英文病歷標(biāo)準(zhǔn)模版

1、Complete HistoryName:Si Ruihua Department:Lumberelectric power bureauSex: female Present address: electric power bureauAge:80 years Date of admission:2003-5-17Nationality: China xinjiangDate of record:2003-5-17Marital status: be marriedReliability:reliableOccupation: family numbersHistory of allergy

2、:denyChief complaints:Palpitation and breathlessnss for 1 hourPresent illness:The patient complained of palpitation with no precipitating factors an hour ago , at the same time she still feel breahlessness and precardial pain which didnt radiated to other parts of body. This discomfort cant be relie

3、ved by take a rest.As couldnt suffer from that she had to came to hospital for help. In the course of theillness, he had no syncope, no cough, no headache, no diarrhea and vomiting. Her appetite, sleep, voiding and stool were normal.Past history:The patient deny the hypertension ,diabetes mellitus,o

4、besity and valvular heart disease history.deny the allegies to pollen,dust medications or food.Deny the surgical procedures and injuries.Review of systems:Respiratory system:no pharyngalgia; no chromic cough or hemoptysis; no dyspnea and thoracalgia;no afternoon fever or night sweats.Circulatory sys

5、tem:no palpitation and breathlessness on exertion: no precordial pain, dizziness and persistent headache; no syncope and hypertension.Digestive system:no sour regurgitation and dysphagia: no chronic abdominal ache, diarrhea and vomiting: no jaundice, hematemesis and melena.Urinary system:no past his

6、tory of edema and proteinuria; no pollakiuria; no urgency and painful micturition; no visible hematuria and hypertension.Endocrine and metabolic system:no irritability, hidrosis or profound fatigue and headache; no impaired vision, exceeding thirsty and polyuria; no excessive hairiness or hair loss;

7、 no pigmentation and sexuality change.Hematopoietic system:no pale shin, no dizziness, blurred vision and tinnitus; no impairment of memory; no petechia and jaundic over the skin and mucosa; no lymph node, liver and spleen enlargement; no abnormal bony pain.Muscle, bone and joint system:no unusual p

8、ain, redness and swelling of the joints; no deformity of joints; no limbs and trunk limitation on motion; no myoasthenia and myoatrophy.Nervous system:no persistent headache and syncope; no memorial impairment orspeaking obstacle; no insomnia and consciousness obstacle; no paresthesia of skin; no pa

9、ralysis and convulsion. Mental status: no hallucination, delirium and orientation obstacle; no abnormal emotionPersonal history:The patiens economic status is good.He has no chance tocontact with poison.He consumed cigrettes 20 stickes per day,and a little of drinking.Bearing history:The patient was

10、 be married when he was 27 years old.He bearing 3 boys and 2grils.His husband died oftraffic accident.Family history:He deny the family history of such disease.PhysicalExaminationT:36.0P:75bpmR:18bpmBP:104/53mmHgW:45kgGeneral condition:normally developed, moderately nourished; active position, alert

11、 andcooperative.Skin and mucosa: normal temperature; no jaundice, eruptions or bleeding spots; no pigmentation,mile to moderate edema.Lymph gland: no superficial lymph nodes enlargement.Head organ: normal shape of head; hair black and shining with average distriution; no scars.Eyes: no edema of eyel

12、ids; no bleeding spots of conjunctiva; no sclera jaundice; corneaclear, pupils round, symmetrical in size and acutely reactive to light.Ears: normal hearing; no purulent secretion of the external canals; on tenderness overmastoids.Mouth:lips red without cyanosis; teeth in alignment, no carious teeth

13、 or gingivalhemorrhage; pharynx injected; no enlarged tonsils seen; smooth and glossy tonguein midline.Neck: supple without rigidity, symmetrical; no cervical venous distention; no abnormal carotidimpulse; trachea in midline; no enlargement of thyroid gland.Chest: symmetrical; thoracic breathing pre

14、dominately; rhythm normal.Lung: Inspection: equal breathing movements on two sides.Palpation: no difference of vocal fremitus over two sides; no friction rub felt,Percussion: resonant on percussion over both lungs. The lower border of lungs lies on right mid-clavicular line at fifth inertcostal spac

15、e and subscapular line at ninth intercostal space and left scapular line at tenth intercostal space. Shifting degree 4cm.Auscultation: normal breath sound, no dry or moist rales audible.Heart:Inspection: no pericardial protuberance. Apex beat seen 1cm within left mid-clavicular line at fifth interco

16、stal space. Diameter of impulse is 1.5cm.Palpation: no thrill or friction felt; no lifting impulse: apex beat observed on the same location as on inspection.Percussion: normal dullness of heart borders. Relative dullness of heart borders measured as follow:Right(cm)Intercostal spaceleft(cm)2.II32.II

17、I43IV7V8.5Auscultation:heart rate: 75/ min;rhythm regular; nogallop thythm; nomurmur or pericardialfriction sound audible.Peripheral vascular sign: full pulse, rhythm regular; no paradoxical pulse and deficient pulse; no water-hammer pulse and gunshot sound; no capillary pulsation.Abdomen: Inspectio

18、n: symmetrical; no abdominal distension or dilated veins; no skin rash or scar; no abnormal intestinal and peristaltic waves seen.Palpation:abdominal wall flat and soft without tenderness or rebounding tenderness. no succession spleen and kidneys not palpablePercussion: no shifting dullness; mild ty

19、mpany. Dullness of liver borders within normal limit. The upper border of liver lies in right mid-clavicular line at fifth intercostal space. No percussion tenderness over the kidney region.Auscultation: normal bowel sounds. No vascular murmur heard.Anus and rectum:no anal fissure or proctoptosis; n

20、o fistulous tract or hemorrhoid.External genitalia:normal distribution if the pubic hair; normal development of external genitalia; no scars or ulcers.Spine:normal spinal curvature without deformities; normal movements; no tenderness.Extremities:moderate pitting edema found over both legs. No clubbe

21、d fingers(toes); nomyoatrophy, varicose veins or fracture; no redness and swelling of joints; notenderness or deformities of joints. motor function normal. no limitation of jointmovement.Neurological reflex:dermatographism. normal abdominal and bicipital muscular reflex; patellar and heel-tap reflex nomal; Babinski sign(-); Oppenhein sign(-); Gordon sign(-); Chaddock sign(-); Hoffmann sign(-)