follow-up was scheduled to monitor his response to treatment and adjust the management plan if necessary.Follow-Up:The patient will be seen for a follow-up visit in two weeks to evaluate his response to treatment and adjust his medication regimen if needed. He was instructed to monitor his lung function at home using a peak flow meter and seek medical attention if there is a significant decrease in his peak flow readings or if his symptoms worsen. The importance of regular follow-up visits and adherence to the prescribed medication regimen was emphasized. Summary:Mr. Smith, a 45-year-old male with a history of asthma, presented with a persistent cough and difficulty breathing. A diagnosis of exacerbation of bronchial asthma was made based on his symptoms, examination findings, and diagnostic tests. The patient was started on appropriate treatment and provided with education regarding trigger avoidance and inhaler technique. Close follow-up was arranged to monitor his response to treatment and ensure optimal management.。

英文病历书写范例

英文病历书写范例（内科）Medical Records for AdmissonMedical Number: 701721General informationName: Liu SideAge: EightySex: MaleRace: HanNationality: ChinaAddress: NO.35, Dandong Road, Jiefang Rvenue, Hankou, Hubei.Tel: 857307523Occupation: RetiredMarital status: MarriedDate of admission: Aug 6th, 2001Date of record: 11Am, Aug 6th, 2001Complainer of history:patient’s son and wifeReliability: ReliableChief complaint: Upper bellyache ten days, haematemesis, hemafecia and unconsciousness for fo ur hours.Present illness:The patient felt upper bellyache about ten days ago. He didn’t pay attention to it and thought heha date something wrong. At 6 o’cloc k this morning he fainted and rejected lots of blood and gore. T hen hemafecia began. His family sent him to our hospital and received emergent treatment. So the patient was accepted because of “upper gastrointestine hemorrhage and exsanguine shock”. Since the disease coming on, the patient didn’t urinate. Past historyThe patient is healthy before.No history of infective diseases. No allergy history of food and drugs.Past history Operative history: Never undergoing any operation. Infectious history: No history of s evere infectious disease. Allergic history: He was not allergic to penicillin or sulfamide. Respirator y system: No history of respiratory disease. Circulatory system: No history of precordial pain. Ali mentary system: No history of regurgitation.Genitourinary system: No history of genitourinary disease.Hematopoietic system: No history of anemia and mucocutaneous bleeding. Endocrine system: No acromegaly. No excessive sweats. Kinetic system: No history of confinement of limbs. Neural sys tem: No history of headache or dizziness. Personal historyHe was born in Wuhan on Nov 19th, 1921 and almost always lived in Wuhan. His living condition s were good. No bad personal habits and customs.Menstrual history: He is a male patient. Obstetrical history: NoContraceptive history: Not clear.Family history: His parents have both deads. Physical examinationT 36.5℃, P 130/min, R 23/min, BP 100/60mmHg. He is well developed and moderately nourished.Active position. His consciousness was not clear. His face was cadaverous and the skin was not sta ined yellow. No cyanosis. No pigmentation. No skin eruption. Spider angioma was not seen. No pi tting edema. Superficial lymph nodes were not found enlarged. HeadCranium: Hair was black and white, well distributed. No deformities. No scars. No masses. No ten derness.Ear: Bilateral auricles were symmetric and of no masses. No discharges were found in external au ditory canals. No tenderness in mastoid area. Auditory acuity was normal.Nose: No abnormal discharges were found in vetibulum nasi. Septum nasi was in midline. No nare s flaring. No tenderness in nasal sinuses. Eye: Bilateral eyelids were not swelling. No ptosis. No e ntropion. Conjunctiva was not congestive. Sclera was anicteric. Eyeballs were not projected or dep ressed. Movement was normal. Bilateral pupils were round and equal in size. Direct and indirect p upillary reactions to light were existent.Mouth: Oral mucous membrane was not smooth, and there were ulcer can be seen. Tongue was in midline. Pharynx was congestive. Tonsils were not enlarged.Neck: Symmetric and of no deformities. No masses. Thyroid was not enlarged. Trachea was in mi dline. ChestChestwall: Veins could not be seen easily. No subcutaneous emphysema. Intercostal space was nei ther narrowed nor widened. No tenderness.Thorax: Symmetric bilaterally. No deformities. Breast: Symmetric bilaterally.Lungs: Respiratory movement was bilaterally symmetric with the frequency of 23/min. thoracic e xpansion and tactile fremitus were symmetric bilaterally. No pleural friction fremitus. Resonance was heard during percussion. No abnormal breath sound was heard. No wheezes. No rales. Heart: No bulge and no abnormal impulse or thrills in precordial area. The point of maximum imp ulse was in 5th left intercostal space inside of the mid clavicular line and not diffuse. No pericardi al friction sound. 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: Flat and soft. No bulge or depression. No abdominal wall varicosis. Gastralintestinal ty pe or peristalses were not seen. Tenderness was obvious around the navel and in upper abdoman. T here was not rebound tenderness on abdomen or renal region. Liver and spleen was untouched. No masses. Fluidthrill negative. Shifting dullness negative. Borhorygmus not heard. No vascular mur murs. Extremities: No articular swelling. Free movements of all limbs.Neural system: Physiological reflexes were existent without any pathological ones. Genitourinary system: Not examed. Rectum: not exanedInvestigationBlood-Rt: Hb 69g/L RBC 2.70T/L WBC 1. 1G/L PLT 120G/L History summary1. Patient was male, 80 years old2. 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 node s were not found enlarged. No abdominal wall varicosis. 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. Fluidthrill ne gative. Shifting dullness negative. Borhorygmus not heard. No vascular murmurs. No other positive signs. 5. investigation information:Blood-Rt: Hb 69g/L RBC 2.80T/L WBC 1.1G/L PLT 120G/LImpression: upper gastrointestine hemorrhage Exsanguine shock出院小结（DISCHARGE SUMMARY）， ===============Department of GastroenterologyChanghai Hospital，No.174 Changhai Road Shanghai, China Phone: 86-21-25074725-803 DISCHARGE SUMMARYDA TE OF ADMISSION: October 7th, 2005 DA TE OF DISCHARGE: October 12th, 2005 ATTE NDING PHYSICIAN: Yu Bai, MD PA TIENT AGE: 18ADMITTING DIAGNOSIS:V omiting for unknown reason: acute gastroenteritis?BRIEF HISTORYA 18-year-old female with a complaint of nausea and vomiting for nearly one month who was see n at Department of Gastroenterology in Changhai Hospital, found to have acute gastroenteritis and non-atrophic gastritis. The patient was subsequently recovered and discharged soon after medicati on.REVIEW OF SYSTEMShe has had no headache, fever, chills, diarrhea, chest pain, palpitations, dyspnea, cough, hemopty sis, dysuria, hematuria or ankle edema.PAST MEDICAL HISTORYShe has had no previous surgery, accidents or childhood illness.SOCIAL HISTORY: She has no history of excessive alcohol or tobacco use.FAMIL Y HISTORYShe has no family history of cardiovascular, respiratary and gastrointestinal diseases. PHYSICAL EXAMINA TIONTemperature is 37, pulse 80, respirations 16, blood pressure 112/70. General: Plump girl in no app arent distress. HEENT: She has no scalp lesions. Her pupils are equally round and reactive to light and accommodation. Extraocular movements are intact. Sclerae are anicteric. Oropharynx is clear. There is no thyromegaly. There is no cervical or supraclvicular lymphadenopathy. Cardiovascular: Regular rate andrhythm, normal S1, S2. Chest: Clear to auscultation bilateral. Abdomen: Bowel sounds present, no hepatosplenomagaly. Extremities: There is no cyanosis, clubbing or edema. Neurologic: Cranial n erves II-XII are intact. Motor examination is 5/5 in the bilateral upper and lower extremities. Sens ory, cerebellar and gait are normal.LABORATORY DATAWhite blood cells count 5.9, hemoglobin 111g/L, hematocrit 35.4. Sodium 142, potassium 4.3, chl oride 106, CO2 25, BUN 2.6mmol/L, creatinine 57μmol/L, glucose 4.1mmol/L, Albumin 36g/L. Endoscopic ExamChronic non-atrophic gastritisHOSPITAL COURSEThe patient was admitted and placed on fluid rehydration and mineral supplement. The patient im proved, showing gradual resolution of nausea and vomiting. The patient was discharged in stable c ondition.DISCHARGE DIAGNOSIS Acute gastroenteritisChronic non-atrophic gastritisPROGNOSISGood. No medications needed after discharge. But if this patient can not get used to Chinese food, she had better return to UK as soon as possible to prevent the relapse of acute gastroenteritis. The patient is to follow up with Dr. Bai in one week. ___________________________ Yu Bai, MD D: 12/10/2005。

