(2021年整理)心內(nèi)科英文病歷模板

1、心內(nèi)科英文病歷模板心內(nèi)科英文病歷模板 編輯整理：尊敬的讀者朋友們：這里是精品文檔編輯中心，本文檔內(nèi)容是由我和我的同事精心編輯整理后發(fā)布的，發(fā)布之前我們對(duì)文中內(nèi)容進(jìn)行仔細(xì)校對(duì)，但是難免會(huì)有疏漏的地方，但是任然希望（心內(nèi)科英文病歷模板）的內(nèi)容能夠給您的工作和學(xué)習(xí)帶來(lái)便利。同時(shí)也真誠(chéng)的希望收到您的建議和反饋，這將是我們進(jìn)步的源泉，前進(jìn)的動(dòng)力。本文可編輯可修改，如果覺(jué)得對(duì)您有幫助請(qǐng)收藏以便隨時(shí)查閱，最后祝您生活愉快 業(yè)績(jī)進(jìn)步，以下為心內(nèi)科英文病歷模板的全部?jī)?nèi)容。 medical records for admisson medical number： 701721general information

2、name： liu sideage: eightysex： malerace： hannationality： chinaaddress： no。35, dandong road, jiefang rvenue, hankou, hubeioccupation: retiredmarital status: marrieddate of admission： aug 6th, 2001date of record: 11am， aug 6th， 2001complainer of history: patients son and wifereliability: reliablechief

3、complaint: upper bellyache ten days， haematemesis， hemafecia and unconsciousness for four hours。present illness: the patient felt upper bellyache about ten days ago。 he didnt pay attention to it and thought he had ate something wrong. at 6 oclock this morning he fainted and rejected lots of blood an

4、d gore. then 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 didnt urinate。 past history the patient is healthy before. no hi

5、story of infective diseases。 no allergy history of food and drugs。 past history operative 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 respirat

6、ory 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 mucocutaneous bleeding. endocrine system： no acromegaly. no excessive sweats。 kine

7、tic system: no history of confinement of limbs. neural system： no history of headache or dizziness。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。menstrual history： he is a male patient。obs

8、tetrical history: nocontraceptive history： not clear。family history： his parents have both deads.physical examination t 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

9、not stained yellow. no cyanosis. no pigmentation. no skin eruption。 spider angioma was not seen。 no pitting edema。 superficial lymph nodes were not found enlarged.head cranium: hair was black and white， well distributed. no deformities. no scars。 no masses。 no tenderness. ear: bilateral auricles wer

10、e 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 eyeli

11、ds 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 were round and equal in size. direct and indirect pupillary reactions to light were existent。 mouth: oral mucous membra

12、ne 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 midline.chest chestwall: veins could not be seen easily. no subcutaneous emphysema

13、. intercostal space was neither 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 expansion and tactile fremitus were symmetric bilaterally。 n

14、o 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 impulse was in 5th left intercostal space inside of the mid clavicular line and no

15、t 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 murmurs。abdomen： flat and soft。 no bulge or depression. no abdominal wall varicosis. gastralintestinal type or peristalse

16、s 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 negative。 shifting dullness negative. borhorygmus not heard. no vascular murmurs。extremities： no articula

17、r 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/lhistory summary1. patient was male， 80 years old2. upper bell

18、yache 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。 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