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首页 各科英文病历集锦心内科英文病历

各科英文病历集锦心内科英文病历.doc

各科英文病历集锦心内科英文病历

bcchen
2018-09-05 0人阅读 举报 0 0 暂无简介

简介:本文档为《各科英文病历集锦心内科英文病历doc》,可适用于医药卫生领域

MedicalRecordsforAdmissonMedicalNumber:GeneralinformationName:LiuSideAge:EightySex:MaleRace:HanNationality:ChinaAddress:NO,DandongRoad,JiefangRvenue,Hankou,HubeiTel:Occupation:RetiredMaritalstatus:MarriedDateofadmission:Augth,Dateofrecord:Am,Augth,Complainerofhistory:patient’ssonandwifeReliability:ReliableChiefcomplaint:Upperbellyachetendays,haematemesis,hemafeciaandunconsciousnessforfourhoursPresentillness:ThepatientfeltupperbellyacheabouttendaysagoHedidn’tpayattentiontoitandthoughthehadatesomethingwrongAto’clockthismorninghefaintedandrejectedlotsofbloodandgoreThenhemafeciabeganHisfamilysenthimtoourhospitalandreceivedemergenttreatmentSothepatientwasacceptedbecauseof“uppergastrointestinehemorrhageandexsanguineshock”Sincethediseasecomingon,thepatientdidn’turinatePasthistoryThepatientishealthybeforeNohistoryofinfectivediseasesNoallergyhistoryoffoodanddrugsPasthistoryOperativehistory:NeverundergoinganyoperationInfectioushistory:NohistoryofsevereinfectiousdiseaseAllergichistory:HewasnotallergictopenicillinorsulfamideRespiratorysystem:NohistoryofrespiratorydiseaseCirculatorysystem:NohistoryofprecordialpainAlimentarysystem:NohistoryofregurgitationGenitourinarysystem:NohistoryofgenitourinarydiseaseHematopoieticsystem:NohistoryofanemiaandmucocutaneousbleedingEndocrinesystem:NoacromegalyNoexcessivesweatsKineticsystem:NohistoryofconfinementoflimbsNeuralsystem:NohistoryofheadacheordizzinessPersonalhistoryHewasborninWuhanonNovth,andalmostalwayslivedinWuhanHislivingconditionsweregoodNobadpersonalhabitsandcustomsMenstrualhistory:HeisamalepatientObstetricalhistory:NoContraceptivehistory:NotclearFamilyhistory:HisparentshavebothdeadsPhysicalexaminationT℃,Pmin,Rmin,BPmmHgHeiswelldevelopedandmoderatelynourishedActivepositionHisconsciousnesswasnotclearHisfacewascadaverousandtheskinwasnotstainedyellowNocyanosisNopigmentationNoskineruptionSpiderangiomawasnotseenNopittingedemaSuperficiallymphnodeswerenotfoundenlargedHeadCranium:Hairwasblackandwhite,welldistributedNodeformitiesNoscarsNomassesNotendernessEar:BilateralauriclesweresymmetricandofnomassesNodischargeswerefoundinexternalauditorycanalsNotendernessinmastoidareaAuditoryacuitywasnormalNose:NoabnormaldischargeswerefoundinvetibulumnasiSeptumnasiwasinmidlineNonaresflaringNotendernessinnasalsinusesEye:BilateraleyelidswerenotswellingNoptosisNoentropionConjunctivawasnotcongestiveSclerawasanictericEyeballswerenotprojectedordepressedMovementwasnormalBilateralpupilswereroundandequalinsizeDirectandindirectpupillaryreactionstolightwereexistentMouth:Oralmucousmembranewasnotsmooth,andtherewereulcercanbeseenTonguewasinmidlinePharynxwascongestiveTonsilswerenotenlargedNeck:SymmetricandofnodeformitiesNomassesThyroidwasnotenlargedTracheawasinmidlineChestChestwall:VeinscouldnotbeseeneasilyNosubcutaneousemphysemaIntercostalspacewasneithernarrowednorwidenedNotendernessThorax:SymmetricbilaterallyNodeformitiesBreast:SymmetricbilaterallyLungs:RespiratorymovementwasbilaterallysymmetricwiththefrequencyofminthoracicexpansionandtactilefremitusweresymmetricbilaterallyNopleuralfrictionfremitusResonancewasheardduringpercussionNoabnormalbreathsoundwasheardNowheezesNoralesHeart:NobulgeandnoabnormalimpulseorthrillsinprecordialareaThepointofmaximumimpulsewasinthleftintercostalspaceinsideofthemidclavicularlineandnotdiffuseNopericardialfrictionsoundBorderoftheheartwasnormalHeartsoundswerestrongandnosplittingRateminCardiacrhythmwasnotregularNopathologicalmurmursAbdomen:FlatandsoftNobulgeordepressionNoabdominalwallvaricosisGastralintestinaltypeorperistalseswerenotseenTendernesswasobviousaroundthenavelandinupperabdomanTherewasnotreboundtendernessonabdomenorrenalregionLiverandspleenwasuntouchedNomassesFluidthrillnegativeShiftingdullnessnegativeBorhorygmusnotheardNovascularmurmursExtremities:NoarticularswellingFreemovementsofalllimbsNeuralsystem:PhysiologicalreflexeswereexistentwithoutanypathologicalonesGenitourinarysystem:NotexamedRectum:notexanedInvestigationBloodRt:HbgLRBCTLWBCGLPLTGLHistorysummaryPatientwasmale,yearsoldUpperbellyachetendays,haematemesis,hemafeciaandunconsciousnessforfourhoursNospecialpasthistoryPhysicalexamination:T℃,Pmin,Rmin,BPmmHgSuperficiallymphnodeswerenotfoundenlargedNoabdominalwallvaricosisGastralintestinaltypeorperistalseswerenotseenTendernesswasobviousaroundthenavelandinupperabdomanTherewasnotreboundtendernessonabdomenorrenalregionLiverandspleenwasuntouchedNomassesFluidthrillnegativeShiftingdullnessnegativeBorhorygmusnotheardNovascularmurmursNootherpositivesignsinvestigationinformation:BloodRt:HbgLRBCTLWBCGLPLTGLImpression:uppergastrointestinehemorrhageExsanguineshockSignature:HeLin()

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