英语病历模板范文

英语病历模板范文Patient Identification:Date of Birth: [DOB]Sex: [Male/Female]Patient ID: [Unique Identifier]Chief Complaint:[Patient's primary concern or reason for the visit, e.g., "Severe headache for the past 3 days"]History of Present Illness:[Detailed account of the onset, duration, severity, and any associated symptoms of the current illness. Include any treatments already attempted.]Past Medical History:[List any previous medical conditions, surgeries, or hospitalizations.]Medications:[List all current medications, including dosages andfrequency.]Allergies:[Note any known allergies to medications, foods, or environmental factors.]Family Medical History:[Provide information on any significant medicalconditions in the patient's family.]Social History:[Include relevant lifestyle factors such as smoking status, alcohol consumption, exercise habits, and occupation.]Review of Systems:[Briefly summarize the patient's current state inrelation to various body systems, e.g., "No chest pain, no shortness of breath."]Physical Examination:[Record findings from the physical examination, including vital signs, general appearance, and specific observations related to the chief complaint.]Assessment:[Summarize the likely diagnosis or condition based on the information gathered.]Plan:[Outline the proposed treatment plan, including medications, referrals, follow-up appointments, and any necessary tests or procedures.]。

医学英语病历写作范文

医学英语病历写作范文Chief Complaint: Left leg pain with recent fall.History of Present Illness: The patient is a 65-year-old male who presents to the emergency department with a chief complaint of left leg pain. He states that he fell down a flight of stairs approximately 3 hours prior to presentation. He reports that he is in moderate to severe pain, which is localized to his left lower extremity. He denies any associated numbness or tingling. He has no prior history of leg pain or injury.Past Medical History: The patient has a history of hypertension, which is well-controlled with medication. He has no other significant medical history.Social History: The patient is married and has two children. He is a retired construction worker. He smokes one pack of cigarettes per day and drinks alcohol socially.Family History: The patient's father has a history of coronary artery disease. His mother has a history of Alzheimer's disease.Physical Examination:Vital signs: Blood pressure 140/80 mmHg, heart rate 80 bpm, respiratory rate 18 breaths per minute, temperature 98.6°F (37°C).General: The patient is in moderate distress due to pain. He is alert and oriented to person, place, and time.HEENT: Normocephalic and atraumatic. Pupils are equal and reactive to light. Extraocular movements are intact. No conjunctival injection or discharge. Tympanic membranes are intact and mobile.Neck: Supple with full range of motion. No masses or tenderness.Chest: Auscultation reveals clear breath soundsbilaterally. No wheezes, rales, or rhonchi.Cardiovascular: Regular rate and rhythm. No murmurs, rubs, or gallops.Abdomen: Soft and non-tender. No masses or organomegaly.Extremities: Left lower extremity: Examination reveals swelling and tenderness of the left knee. There is a palpable step-off deformity of the lateral aspect of theleft knee. Active and passive range of motion is limiteddue to pain. Distal pulses are palpable and capillaryrefill is brisk. Sensation is intact. Right lower extremity: Examination reveals no abnormalities.Neurological Examination:Mental status: Alert and oriented to person, place,and time. No deficits in attention, memory, or language.Cranial nerves: No deficits.Motor: Strength is 5/5 in both upper and lower extremities. No atrophy or fasciculations.Sensory: Sensation is intact to light touch, pinprick, and temperature in all four extremities.Diagnostic Studies:X-ray of the left knee: The X-ray shows a displaced lateral tibial plateau fracture.Assessment:Left knee pain.Displaced lateral tibial plateau fracture.Plan:The patient will be admitted to the hospital for further evaluation and treatment.He will be placed in a knee immobilizer and will be started on pain medication.Orthopedic surgery will be consulted for further management.。

大病历模板(英文)

