英文病歷模版

1、Divisio n:Ward:Bed:Case No.Name:Sex:Age:Nation:BirthPlace:MaritalStatus:Work-organization&Occupation:LivingAddress&Tel:Dateofadmission:Dateofhistorytaken:Informant:ChiefComplaint:HistoryofPresentIllness:PastHistory:GeneralHealthStatus:1.good2.moderate3.poorDiseasehistory:(ifany,pleasewritedo

2、wnthedateofonset,briefdiagnosticandtherapeuticcourse,andtheresults.)IIDivisi on:Ward:Bed:Case No.Respiratorysystem:1.None2.Repeatedpharyngealpain3.chroniccoughd.expectoration:5. Hemoptysis6.asthma7.dyspnea8.chestpainCirculatorysystem:1 .None2.Palpitation3.exertionaldyspnea4.cyanosis5.hemoptysis6. Ed

3、emaoflowerextremities7.chestpain8.syncope9.hypertensionDigestivesystem:I.None2.Anorexia3.dysphagia4.sourregurgitation5.eructation6.nausea7.Emesis8.melena9.abdominalpain10.diarrhea11.hematemesis12.Hematochezia13.jaundiceUrinarysystem:1.None2.Lumbarpain3.urinaryfrequency4.urinaryurgency5.dysuria6.olig

4、uria7.polyuria8.retentionofurine9.ineontinenceofurine10.hematuriall.Pyuria12.nocturia13.puffyfaceHematopoieticsystem:1.None2.Fatigue3.dizziness4.gingivalhemorrhage5.epistaxis6.subcutaneoushemorrhageMetabolicandendocrinesystem:I.None2.Bulimia3.anorexia4.hotintoleranee5.coldintoleranee6.hyperhidrosis7

5、.Polydipsia8.amenorrhea9.tremorofhands10.characterchangeII.Markedobesity12.markedemaciation13.hirsutism14.alopecia15.Hyperpigmentation16.sexualfunctionchangeNeurologicalsystem:1 .None2.Dizziness3.headache4.paresthesia5.hypomnesis6.Visualdisturbanee7.lnsomnia8.somnolence9.syncope10.convulsionII.Distu

6、rbaneeofconsciousness12.paralysis13.vertigoReproductivesystem:1.None2.othersMusculoskeletalsystem:1.None2.Migratingarthralgia3.arthralgia4.artrcocele5.arthremia6.Dysarthrosis7.myalgia8.muscularatrophyInfectiousDisease:1.None2.Typhoidfever3.Dysentery4.Malaria4.Schistosomiasis4. Leptospirosis7.Tubercu

7、losis8.Epidemichemorrhagicfever9.othersVaccineinoculation:1 .None2.Yes3.NotclearVaccinedetailTraumaand/oroperationhistory:Operations:1.None2.YesOperationdetails:Traumas:1.None2.YesTraumadetails:Bloodtransfusionhistory:1.None2.Yes(1.Wholeblood2.Plasma3.Ingredienttransfusion)Bloodtype:Transfusiontime:

8、Transfusionreaction1.None2.YesClinicmanifestation:Allergichistory:1.None2.Yes3.Notclearallergen:clinicalmanifestation:Personalhistory:CustomlivingaddresResidenthistoryinendemicdiseasearea:Smoking:1.No2.YesAveragepiecesperday;aboutyearsGiving-up1.No2.Yes(Time:)Drinking:1.No2.YesAveragegramsperday;abo

9、utyearsGiving-up1.No2.Yes(Time:)Drugabuse:1.No2.YesDrugnames:Maritalandobstetricalhistory:Marriedage:yearsoldPregnancytimesLabortimes(.Naturallabor:times2.0perativelabor:times3 .Naturalabortion:times4.Artificialabortion:times5 .Prematurelabor:times6 .st川birthtimes)HealthstatusoftheMate:1 .Well2.Notf

10、ineDetails:Menstrualhistory:Menarchalage:DurationdayIntervaldaysLastmenstrualperiod:Menopausalage:yearsoldAmountofflow:1.small2.moderate3.largeDysmenorrheal:1.presenee2.absencMenstrualirregularity1.No2.YesFamilyhistory:(especiallypayattentiontotheinfectiousandhereditarydiseaserelatedtothepresentilln

11、ess)Father:l.healthy2.ill:3.deceasedcause:Mother:1.healthy2.ill:3.deceasedcause:Others:Datetime:Theanteriorstatementwasagreedbytheinformant.Signatureofinformant:PhysicalExaminationVitalsigns:Temperature:CBloodpressure:/mmHgPulse:bpm(l.regular2.irregular)Respiration:_bpm(l.regular2.irregular)Generalc

12、onditions:Development:I.Normal2.Hypoplasia3.HyperplasiaNutrition:l.good2.moderate3.poor4.cachexiaFacialexpression1.normal2.acute3.chronicotherHabitus:l.asthenictype2.sthenictype3.ortho-thenictypePosition:pulsive4.otherConsciousnessl.clear2.somnolence3.confusion4.stupor5.slightcoma6.mediatecoma7.deep

