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首页 各科英文病历集锦呼吸科英文病历

各科英文病历集锦呼吸科英文病历.doc

各科英文病历集锦呼吸科英文病历

bcchen
2018-09-05 0人阅读 举报 0 0 暂无简介

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

ENGLISHCASE(Respiratorydepartment)Name:Liyuzhen`Age:yearsSex:FemaleRace:HanOccupation:FreeoccupationNationality:ChinaMarriedstatus:marriedAddress:QianjingRoadNo,WuhanHankouDateofadmission:Julyth,Dateofrecord:Julyth,Complainerofhistory:PatientherselfReliability:ReliableChiefComplaint:CoughanddyspneafordaysPresentillness:TwodaysagothepatientsuddenlystartedtocoughandfeeldyspneaafterhavingabathItbecamemoreandmoreserious,sothepatientwentadjacenthospitalAftersometreatment,hersymptomswerestillSoshecametoourhospitalSinceitscomingon,sheneverfeltheadache,nausea,bellyacheandherphlegmwasfewHerspirit,sleep,appetitewerenormalstoolandurinewerenormal,tooPastHistory:Generalhealthstatus:normalOperationhistory:thyroidectomyInfectionhistory:NohistoryoftuberculosisorhepatitisAllergichistory:allergictoalotofdrugssuchassulfanilamideTraumatichistory:NotraumatichistorySystemreviewRespiratorysystem:Nohistoryofrepeatedpharyngodynia,chroniccough,expectoration,hemoptysis,asthma,dyspneaorchestpainCirculationsystem:Nohistoryofpalpitation,hemoptysis,legsedema,shortbreathaftersports,hypertension,precordiumpainorfaintnessDigestivesystem:Nohistoryoflowappetite,sourregurgitation,belching,nausea,vomiting,abdominaldistension,abdominalpain,constipation,diarrhea,hemaptysis,melena,hematocheziaorjaundiceUrinarysystem:Nohistoryoflumbago,frequencyofurination,urgencyofurination,odynuria,dysuria,bloodyurine,polyuriaorfacialedemaHematopoieticsystem:Nohistoryofacratia,dizziness,gingivalbleeding,nasalbleeding,subcutaneousbleedingorostealgiaEndocrinesystem:Nohistoryofappetitechange,sweating,chillyexcessivethirst,polyuria,handstremor,characteralternation,obesity,emaciation,hairchange,pigmentationoramenorrheaKineticsystem:Nohistoryofwanderingarthritis,jointpain,redswellingofjoint,jointdeformity,musclepainormyophagismNeuralsystem:Nohistoryofdizziness,headache,vertigo,insomnia,disturbanceofconsciousness,tremor,convulsion,paralysisorabnormalsensationPersonalHistory:ShewasborninHubeiSheneversmokesandDrinksNoexposurehistorytotoxicsubstances,andinfectedwaterHermenstruationwasnormalLMP:,FamilyHistory:HerparentsarelivingandwellNocongenitaldiseaseinherfamilyPhysicalExaminationVitalsigns:T`C,Pmin,Rmin,BPmmHgGeneralinspection:Thepatientisawelldeveloped,wellnourishedadultfemaleapparentlyinnoacutedistress,pleasantandcooperativeSkin:NormallyfreeoferuptionorunusualpigmentationLymphnodes:TherearenoswellingoflymphnodesHead:NormalskullNobaldness,noscarsEyes:NoptosisExtraocularnormalConjuctivanormalThePupilsareround,regular,andreacttolightandacCommodationEars:ExternallynormalCanalsclearThedrumsnormalNose:NoabnormalitiesnotedMouthandthroat:lipsred,tongueredAlveolarridgesnormalTonsilsatrophilanduninfectedNeck:NoadenopathyThyroidpalpable,butnotenlargedNoAbnormalpulsationsTracheainmiddleChestandlung:NormalcontourBreastnormalExpansionequalFremitusnormalNounusualareasofdullnessDiaphragmaticpositionandexcursionnormalNoabnormalbreathsoundNomoistralesheardNoaudiblepleuralfricionTherearelotsofrhonchiralesandwhoopcanbeheardHeart:PMIcmtoleftofmidolavicularlineinthinterSpaceForcefulapexbeatNothrillsNopathologicheartmurmurHeartbeatandrhythmisnormalAbdomen:FlatabdomenGoodmuscletoneNodistensionNovisibleperistalsisNorigidityNomasspalpableTenderness(),reboundtenderness()LiverandspleenarenotpalpableShiftingdullness()BowlsoundsnormalSystolicblowingmurmurcanbeheardattherightsideofthenavelExtremities:NojointdiseaseMusclestrengthnormalNoabnormalmotionThumbsign()Wristsign()Neuralsystem:Kneejerk()Achillesjerk()Babinskisign()Oppenheimsign()Chaddocksign()Condasign()Hoffmannsign()Necktetany()Kernigsign()Brudzinskisign()Genitourinarysystem:NormalRectum:NotendernessOutpatientdepartmentdata:NoHistorysummary)LiYuzhen,female,y)Coughanddyspneafordays)PE:T`C,Pmin,Rmin,BPmmHgsuperficialnodeswerenotpalpableNormalvisionUpperpalatehaunchupedHR:bpm,rhythmisnormalTherearelotsofrhonchiralesandwhoopcanbeheardFlatabdomen,Tenderness(),reboundtenderness()LiverandspleenarenotpalpableShiftingdullness()Bowlsoundsnormal)Outpatientdata:seeaboveImpression:BronchialasthmaSignature:HeLin

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各科英文病历集锦呼吸科英文病历

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