Union Hospital affiliated to Huazhong University of Science and TechnologyAdmission Record 0000337023Department: Respiratory Medicine Area: J17 Respiratory Medicine Bed No. 109031 Case No. 1565825Name: Hou Deguang Gender: Male Date of Birth:15/9/ 1936 Age:78 Nationality: ChinaID No. 42021 Ethnicity: Han Occupation: other Marital status: MarriedAddress: Nanchong，Sichuan Tel No.Source of History: Patient herself Reliability: ReliableAdmission Date & Time: 4/11/2021 14:36Chief Complaint: Found pleural effusion for about 2 months.Present Illness: The patient received the chest CT scan in the Wuhan Traditional Medicine Hospital two months ago and found right-side pleural effusion, right-sidepulmonary atelectasis. After that, he was hospitalized in the EndocrinologyDept of our hospital for poor management of blood glucose level. On thisadmission, He received the thoracocentesis, and the laboratory examinationresults indicated the large possibility of tuberculous pleural effusion. Nospecial treatment was given at that time. The patient was aware of a sense ofpolypnea after long walk, without cough, expectoration, night sweats, chestdistress, thoracalgia, wheeze, dyspnea and can lie down to sleep at night. Thereturn-visit in the clinic at October 13th showed that there were a few pleuraleffusion on the right side and is hard to be localized. Now the patient came toour hospital for further treatment and was admitted as “Pleural effusionorigin unknown〞.Since the onset of the disease, the patient’s sp irit, appetite and sleep arenormal. Nocturia for 1 time per night. Stool are as usual. No obvious weightand physical strength change.Past History: General Health Status: Relatively bad; Respiratory Syste m: Chronic bronchitis for about 10 years; Circulatory System: Hypertension for about 20years, highest reached 180/95mmHg, took Amlodipine orally 5mg qd, BP managementis good. Diagnosed of coronary heart disease in 2007, underwentintracoronary stent implantation in 2021, 3 stents were implanted; DigestiveSystems: None; Urinary System: Benign prostatic hyperplasia for about 5 years,Diabetic nephropathy for 3 years; Hematologic System: Thrombocytopenia for 2years; Endocrine System: None. Nervous System: Lacunar infarction in 2021;Motor System: None; Infection History: No infection of hepatitis and TB. Others:None special; Preventive Inoculation: In accordance with the stateplan;Operation History:underwent intracoronary stent implantation in 2021, 3stents was implantated; Blood Transfusion History:None; Traumatic History:None; Allergic History: None;Personal History: Habitual Residence: Hubei; Residential Environment: No exposure history to toxic substances and infected water; Travelling History: None; Smoking History:Smoking for about 40 years, 3 cigarettes per day. Quit smoking in 2021;Drinking History: Drinking for 40 years, 150g-350g per day, Quit drinking in2021;Marital History: Married,Menstrual History: MaleFamily History:Father is deceased, mother is deceased. No other infective and hereditary diseases.Physical ExaminationVital Signs: T:℃. P:86 bpm, regular. R: 20min, regular. BP: 132/74 mmHg. Height: 164cm.Weight: 64kg. Expression: Normal. Development: Well. Nutritional status: Fairly.Consciousness: Conscious. Spirit: Well. Gait: Normal. Position: Active.Coordination with Examination: Cooperative.Skin and Lymph Nodes:No jaundice. Some scattered scratch in hands and abdomen, No subcutaneous bleeding, edema, nodules or unusual pigmentation. Liverpalm(-). Spider angioma(-). No swelling of general superficial lymphnodes.HEENT(Head, Eye, Ear, Nose, Throat): Normal skull. No baldness, no scars. Eyes: No ptosis.Conjuctiva normal. The pupils are round, symmetric and responsive to lightand accommodation is normal. Ears: Externally normal. Canals clear. Drumsnormal. Noses: No abnormalities noted. Month and Throat: lips red, tongue red,no swelling of tonsils.Neck: Motion free. Thyroid is not enlarged. No abnormal pulsations. Trachea in middle. Carotid: Pulse is normal. Hepatojugular reflux sign(-). Vascular bruit: None.Chest and Lung:Normal contour. Breast normal. Inspection: respiratory movement symmetric and regular. Palpation: Normal and symmetric. No pleural friction fremitus. Percussion: both sides resonance. Auscultation: right-side breath sounds weaken, left-side is normal. No moist or dry rales. No pleural friction rubs.Heart:No protrusion of precordium. Normal apical impulse. No thrill. No enlarged cardiac dullness border. Heart rate: 88bpm, rhythm normal. No abnormal and extra cardiac sounds or cardiac murmurs. No peripheral vascular signs.Abdomen:Flat abdomen. No gastric or intestinal pattern. No visible peristalsis. Normal bowel sound. No rigidity. No mass palpable. No tenderness and rebound tenderness. Liver and spleen are not palpable. Kidneys are not palpable. No percussion tenderness over kidney regions. No shifting dullness.Rectum: Normal anus and perineum.Genitourinary System: Normal.Neural System: Normal.Extremities: No joint disease. Muscle strength normal. Pathological reflex (-).Specialty Examination: Right-side breath sounds weaken, left side normal. No moist or dry rales, No swelling of general superficial lymph nodes. No edema inneither lower extremities.Accessory Examination:Discharge record of Endocrinology Dept. of our hospital at September 2021; Clinic examination at October 13th: a few pleural effusion on theright side and is hard to be localized.History summary: 1. Hou Deguang, male, 78 yr.2. Admitted for 〞Found plaural effusion for about 2 months〞.3. T:℃. P:86 bpm, regular. R: 20min, regular. BP: 132/74 mmHg.Expression: Normal. Spirit clear. Cardiac sounds normal, HR: 72 bpm, rhythmnormal, No abnormal and extra cardiac sounds or cardiac murmurs. Right-side breathsounds weaken, left side normal. No moist or dry rales, no pleural friction rubs.Flat abdomen. No rigidity.4. Special examination:Trachea in middle. Contour symmetric.Respiratory movement regular. Right-side breath sounds weaken, left side normal. Nomoist or dry rales, no pleural friction rubs.5. Accessory Examination: Discharge record of Endocrinology Dept of ourhospital at September 2021; Clinic examination at October 13th: a few pleuraleffusion on the right side and is hard to be localized.6. Past history: Respiratory Syste m: Chronic bronchitis for about 10years; Circulatory System: Hypertension for about 20 years, highest reached180/95mmHg, took Amlodipine orally 5mg qd, BP management is good. Diagnosed ofcoronary heart disease in 2007, underwent intracoronary stent implantation in2021, 3 stents was implantated; Digestive Systems: None; Urinary System: Benignprostatic hyperplasia for about 5 years, Diabetic nephropathy for 3 years;Hematologic System: Thrombocytopenia for 2 years; Endocrine System: None.Nervous System: Lacunar infarction in 2021; Motor System: None;InfectionHistory: No infection of hepatitis and TB. Others: None special; PreventiveInoculation: In accordance with the stateplan; Operation History:underwentintracoronary stent implantation in 2021, 3 stents was implantated; BloodTransfusion History: None; Traumatic History: None; Allergic History: None; Impression: 1. Right-side pleural effusion origin unknown: TB? Tumor?2. II diabetes mellitus, Diabetic nephropathy3. Hypertension III, high risk4. Coronary heart disease, post-intracoronary stent implantation5. Lacunar infarction6. Thrombocytopenia7. Benign prostatic hyperplasiaRecorder: Cheng LongDate & Time: 4/11/2021 16:14Checker: Xu JuanjuanDate & Time: 5/11/2021 10:22。

英语作文病历模板

英语作文病历模板英文回答：Medical History Template。

Patient Information。

Name:Date of Birth:Gender:Address:Phone Number:Email Address:Reason for Visit。

What brings you to the clinic today?Medical History。

Past Medical History。

Do you have any past medical conditions?Have you ever been hospitalized or had surgery?Do you currently take any medications?Do you have any allergies?Family Medical History。

Do any of your close family members have any medical conditions?Have any of your close family members passed away at a young age due to illness?Social History。

What is your occupation?Are you currently married or in a relationship? Do you have any children?Do you smoke, drink alcohol, or use drugs?Physical Examination。

General Appearance:Height:Weight:BMI:Vital Signs:Blood pressure: Pulse:Respiratory rate: Temperature:Cardiovascular:Heart rate:Heart sounds:Blood pressure: Respiratory:Respiratory rate: Lung sounds:Abdomen:Girth:Soft and non-tender: Liver span:Musculoskeletal:Range of motion:Strength:Reflexes:Skin:Color:Texture:Turgor:Assessment。

英文病历报告作文模板

英文病历报告作文模板英文：Medical Record Report。

Name: John Smith。

Age: 35。

Gender: Male。

Date of Admission: 05/01/2021。

Date of Discharge: 05/07/2021。

Chief Complaint:The patient complained of a persistent cough and shortness of breath.History of Present Illness:The patient had a persistent cough and shortness of breath for two weeks. He tried to treat himself with over-the-counter medication but his symptoms did not improve. He decided to seek medical attention when his cough became more severe and he started to experience chest pain.Past Medical History:The patient has a history of asthma and seasonal allergies. He has been hospitalized in the past for asthma exacerbations.Physical Examination:On physical examination, the patient had wheezing and crackles in his lungs. His oxygen saturation was 92% on room air.Diagnostic Tests:A chest X-ray showed bilateral infiltrates consistent with pneumonia. A COVID-19 test was negative.Treatment:The patient was started on antibiotics for pneumonia and given nebulizer treatments for his asthma exacerbation. He was also given supplemental oxygen to maintain his oxygen saturation above 94%.Outcome:The patient's symptoms improved with treatment and he was discharged home after a week in the hospital.中文：病历报告。

住院病历英语作文

住院病历英语作文{z}Title: Hospital Admission RecordHospital Admission RecordPatient Information:ame: [Patient"s Name]Age: [Patient"s Age]Gender: [Patient"s Gender]Date of Admission: [Date]Medical History:The patient, [Patient"s Name], a [Patient"s Age]-year-old [Patient"s Gender], was admitted to our hospital on [Date] due to [reason for admission].The patient has a history of [previous medical conditions, if any], and is currently taking [list of medications, if any].Physical Examination:Upon admission, the patient was found to have [physical examination findings, such as vital signs, general appearance, and specific organ system assessments].The patient complained of [list of symptoms, if any], and there were signs of [any observed abnormalities or symptoms].Diagnosis:Based on the patient"s medical history and physical examination, the following diagnosis was made: [list of diagnosed conditions or diseases].Treatment Plan:The patient was recommended to undergo [list of treatments, such as surgery, medication, or therapy] for the management of their condition.The treatment plan was discussed with the patient and/or their guardian, and informed consent was obtained.Progress Notes:[List of any significant changes in the patient"s condition, response to treatment, and any other relevant updates during the hospital stay].Discharge Summary:The patient, [Patient"s Name], was discharged from our hospital on [Date].At the time of discharge, the patient"s condition had improved significantly, and they was deemed stable for discharge.The patient was provided with discharge instructions, including any necessary medications, follow-up appointments, and lifestyle modifications.It is recommended that the patient continue to follow up with their primary care physician or designated healthcare provider for further monitoring and management of their condition.Any concerns or exacerbation of symptoms should prompt immediate medical attention.Please note that this document is a sample hospital admission record and should be customized according to the specific patient"s information and clinical details.。