13、coma8.deliriumCooperation:1Yes2.NoGait:l.normal2.abnormaliiiDivisi on:Ward:Bed:Case No.Skinandmucosa:Color:1.normal2.pale3.redness4.cyanosis5.jaundice6.pigmentationSkineruption:1.No2.Yes(type:distribution:)Subcutaneousbleeding:.no2.yes(type:distribution:)Edema:1.no2.yes(locationanddegree)Hair:1.norm

14、al2.abnormal(details)Temperatureandmoisture:normalcoldwarmdrymoistdehydrationLiverpalmar:1.no2.yesSpiderangioma(location:)Others:Lymphnodes:enlargementofsuperficiallymphnode:1.no2.yesDescription:Head:Skullsize1.normal2.abnormal(description:)Skullshaped.normal2.abnormal(description:)Hairdistribution:

15、1.normal2.abnormal(description:)Others:Eye:exophthalmos:eyelid:conjunctiva:sclera:Cornea:Pupil:l.equallyroundandinsize2.unequal(RmmLmm)Pupilreflex:l.normal2.delayed(RsLs)3.absent(R_L)others:Ear:Auriclel.normal2.desformation(description:)Dischargeofexternalauditorycanal:1.no2.yes(l.left2.rightquality

16、:)Mastoidtenderness1.no2.yes(l.left2.rightquality:)Disturbaneeofauditoryacuity:1.no2.yes(1eft2.rightdescription:)Nose:Flaringofalaenasi:1.no2.yesStuffydischarge1.no2.yes(quality_)Tendernessoverparanasalsinuses:1.no2.yes(location:)Mouth:LipMucosaTongueTeeth:1.normal2.Agomphiasis3.Eurodontia4.others:G

17、um:1.normal2.abnormal(Description)Tonsil:Pharynx:Sound:1.normal2.hoarseness3.others:Neck:Neckrigidity1.no2.yes(transversfingers)Carotidartery:1.normalpulsation2.increasedpulsation3.markeddistentionTrachealocation:l.middle2.deviation(1.1eftward2.rightward)Hepatojugularveinreflux:1.negative2.positiveT

18、hyroid:1.normal2.enlarged3.bruit(1.no2.yes)Chest:Chestwall:.minenceorretraction:(leftrightPrecordialprominence)Percussionpainoversternum1.No2.YesBreast:I.Normal2.abnormalLung:Inspection:respiratorymovementl.normal2.abnormalPalpation:vocaltactilefremitus:1.normal2.abnormalpleu

19、ralrubbingsensation:1.no2.yesSubcutaneouscrepitussensation:1.no2.yesPercussion:1resonance2.Hyperresonance&location3. Flatness&location4. dullness&location:5. tympany&location:lowerborderoflung:(detailedpercussioninrespiratorydisease)midclavicularline:R:intercostaeL:intercostaemidaxil

20、laryline:R:intercostaeL:intercostaescapularline:R:intercostaeL:intercostaemovementoflowerborders:R:cmL:cmAuscultation:Breathingsound:1.normal2.abnormalRales:1.no2.yesHeart:lnspection:Apicalpulsation:1.normal2.unseen3.increase4.diffuseSubxiphoidpulsation:1.no2.yesLocationofapexbeat:1.normal2.shift(in

21、tercosta,distaneeawayfromleftMCLcm)Palpation:Apicalpulsation:1.normal2.liftingapeximpulse3.negativepulsationThrill:1.no2.yes(location:phase:)Percussionrelativedullnessborder:l.normal2.abnormalRight(cm)AnteriormidlineLeft(cm)IIIIIIVV(DistaneebetweenAnteriorMedlineandleftMCLcm)Auscultation:Heartrate:_

22、bpmRhythm:1.regular2.irregularHeartsound:1.normal2.abnormalExtrasound:1.no2.S33.?4.openingsnapP2APericardialfrictionsound:1.no2.yesMurmur:1.no2.yes(locationphasequalityintensitytransmissioneffectsofpositioneffectsofrespirationIXDivisi on:Ward:Bed:Case No.Peripheralvascularsigns1.None2.paradoxicalpul

23、se3.pulsusalternans4.Waterhammerpulse5.capillarypulsation6.pulsedeficit7.Pistolshotsound8.DuroziezsignAbdomen:lnspection:Shape:.tuberanee3.scaphoid4.frog-bellyGastricpattern1.no2.yesIntestinalpattern1.no2.yesAbdominalveinvaricosis1.no2.yes(direction:)Operationscarl.no2.yesPalpation:l.soft2.tensive(location:)Tenderness:1.no2.yes(location:)Reboundtenderness:1.no2.yes(location:)Fluctuation:l.present2.abscentSuccussionsplash:1.negative2.positiveLiver:Murphy sign:Gallbladder:Spleen:Kidneys:Abdominalmass:Others:PercussionLiverdullnessborder:l.norma