儿科英文病历模板

Medical Records for Admisson

Medical Number: 696235 General information

Name:Zhang Yi

Age: thirteen

Sex: Female

Race:Han

Nationality:China

Address: NO.23, Yunchun Road, Jiefang Rvenue, Hankou, Hubei. Tel: 85763723

Parents Name: father Zhang Hesheng

Mother Yang Chiulian Date of admission: May 8th, 2001 Date of record: 11Am, May 8th, 2001

Complainer of history: patient’s mother

Reliability: Reliable

Chief complaint: Pharyngalgia and fever for four days.

Present illness:

The patient felt pharyngalgia and weak about four days ago. She ate some medicine (not clear), but it do nothing. Then she found ulcer in her mouth and fever all along, but she felt no nausea and never vomited. So her parents took her to Wuhan Children’s Hospital, there she received treatment of antibiotics, but her symptoms didn’t abate. So her parents took her to our hospital, she was admitted with a diagnosis of “fever of unknown”

Since onset, her appetite was not good, and both her spiritedness and physical energy are bad. Defecation and urination are normal.

Past history

The patient is healthy before.

No history of “measles”or “pertussis”etc and no contact history with T.B or other infective diseases. No allergy history of food but she was allergy to sulfa.

Personal history

1.Natal: First birth born, uneventfully and on full term with birth

weight 2.7 Kg. The state of her at birth was good, no cyanosis, apnea, convulsion or bleeding.

2.Development: Able to raise head at second month. The first tooth

erupted at 6th. She began to walk at one. Her intelligence was normal.

3.Nutrition: She was only feeded with breast milk before she was 6

months old. Then the additives were added. She was weaned from the breast at 14th month.

4.Immunization: Inoculated on schedule after birth (such as B.C.G,

D.P.T and smallpox voccination).

Physical examination

T 39.5℃, P 120/min, R 30/min, BP 110/90mmHg. She is well developed and moderately nourished. Active position. The skin was not stained yellow. No cyanosis. No pigmentation. No skin eruption. Spider angioma was not seen. No pitting edema. Superficial lymph nodes were found enlarged in her neck, but no flare and tenderness. Head

Cranium: Hair was black and 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 mastoid 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. Movement was normal. Bilateral pupils