自发性气胸住院病历模板范文

自发性气胸住院病历模板范文英文回答：Spontaneous pneumothorax is a condition where air accumulates in the space between the lung and the chest wall, causing the lung to collapse. I experienced this condition recently and was hospitalized for treatment. Here is a template of my medical record during my hospitalization:Patient Name: [Your Name]Age: [Your Age]Gender: [Your Gender]Date of Admission: [Admission Date]Date of Discharge: [Discharge Date]Chief Complaint:I presented to the emergency department with sudden onset of sharp chest pain on the right side, which worsened with deep breaths. I also had difficulty breathing and felt lightheaded.History of Present Illness:I was at home when I suddenly felt a sharp pain in my right chest. The pain was so severe that it made itdifficult for me to take deep breaths. I also noticed that my breathing became more rapid and shallow. I felt lightheaded and had to sit down to catch my breath. The pain persisted for several hours, so I decided to go to the hospital.Past Medical History:I have never experienced any significant medical problems in the past. I do not have any history of lung diseases or previous episodes of pneumothorax.Physical Examination:Upon examination, I was found to have decreased breath sounds on the right side of my chest. My chest was slightly asymmetrical, with decreased movement on the right side. A chest X-ray confirmed the diagnosis of a spontaneous pneumothorax.Treatment:I was admitted to the hospital for further management.A chest tube was inserted into my right chest to remove the accumulated air and re-expand the lung. I was also given supplemental oxygen to help with my breathing. Pain medication was administered to alleviate my chest pain.Progress:Over the course of my hospitalization, my symptoms gradually improved. The chest tube was removed after a few days when the lung was fully re-expanded. I was able tobreathe comfortably and my chest pain resolved. I was discharged with instructions to follow up with my primary care physician for further evaluation and to discuss the possibility of preventive measures to reduce the risk of recurrence.中文回答：自发性气胸是一种空气在肺与胸壁之间积聚，导致肺部塌陷的状况。

英语写病历作文模板

英语写病历作文模板 Patient History Template。

英文回答：General Information。

Name:Age:Gender:Occupation:Address:Phone number:Emergency contact:Medical History。

Past medical history: List any previous illnesses, surgeries, hospitalizations, or accidents.Family medical history: Note any history of chronic diseases, such as heart disease, cancer, or diabetes, in the patient's family.Allergies: List any known allergies to medications, foods, or other substances.Medications: List all current medications, including prescription drugs, over-the-counter medications, and herbal supplements.Social history: Discuss the patient's lifestyle, including diet, exercise, smoking, alcohol use, and drug use.Present Illness。

Chief complaint: State the patient's primary reasonfor seeking medical attention.History of present illness: Describe the onset, duration, severity, and progression of the patient's symptoms.Physical Examination。

住院病历英语作文

住院病历英语作文English:The hospitalization medical record serves as a crucial document in the continuum of patient care, encapsulating vital information about the patient's condition, treatment plan, and progress throughout their hospital stay. It typically includes demographic details, such as the patient's name, age, and contact information, alongside a comprehensive medical history detailing any pre-existing conditions, allergies, and medications. The presenting complaint and pertinent physical examination findings are documented, followed by diagnostic test results, including laboratory investigations, imaging studies, and other specialized tests. The treatment regimen, encompassing medications, procedures, surgeries, and therapeutic interventions, is meticulously recorded, along with any adverse reactions or complications encountered during the hospitalization. Moreover, the medical record serves as a communication tool among healthcare professionals, ensuring continuity of care and facilitating interdisciplinary collaboration. Ultimately, it plays a pivotal role in clinical decision-making, quality assessment, and medico-legal matters, serving as a repository of essential clinicalinformation essential for optimal patient management and healthcare delivery.Translated content:住院病历是患者医疗过程中不可或缺的文件，记录了患者在住院期间的病情、治疗方案和进展等重要信息。

英文病历书写范例(内科)

Medical Records for AdmissonMedical Number: 701721General informationName: Liu SideAge: EightySex: MaleRace: HanNationality: ChinaAddress: NO.35, Dandong Road, Jiefang Rvenue, Hankou, Hubei. Tel: 857307523 Occupation: RetiredMarital status: MarriedDate of admission: Aug 6th, 2001Date of record: 11Am, Aug 6th, 2001Complainer of history: patient’s son and wifeReliability: ReliableChief com plaint: Upper bellyache ten days, haem atem esis, hem afecia and unconsciousness for four hours.Present illness:The patient felt upper bellyache about ten days ago. He didn’t pay attention to it and thought he had ate som ething wrong. At 6 o’clock this m orning he fainted and rejected lots of blood and gore. Then hemafecia began. His family sent him to our hospital and received emergent treat m ent. So the patient was accepted because of “upper gastrointestine hemorrhage and exsanguine shock”.Since the disease com ing on, the patient didn’t urinate.Past historyThe patient is healthy before.No history of infective diseases. No allergy history of food and drugs.Past historyOperative history: Never undergoing any operation.Infectious history: No history of severe infectious disease.Allergic history: He was not allergic to penicillin or sulfamide.Respiratory system: No history of respiratory disease.Circulatory system: No history of precordial pain.Alimentary system: No history of regurgitation.Genitourinary system: No history of genitourinary disease.Hematopoietic system: No history of anemia and mucocut aneous bleeding. Endocrine system: No acromegaly. No excessive sweats.Kinetic system: No history of confinement of limbs.Neural system: No history of headache or dizziness.Personal historyHe was born in Wuhan on Nov 19th, 1921 and almost always lived in Wuhan. His living conditions were good. No bad personal habits and custom s.Menstrual history: He is a male patient.Obstetrical history: NoContraceptive history: Not clear.Family history: His parents have both deads.Physical examinationT 36.5℃, P 130/min, R 23/min, BP 100/60mmHg. He is well developed and moderately nourished. Active position. His consciousness was not clear. His face was cadaverous and the skin was not stained yellow. No cyanosis. No pigm entation. No skin eruption. Spider angioma was not seen. No pitting edem a. Superficial lymph nodes were not found enlarged.HeadCranium: Hair was black and white, well distributed. No deformities. No scars. No masses. No tenderness.Ear: Bilateral auricles were symmetric and of no masses. No discharges were found in external auditory canals. No tenderness in m astoid area. Auditory acuity was normal.Nose: No abnormal discharges were found in vetibulum nasi. Septum nasi was in midline. No nares flaring. No tenderness in nasal sinuses.Eye: Bilateral eyelids were not swelling. No ptosis. No entropion. Conjunctiva was not congestive. Sclera was anicteric. Eyeballs were not projected or depressed. Movem ent was normal. Bilateral pupils were round and equal in size. Direct and indirect pupillary reactions to light were existent.Mouth: Oral mucous membrane was not sm ooth, and there were ulcer can be seen. Tongue was in midline. Pharynx was congestive. Tonsils were not enlarged. Neck: Symmetric and of no deformit ies. No masses. Thyroid was not enlarged. Trachea was in m idline.ChestChestwall: Veins could not be seen easily. No subcutaneous em physema. Intercostal space was neither narrowed nor widened. No tenderness.Thorax: Symmetric bilaterally. No deformit ies.Breast: Symm etric bilaterally.Lungs: Respiratory m ovement was bilaterally symmetric with the frequency of 23/min. thoracic expansion and tactile fremitus were symmetric bilaterally. No pleural friction frem itus. Resonance was heard during percussion. No abnormal breath sound was heard. No wheezes. No rales.Heart: No bulge and no abnormal impulse or thrills in precordial area. The point of maximum impulse was in 5th left intercostal space inside of the mid clavicular line and not diffuse. No pericardial friction sound. Border of the heart was normal. Heart sounds were strong and no splitting. Rate 150/min. Cardiac rhythm was not regular. No pathological m urmurs.Abdomen: Flat and soft. No bulge or depression. No abdominal wall varicosis. Gastralintestinal type or peristalses were not seen. Tenderness was obvious around the navel and in upper abdoman. There was not rebound tenderness on abdomen orrenal region. Liver and spleen was untouched. No m asses. Fluidthrill negative. Shifting dullness negative. Borhorygmus not heard. No vascular murmurs. Extremit ies: No articular swelling. Free m ovements of all limbs.Neural system: Physiological reflexes were existent without any pathological ones. Genitourinary system: Not examed.Rectum: not exanedInvestigationBlood-Rt: Hb 69g/L RBC 2.70T/L WBC 1. 1G/L PLT 120G/LHistory summary1. Patient was m ale, 80 years old2. Upper bellyache ten days, haem atemesis, hem afecia 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. No abdominal wall varicosis. 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 m asses. Fluidthrill negative. Shifting dullness negative. Borhorygmus not heard. No vascular murmurs. No other positive signs.5. investigation information:Blood-Rt: Hb 69g/L RBC 2.80T/L WBC 1.1G/L PLT 120G/LImpression: upper gastrointestine hemorrhageExsanguine shock出院小结（DISCHARGE SUMMARY），===============Depart m ent of GastroenterologyChanghai Hospital，No.174 Changhai Road Shanghai, ChinaPhone: 86-21-25074725-803DISCHARGE SUMMARYDATE OF ADMISSION: October 7th, 2005DATE OF DISCHARGE: October 12th, 2005ATTENDING PHYSICIAN: Yu Bai, MDPATIENT AGE: 18ADMITTING DIAGNOSIS:Vomiting for unknown reason: acute gastroenteritis?BRIEF HISTORYA 18-year-old fem ale with a complaint of nausea and vomiting for nearly one month who was seen at Depart m ent of Gastroenterology in Changhai Hospital, found to have acute gastroenteritis and non-atrophic gastritis. The patient was subsequently recovered and discharged soon after m edication.REVIEW OF SYSTEMShe has had no headac he, fever, chills, diarrhea, chest pain, palpitations, dyspnea, cough, hem optysis, dysuria, hematuria or ankle edema.PAST MEDICAL HISTORYShe has had no previous surgery, accidents or childhood illness.SOCIAL HISTORY: She has no history of excessive alcohol or tobacco use.FAMILY HISTORYShe has no family history of cardiovascular, respiratary and gastrointestinal diseases.PHYSICAL EXAMINATIONTem perature is 37, pulse 80, respirations 16, blood pressure 112/70. General: Plump girl in no apparent distress. HEENT: She has no scalp lesions. Her pupils are equally round and reactive to light and accommodation. Extraocular movem ents are intact. Sclerae are anicteric. Oropharynx is clear. There is no thyrom egaly. There is no cervical or supraclvicular lymphadenopathy. Cardiovascular: Regular rate and rhythm, normal S1, S2. Chest: Clear to auscultation bilateral. Abdomen: Bowel sounds present, no hepatosplenomagaly. Extremities: There is no cyanosis, clubbing or edema. Neurologic: Cranial nerves II-XII are intact. Motor examination is 5/5 in the bilateral upper and lower extremit ies. Sensory, cerebellar and gait are normal.LABORATORY DATAWhite blood cells count 5.9, hem oglobin 111g/L, hematocrit 35.4. Sodium 142, potassium 4.3, chloride 106, CO2 25, BUN 2.6mmol/L, creatinine 57μmol/L, glucose 4.1mmol/L, Albumin 36g/L.Endoscopic ExamChronic non-atrophic gastritisHOSPITAL COURSEThe patient was adm itted and placed on fluid rehydration and mineral supplem ent. The patient improved, showing gradual resolution of nausea and vomit ing. The patient was discharged in stable condition.DISCHARGE DIAGNOSISAcute gastroenteritisChronic non-atrophic gastritisPROGNOSISGood. No m edications needed after discharge. But if this patient can not get used to Chinese food, she had better return to UK as soon as possible to prevent the relapse of acute gastroenteritis.The patient is to follow up with Dr. Bai in one week.___________________________Yu Bai, MD。

住院病历中英文对照

随着中外交流的加强，专业英语对医院也是越来越重要！花了点时间整理了下“住院病历的英汉对照”的格式，发上来和大家分享，希望对能用到的人有所帮助！POMR (Problem-Oriented Medical Records)表格式住院病历Biographical data:一般项目：Name Age Sex Marital status Nativity Race姓名年龄性别婚否籍贯民族Occupation Date of admission Informant History职业入院日期病史叙述者病史Chief complaint主诉History of present illness现病史Past history既往史：Previous health status: well ordinary bad Infectious diseases平素健康状况：良好一般较差传染病史Immunizations Allergies: N Y clinical manifestation预防接种史过敏史无有临床表现allergen: Trauma: Surgery:过敏原外伤史手术史Review of systems:(Tick if positive, cross out if negative. If postive, you should write down your disease history and brief course of diagnose and therapy)系统回顾：(有打√无打×阳性病史应在下面空间内填写发病时间及扼要诊疗经过) Respiratory system:呼吸系统Sore throat chronic cough sputum hemoptysis wheezing咽痛慢性咳嗽咳痰咯血哮喘dyspnea chest pain呼吸困难胸痛cadiovascular system:循环系统Palpitation dyspnea on exertion hemoptysis syncope心悸活动后气促咯血晕厥edema of lower limbs precordial pain hypertention下肢水肿心前区疼痛高血压Digestive system:消化系统Anorexia sour regurgitation belching nausea vomitting食欲减退反酸嗳气恶心呕吐abdominal distention abdominal pain constipation diarrhea腹胀腹痛便秘腹泻hematemesis melena hematochezia jaundice呕血黑便便血黄疸Urinary system:泌尿系统Lumbago frequent micturition urgent micturition urodynia腰痛尿频尿急尿痛dysuria hematuria nocturia polyuria oliguria facial edema排尿困难血尿夜尿多尿少尿面部水肿Hematopoietic system造血系统Fatigue dizziness blurred vision gingival bleedig乏力头昏牙龈出血subcutaneous hemorrhage ostealgia epistaxis皮下出血骨痛鼻衄Metabolic and endocrine system:代谢及内分泌系统Excessive appetite anorexia sweats cold intolerance食欲亢进食欲减退多汗畏寒polydipsia tremor hands change of character obvious obesity 多饮双手震颤性格改变显著肥胖emaciation hirsutism hair losing pigmentation消瘦多毛毛发脱落色素沉着chang of sexual function amenorrhea性功能改变闭经Musculoskeletal system肌肉骨骼系统Floating arthralgia arthraliga swelling of joints游走性关节痛关节痛关节红肿deformiteies of jionts myalgia atrophy of muscle关节变形肌肉痛肌肉萎缩Nervous system神经系统Dizziness headache vertigo syncope degeneration of memory 头昏头痛眩晕晕厥记忆力减退visual disturbance insomnia disturbance of consciousness视力障碍失眠意识障碍tremor spasm paralysis paresthesia颤动抽搐瘫痪感觉异常Personal history:个人史Birthplace Occupation sexual history smoking N Y出生地职业冶游史吸烟无有about years average pieces per day ceased for years约年平均支/日戒烟年alcohol intake N occasional frequent about years嗜酒无偶有经常约为年average ml per day others平均 ml/日其他Marital history:婚姻史：Marrying age companion’s state of health结婚年龄配偶健康状况Menorrhea and Childbearing:月经及生育史Menarche age cycle lasting for days date of last period初潮每次持续时间末次月经时间(age of menopause)绝经年龄Amount of flow: little normal large menstrual pain: N Y经量少正常多痛经无有cycle: regular irregular pregnancy times natural labor经期规则不规则妊娠次顺产times abortions times premature delivery times胎流产胎早产胎stillbirths times difficult labor and its condition死产胎难产及病情Familly history (pay attention to the congenital diseases andcommunicable diseases and communicable dieases related to the paitent家族史（注意与患者现病有关的遗传病和传染性疾病）Father: still alive illness died cause of deaths mother:父：健在患病已故死因母 still alive illness died cause of death siblings: others:健在患病已故死因兄弟姐妹子女其他Physical examination体格检查Vital signs生命体征:Temperature体温pulse脉搏 /min次/分respiration呼吸 /min次/分B.P血压 mmHgGeneral Appearance一般状况:Development发育:ortho-sthenic type正常asthenic type不良sthenic type超常nutrition营养:well良好fairly中等poor不良cachexia恶病质Facial features面容:normal无病容acute急性chronic慢性病容others其他Expression表情:natural自知painful痛苦anxious忧虑dreadful恐惧indifferent淡漠Position: active semi-recumbent others体位：自主半卧位其他Gait: normal abnormal步态正常不正常Conciousness: aware somnolence confusion stupor coma神志清楚嗜睡模糊昏睡昏迷delirium coppperatio; well badly谵妄配合检查合作不合作Mucocutaneous color: normal red pale cyaosis stainted皮肤粘膜色泽无病容潮红苍白紫绀yellow pigmentation lesions:N Y (type and distribution)黄染色素沉着皮疹无有（类型及分布）Subcutaneous hemorrhange: N Y(type and distribution)皮下出血无有（类型及分布）Hair: normal reduced edema: N Y(position and degree)头发分布正常减退水肿无有（部位及程度）Hepatic palm: N Y spider angionma:N Y（position numbers ） others:肝掌无有蜘蛛痣无有(部位数目) 其他Lymphnodes:淋巴结Superficial lymph nodes: non-swelling swelling(position and characteristics)全身淋巴结肿大无肿大肿大（部位及特征）Head : cranium : size : normal large small deformity:头部头颅大小正常大小畸形N Y(coxycephaly squared skull deforming skull)无有（尖颅方颅变形颅）Others: tenderness mass sunk (position)其他异常：压痛包块凹陷（部位）Eyes eyelid: normal edema ptosis trichiasis conjunctive :眼睑正常水肿下垂倒睫结膜normal hyperemia edema hemrrhage正常充血水肿出血eye ball: normal proptosis depression tremor眼球正常突出凹陷震颤motion dysfunction(left right)运动障碍Sclera :normal yellow cornea : normal abnormal ( left right )巩膜无黄染有黄染角膜正常异常（左右）Pupils: equal roundness same size unequal left cm瞳孔等圆等大不等左 cmreaction to light: normal delay (left right) disappear (left right) 对光反射正常迟钝（左右）消失（左右）Others:其他Ears: auricle :normal deformity fistula others (left right )耳耳廓正常畸形瘘管其他（左右）excretions of external auditory canal: N Y (left right feature)外耳道分泌物无有（左右性质）Tenderness of mastoid : N Y audation dysfunction: N Y (left right)乳突压痛无有听力粗试障碍无有（左右）Nose: shape : normal: abnormal ( ) other abnormalities:N Y鼻外形正常异常（）其他异常无有Nosalala flap obsruction excretions nasal sinus tenderness:鼻翼扇动鼻塞分泌物鼻旁窦压痛N Y (position )无有（部位）Mouth lips :red syanosis pale herpes fissure mucosa :normal口唇红润发绀苍白疱疹皲裂粘膜正常abnormal ( pale petechia)异常（苍白出血点）Opening of parotid gland duct: normal abnormal (swelling腮腺导管开口正常异常（肿胀suppurative excretions)脓性分泌物）Tongue:normal abnormal (coverings tremor leaning to left or right)舌正常异常（舌苔伸舌震颤向左、向右偏斜）Gums: normal swelling pus overflow hemorrhage pigments牙龈正常肿胀溢脓出血色素沉着lead line tooth:regular edentulous carious teeth铅线牙列齐缺牙—|—龋齿—|—Tonsils: pharynx: voice: normal hoarse扁桃体咽声音正常嘶哑Neck:resistence:N Y carotid artery pulsation: normal increased颈部抵抗感无有颈动脉搏动正常增强decreased (left right) jugular vein:normal distention减弱（左右）颈静脉正常充盈high distention trachea:middle deviation to (left right)怒张气管正中偏移（向左向右）Hepatojugular reflux:(-) (+) thyroid: normal swelling degree肝颈静脉回流征：（-）（+）甲状腺正常肿大度Symmetry 对称Dominance in one side: spreading nodular:soft hard others :N Y 侧为主弥漫性结节性质软质硬其他无有(tenderness tremor bruits)（压痛震颤血管杂音）Chest topography:normal barrel chest pigeon chest funnel chest胸部胸廓正常桶状胸鸡胸漏斗胸flat chest bulging or retraction (left right )扁平胸膨隆或凹陷（左右）bulging in the precordial region tenderness of sternum心前区膨隆胸骨压痛Breast: normal symmetrical abnormal : left right(gynecomastia乳房正常对称异常左右（男乳女化mass tenderness excretions of nipples)包块压痛乳头分泌物）Lung肺Inspection : movement of respiration : normal abnormal : left视诊呼吸运动正常异常左right( increased decreased)右（增强减弱）Intercostal space :normal wide narrow(position)肋间隙正常增宽变窄（部位）Palpation : vocal fremitus:normal abnormal :left right (increased触诊：语颤正常异常左右（增强decreased ) pluernal friction rubs: N Y（position）减弱胸膜摩擦感：无有（部位）Subcutaneous crepitus: N Y(posotion) percussion: resonance皮下捻发感无有（部位）叩诊正常清音abnormal dullness flatness hyperresonance tympany异常叩诊音浊音实音过清音鼓音Lower borders:scapular line: right intercostal space, left肺下界肩胛线右肋间左intercostal space Range of mobility: right cm , left cm肋间移动度右 cm，左 cmDusculation: breath regular irregular听诊呼吸规整不规整Breath sound: normal abnormal( feature, position )呼吸音正常异常（性质，部位描写）Rale: N Y ：ronchi: sonorous sibilant啰音：无有：干性鼾音哨笛音Moist rales: coarse medium fine rales crepitus湿性大中小水泡音捻发音Vocal conduction: normal abnormal: reduced increased(position)语音传导正常异常减弱增强（部位）Plueral friction rubs: N Y (position)胸膜摩擦音无有（部位）Heart 心Inspection:bulging in precordial region : N Y apex impulse:视诊心前区隆起无有心尖搏动normal unseen increased diffusing position: normal正常未见增强弥散心尖搏动位置正常deviation ( the distance from midclavicular line cm)移动（距左锁骨中线内外厘米）Other precordial pulsations: N Y (position)其他部位搏动无有（部位）Palpation:apex impulse:normal increased thrust unclear触诊心尖搏动正常增强抬举感触不清thrills :N Y (position period) percardial friction rubs:N Y震颤无有（部位时期）心包摩擦感无有Percussion:relative cardiac outline: normal shrink extant (right left )叩诊相对浊音界正常缩小扩大（右左）Ausculation: heart rate bpm/min rhythm(regular irregular听诊心率次/分心律（齐不齐）absolutly irrgelar) heart sound:S1normal increased decreased绝对不齐心音 S1 正常增强减弱split S2 normal increased decreased split分裂 S2 正常增强减弱分裂S3 N Y S4 N Y A2 P2S3 无有 S4 无有 A2 P2Extra heart sound N gallop (diastolic presystotic summalion额外心音无奔马律（舒张期收缩前期重叠gallop) opening snap others murmurs: N Y (degree conduction)开瓣音其他杂音无有（图示并描述传导）Pericardial friction rubs N Y心包摩擦音无有Peripheral vessals: normal pistal shot of big arteries周围血管无异常血管征大血管枪击音Duroziez’s sign water hammer pulse capillary pulsa tion二重杂音水冲脉毛细血管搏动pulse deficit paradoxical pulse pulsus alternans other脉搏短绌奇脉交替脉其他Abdoman腹部Inspection: shape normal distention frog abdomen( size cm)视诊外形正常膨隆蛙腹（腹围厘米）scaphoid apical abdomen gastral pattern intestinal pattern舟腹尖腹胃型肠型peristalsis abdominal respiration:existance disappear umbilicus:蠕动波腹式呼吸存在消失脐normal protruding excretions others: N Y(venous distention of正常凸出分泌物其他异常无有（腹壁静脉曲张abdoman purple striae surgical scars hernia)条纹手术疤痕疝）Palpation: soft muscle tension position tenderness N Y触诊柔软腹肌紧张部位压痛无有rebound tenderness N Y fluidthtill N Y succussions plash N Y 反跳痛无有液波震颤无有振水音无有Mass N Y(position size) discription of feature liver:can’t be 腹部包块无有（部位大小）特征描述肝未触及touched can be touched :subcostal cm under xipfoid process可触及肋下厘米剑突下discription of feature gallbladder: can’t be touched can be touched特征描述胆囊未触及可触及size cm tenderness N Y Murphy’s sign spleen: can’t be 大小厘米压痛无有 Murphy征脾未触及touched can be touched distance from costal margin cm可触及肋下厘米Kideny:can’t be touched can be touched size consistency肾未触及可触及大小硬度tenderness mobility tenderness of ureters: N Y (position)压痛移动度输尿管压痛点无有（部位）percussion: borders of liver dull(existance shrink obliteration )叩诊肝浊音界（存在缩小消失）Upper borders of liver on right midclavicular line intercostal space 肝上界位于右锁骨中线肋间shifting dullness N Y tenderness in renal region N Y (right left )移动性浊音无有肾区叩痛无有（右左）ausculation : borhorygmus normal increased decreased听诊肠鸣音正常增强减弱disappear gurgling N Y vessal bruits N Y (position)消失气过水声无有血管杂音无有（部位）Genitalia :not examined normal abnormal Rectum and Anus :生殖器未查正常异常肛门直肠not examined normal abnormal未查正常异常Spine and Extremities脊柱四肢Spine : normal deformities (lateral anterior posterior protruding)脊柱正常畸形（侧前后凸）Spinous process : tenderness pain while percussed ( position )棘突压痛叩痛（部位）Mobility : normal restricted extremeties: normal abnormal移动度正常受限四肢正常异常deformity swelling of joints joints stiffness畸形关节红肿关节强直tenderness of muscles atrophy of muscles肌肉压痛肌肉萎缩Venous distention of lower limbs (position and feature ) acropachy下肢静脉曲张（部位及特征）杵状指Nervus System神经系统Abdominal wall reflex ( normal ) muscle tone ( normal )腹壁反射（正常）肌张力（正常）Myodynamia ( degree ) paralysis of limbs N Y (left right肌力（级）肢体瘫痪无有（左右upper lower) biceps reflex left (normal) right (normal)上下）肱二头肌反射左（正常）右（正常） knee jerk left (normal) right( normal) achilles jerk left膝健反射左（正常）右（正常）跟腱反射左(normal) right ( normal )正常右（正常）Hoffmann’s di gn left (+)(-) right(+)(-)Hoffmann征左（+）(-) 右（+）（-）Babinski’s sign left(+)（-） right(+)(-)Babinski 左（+）（-）右（+）（-）Kernig’s sign left(+)（-）right(+)(-) othersKernig征左（+）（-）右（+）（-）其他Laboratory findings实验室及器械检查结果（The important laboratory examination .X-ray . ECG and other result areincluded） (重要的化验、X线、心电图及其他有关化验) Nunber of X-rayX线片号Abstract病历摘要Diagnosis(impressions)入院诊断Recorder病史记录者Examiner并使审阅者Date of record 记录日期 . ..。

英文病历范文

英文病历范文Title: English Medical Record Sample (Creating and Expanding on a Matching Content)Medical RecordNa John SmithDate of Birth: February 15, 1985Gender: MaleNationality: AmericanOccupation: AccountantChief Complaint:The patient presented with a complaint of persistent cough, shortness of breath, and chest pain for the past week.History of Present Illness:The symptoms initially started as a mild cough, which gradually worsened over the week. The patient also experienced shortness of breath, especially during physical activities. He reported occasional chest pain, which was sharp in nature and intensified during deep breaths. The patient denied any fever, night sweats, or weight loss.Past Medical History:The patient has a history of asthma since childhood and has been using an inhaler as needed. He had a similar episode ofpersistent cough and shortness of breath six months ago, which resolved with a course of oral steroids. No other significant medical history was reported.Social History:The patient is a non-smoker and denies any alcohol or illicit drug use. He lives with his wife and two children in a smoke-free environment. The patient works as an accountant and does not have any known occupational exposures.Family History:There is no significant family history of respiratory diseases or any chronic illnesses.Review of Systems:The review of systems was unremarkable except for the respiratory symptoms mentioned above.Physical Examination:On examination, the patient appeared to be in no acute distress. Vital signs were within normal limits. Auscultation of the lungs revealed mild wheezing bilaterally. Heart sounds were normal, and there were no signs of peripheral edema or cyanosis. Other systemic examinations were within normal limits.Investigations:Laboratory investigations, including complete blood count, liver and kidney function tests, and electrolyte levels, were all within normal range. Chest X-ray showed hyperinflation of lungs and no evidence of infiltrates or consolidation.Assessment and Plan:Based on the history, clinical findings, and investigations, the patient's symptoms and past medical history suggest asthma exacerbation. Initial management includes a trial of short-acting bronchodilators, oral corticosteroids, and close monitoring of symptoms. The patient was educated about proper inhaler technique and advised to follow up in one week for reassessment.Education and Counseling:The patient was counseled on the importance of adherence to the prescribed medication and the need to avoid triggers for asthma exacerbation, such as allergens and respiratory infections. He was also provided with a written asthma action plan for self-management and advised to seek medical attention if symptoms worsen or do not improve within a week.Follow-up:The patient will be scheduled for a follow-up visit in one week to reassess symptoms, evaluate response to treatment, andadjust the management plan accordingly.This medical record documents the patient's chief complaint, history of present illness, past medical history, social and family history, physical examination findings, investigations, diagnosis, and treatment plan. It serves as a comprehensive guide for healthcare professionals involved in the patient's care.。

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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.good 2.moderate 3.poorDisease history: (if any, please write down the date of onset, brief diagnosticand therapeutic course, and the results.)Respiratory system:1. None2.Repeated pharyngeal pain3.chronic cough4.expectoration:5. Hemoptysis6.asthma7.dyspnea8.chest pain_______________________________________________________________ Circulatory system:1.None2.Palpitation3.exertional dyspnea4..cyanosis5.hemoptysis6.Edema of lower extremities7.chest pain8.syncope9.hypertension _______________________________________________________________ Digestive system:1.None2.Anorexia3.dysphagia4.sour regurgitation5.eructation6.nausea7.Emesis8.melena9.abdominal pain 10.diarrhea11.hematemesis 12.Hematochezia 13.jaundice_______________________________________________________________ Urinary system:1.None2.Lumbar pain3.urinary frequency4.urinary urgency5.dysuria6.oliguria7.polyuria8.retention of urine9.incontinence of urine10.hematuria 11.Pyuria 12.nocturia 13.puffy face_______________________________________________________________ Hematopoietic system:1.None2.Fatigue3.dizziness4.gingival hemorrhage5.epistaxis6.subcutaneous hemorrhage_______________________________________________________________ Metabolic and endocrine system:1.None2.Bulimia3.anorexia4.hot intolerance5.cold intolerance6.hyperhidrosis7.Polydipsia8.amenorrhea9.tremor of hands 10.character change 11.Marked obesity12.marked emaciation 13.hirsutism 14.alopecia15.Hyperpigmentation 16.sexual function change_______________________________________________________________ Neurological system:1.None2.Dizziness3.headache4.paresthesia5.hypomnesis6. Visual disturbance7.Insomnia8.somnolence9.syncope 10.convulsion 11.Disturbance of consciousness12.paralysis 13. vertigo_______________________________________________________________ Reproductive system:1.None2.others_______________________________________________________________ Musculoskeletal system:1.None2.Migrating arthralgia3.arthralgia4.artrcocele5.arthremia6.Dysarthrosis7.myalgia8.muscular atrophy_______________________________________________________________ Infectious Disease:1.None2.Typhoid fever3.Dysentery4.Malaria 4.Schistosomiasis4.Leptospirosis 7.Tuberculosis 8.Epidemic hemorrhagic fever9.others_______________________________________________________________ Vaccine inoculation:1.None2.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.Plasma3.Ingredient transfusion)Blood type:____________ Transfusion time:___________Transfusion reaction1.None2.YesClinic manifestation:_____________________________ Allergic history:1.None2.Yes3.Not clearallergen:________________________________________________clinical manifestation:_____________________________________Personal history:Custom living address:____________________________________________ Resident history in endemic disease area:_____________________________ Smoking: 1.No 2.YesAverage ___pieces per day; about___yearsGiving-up 1.No 2.Yes (Time:_______________________) Drinking: 1.No 2.YesAverage ___grams per day; about ___yearsGiving-up 1.No 2.Yes(Time:________________________) Drug abuse:1.No 2.YesDrug names:_______________________________________ _______________________________________________________________ Marital and obstetrical history:Married age: __________years old Pregnancy ___________timesLabor _______________times(1.Natural labor: _______times 2.Operative labor: ________times3.Natural abortion: ______times4.Artificial abortion: _______times5.Premature labor:__________times6.stillbirth__________times)Health status of the Mate:1.Well2.Not fineDetails: _______________________________________________ Menstrual history:Menarchal age: _______ Duration ______day Interval ____daysLast menstrual period: ____________ Menopausal age: ____years oldAmount of flow: 1.small 2. moderate 3. largeDysmenorrheal: 1. presence 2.absence Menstrual irregularity 1. No 2.Yes Family history: (especially pay attention to the infectious and hereditary diseaserelated to the present illness)Father: 1.healthy 2.ill:________ 3.deceased cause: ___________________ Mother:1.healthy 2.ill:________ 3.deceased cause: ___________________ Others: ________________________________________________________ The anterior statement was agreed by the informant.Signature of informant: Datetime:Physical ExaminationVital signs:Temperature:______0C Blood pressure:_______/_______mmHg Pulse: _____ bpm (1.regular 2.irregular_____________________________) Respiration: ___bpm (1.regular 2.irregular____________________________) General conditions:Development: 1.Normal 2.Hypoplasia 3.HyperplasiaNutrition: 1.good 2.moderate 3.poor 4.cachexiaFacial expression: 1.normal 2.acute 3.chronic other_____________________ Habitus: 1.asthenic type 2.sthenic type 3.ortho-thenic typePosition: 1.active 2.positive pulsive 4.other_______________________ Consciousness: 1.clear 2.somnolence 3.confusion 4.stupor 5.slight coma6.mediate coma7.deep coma8.deliriumCooperation: 1Yes 2.No Gait: 1.normal 2.abnormal______Skin and mucosa:Color: 1.normal 2.pale 3.redness 4.cyanosis 5.jaundice 6.pigmentationSkin 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: normal cold warm dry moist dehydration Liver palmar : 1.no 2.yes Spider angioma (location:________________) Others: __________________________________________________________ Lymph nodes: enlargement of superficial lymph node:1.no2.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:________________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.right 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. Eurodontia 4.others:____________________Gum :1.normal 2.abnormal (Description____________________________)Tonsil:___________________________Pharynx:_____________________Sound: 1.normal 2.hoarseness 3.others:_____________________________ Neck:Neck rigidity 1.no 2.yes (______________transvers fingers)Carotid artery: 1.normal pulsation 2.increased pulsation 3.marked distention Trachea location: 1.middle 2.deviation (1.leftward_______2.rightward______) Hepatojugular vein reflux: 1. negative 2.positiveThyroid: 1.normal 2.enlarged _______ 3.bruit (1.no 2.yes ________________) Chest:Chest wall: 1.normal 2.barrel chest 3.prominence or retraction:( left________right_________Precordial prominence__________) Percussion pain over sternum 1.No 2.YesBreast: 1.Normal 2.abnormal _______________________________________ Lung:Inspection: 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 border of lung: (detailed percussion in respiratory disease) midclavicular line : R:_____intercostae L:_____intercostaemidaxillary line: R:______intercostae L:_____intercostaescapular line: R:______intercostae L:_____intercostaemovement of lower borders:R:_______cmL:__________cm Auscultation: Breathing sound : 1.normal 2.abnormal _______________Rales:1.no 2.yes__________________________________ Heart: Inspection:Apical pulsation: 1.normal 2.unseen 3.increase 4.diffuseSubxiphoid pulsation: 1.no 2.yesLocation of apex beat: 1.normal 2.shift (______ intercosta,distance away from left MCL______cm) Palpation:Apical pulsation:1. normal 2.lifting apex impulse 3.negative pulsationThrill:1.no 2.yes(location:___________ phase:_________________)Percussion: relative dullness border: 1.normal 2.abnormalAuscultation: Heart rate:___bpm Rhythm:1.regular 2.irregular_______ Heart sound: 1.normal 2.abnormal________________________Extra sound: 1.no 2.S3 3.S4 4. opening snapP2_________ A2_________Pericardial friction sound:1.no 2.yesMurmur: 1.no 2.yes (location____________phase_____________quality______intensity________ transmission___________effects of position_________________________________effects of respiration______________________________ Peripheral vascular signs:1.None2.paradoxical pulse3.pulsus alternans4. Water hammer pulse5.capillary pulsation6.pulse deficit7.Pistol shot sound8.Duroziez signAbdomen:Inspection: Shape: 1.normal 2.protuberance 3.scaphoid 4.frog-bellyGastric pattern 1.no 2.yes Intestinal pattern 1.no 2.yesAbdominal vein varicosis 1.no 2.yes(direction:______________ )Operation scar1.no 2.yes ________________________________ Palpation: 1.soft 2. tensive (location:____________________________)Tenderness: 1.no 2.yes(location:_______________________)Rebound tenderness:1.no 2.yes(location:________________)Fluctuation: 1.present 2.abscentSuccussion splash: 1.negative 2.positiveLiver:_______________________________________________Gallbladder: __________________Murphy sign:____________Spleen:______________________________________________Kidneys:____________________________________________Abdominal mass:______________________________________Others:______________________________________________ Percussion: Liver dullness border: 1.normal 2.decreased 3.absentUpper hepatic border:Right Midclavicular Line ________IntercostaShift dullness:1.negative 2.positive Ascites:_____________degreePain on percussion in costovertebral area: 1.negative 2.positve ____ Auscultation: Bowel sounds : 1.normal 2.hyperperistalsis 3.hypoperistalsis4.absence Gurgling sound:1.no 2.yesVascular bruit 1.no 2.yes (location_____________________) Genital organ: 1.unexamined 2.normal 3.abnormalAnus and rectum: 1.unexamined 2.normal 3.abnormalSpine and extremities:Spine: 1.normal 2.deformity (1.kyphosis 2.lordosis 3.scoliosis)3.Tenderness(location______________________________)Extremities:1.normal 2.arthremia & arthrocele (location_________________)3.Ankylosis (location__________)4.Aropachy: 1.no 2.yes5.Muscular atrophy (location_______________________) Neurological system:1.normal 2.abnormal_______________________________ _____________________________________________________________________ Important examination results before hospitalized___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ Summary of the history:______________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ Initial diagnosis:_____________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________Recorder:Corrector:。

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