英文病历范文.docx

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1、英文病历范文Name（姓名）：zhangsanOccupation（职业）:teacher（教师）Gender（性别）:fema1e（女）Address（通讯地址）：No167,Bei1ishiRoad,Beijing（mou路167号）ge（年龄）:30yearso1d（30岁）Timeadmission（入院日期）:2014-2-1417:00Nationa1ity（民族）:Han（汉）Timerecording（病史采集日期）:2014-2-1417:00Birthp1ace（出生地）:Beijing（北京）ReIiabiIity（可信度）：ReIiabIe（可靠）Marita1stat

2、us（婚姻状况）：married（已婚）Historyoffer（病史陈述者）：herse1f（患者本人）Chiefcomp1aint（主诉）:Pa1pitationsfortwentyyearsandchi11s,fever,dyspneaandedemaoftheank1eforha1famonth心悸持续20年，寒战、发热、呼吸困难及踝部水肿15天Presenti11ness（现病史）：Abouttwentyyearsago,thepatientsufferedforthefirsttimefrompa1pitationswhichoccurredaftershehaddonevigor

3、ousphysica1exercise,andwhichhavebeengradua11yworseningeversince.Tenyearsago,shebegantoexperiencedyspneawhi1egoingupstairsordoingwork;therefore,shehadsoughtmedica1treatment.cardiacmurmurwassubsequent1ydiscoveredandadiagnosisofheartdiseasewasgiven,whichwasnottreated.Neverthe1ess,shehadbeencapab1eofdoi

4、ng1ightworkunti1ha1famonthago,whenshecaughtabadco1d,whichwasaccompaniedbychi11s,coughnon-productiveofsputum.Inthe1astfewdays,herconditionhasbeenaggravatedbyepigastricdistention,nausea,vomitingandedemaoftheank1es;shewasthusunab1eto1iesupine.Pa1pitationsanddyspneawerefurtheraggravatedatthesametime.For

5、thisreason,shehadtocometothehospita1fortreatment.患者于20年前因剧烈运动开始出现从心悸症状，并逐渐恶化。于10年前开始出现上楼后及劳累后发作性呼吸困难，因此求医，遂查出心脏杂音，诊断为冠心病心脏病，未做治疗。此后仍可从事轻体力活动。15天前患重感冒，伴寒战、咳嗽无痰。近几日病情加重，出现脱腹胀满、恶心、呕吐和脚踝水肿，不能平卧，心悸和呼吸困难进一步加剧，为求诊治来我院就诊。Inthecourseofheri11ness,shehashadanorexiaando1iguriawithoutabnorma1bowe1motions;shehasn

6、ottakendigoxinoritsequiva1ent;andshehasnotsufferedfromparoxysma1nocturna1asthma.发病以来，患者食欲下降、少尿，大便通畅。无地高辛类药物服用史。不伴阵发性夜间哮喘。Pasthistory（既往史）:Priormajori11nessandinjuries:shehasoftenhadIarynga1giaandArthra1giasinceherchi1dhood.疾病和外伤史：自幼年经常喉痛和关节痛。Prioroperations（手术史）：Noprioroperations（无手术史）。Priorhospita1

7、izations（住院史）:Nopriorhospita1izations（无住院史）。A11ergies（过敏史）:Nofood,medications,chemica1sa11ergy（无食物、药物及化学品过敏史）。AgeappropriateimmunizationStatUS（免疫接种史）：Unknown（不详）。Reviewofsystems（系统回顾）：Respiratorysystem:Deniedhemoptysis,asthma,bronchitis,orthopnea,emphysema.呼吸系统：无咯血、哮喘、支气管炎、端坐呼吸和肺气肿。Cardiovascu1arsys

8、tem:Deniedparoxysma1nocturna1dyspnea,orthopnea,edema,butchestpain,pa1pitations.心血管系统：无夜间阵发性呼吸困难、端坐呼吸、水肿，有胸痛、心悸。Gastrointestina1system:Deniedrecta1b1eeding,vomitingb1ood,b1acktarrystoo1s,abdomina1pain,jaundice,hepatitis,diarrhea,changeinbowe1habits,constipation.消化系统：无直肠出血、吐血、柏油样便、腹痛、黄疸、肝炎、腹泻、排便习惯改变、便

9、秘。Urinarysystem:Deniedpo1yuria,dysuria,hematuria,incontinence,urinaryinfections,stones.泌尿系统：无多尿、排尿困难、血尿、尿失禁、尿路感染、尿结石。Hemato1ogicsystem:Deniedanemia,easybruisingorb1eeding.血液系统：无贫血、易发瘀斑及出血。Endocrinesystem:Deniedthyroidtroub1e,heatorco1dinto1erance,excessivesweating,diabetes,excessivethirst,hungerorur

10、ination.内分泌系统：无甲状腺功能异常、恶寒/热、多汗，无糖尿病、口渴、过饥及多尿。Muscu1oske1eta1system:Deniedjointpainsorstiffness,arthritis,gout,backpain.Deniedmusc1epainsandcramps.肌肉骨骼系统：无关节疼痛或僵硬、关节炎、痛风、背痛。无肌肉疼痛及痉挛。Neuro1ogica1system:Deniedseizures,para1ysis,1oca1weakness,numbness,tremors,memoryprob1ems.神经系统：无癫痫发作、肌肉麻痹、局部肢体无力、麻木、震颤及

11、记忆障碍。Persona1history（个人史）：Currentemp1oyment（从事职业）：WOrker（工人）Useofdrugs（药物史）：Nomedicationsweredai1yused（无药物滥用史）Useofa1coho1（饮酒史）：Nodrinking（无饮酒史）Useoftobacco（吸烟史）：Nosmoking（无吸烟史）1eve1ofeducation（教育背景）：co11ege（本科）Marita1history（婚姻史）:Shegotmarriedattheageofnineteen.Herhusbandishea1thy,andtheirre1ations

12、hipisharmony.19岁结婚，配偶身体健康，夫妻关系和谐。Menstrua1historyandChi1dbearinghistory（月经史及孕产史）：Hermenarchebeganwhenshewasfifteenanditwasregu1ar.Ayearafterhermarriage,shenorma11yde1iveredababyboy,whoisnowtenyearso1dandhea1thy.15岁月经初潮，经期正常。婚后1年内产一男婴，现已10岁，身体健康。Fami1yhistory（家族史）:Hea1thstatusorcauseofdeathofparents,

13、sib1ingsandchi1dren:A11arehea1thy.父母、兄弟姐妹和子女健在（或死因无异常）。Specificdiseasesre1atedtoprob1emsidentifiedinthechiefcomp1aintorhistoryofthepresenti11nessand/orsystemreview:None.无与主诉及现病史/系统回顾中相关疾病史（即无心脏病及相关性病史）。Diseasesoffami1ymemberswhichmaybehereditaryorp1acethepatientatrisk:Nohereditarydiseases.直系家属遗传病史或潜

14、在风险：无家族遗传疾病。Physica1examination（体格检查）T38P108/minR:24/minBP:12080mmHgNorma11ydeve1oped.Moderate1ynourished.Mindc1ear.Inasemi-sittingposition.Acute1yi11-1ooking,showingdyspnea,s1ightcyanosisandf1ushing.Superficia11ymphnodesnotpa1pab1e.Nojaundiceonskinorsc1era.Pharynxs1ight1ycongested.Necksoftandsupp1e

15、.Tracheainmid1ine.Nothyroiden1argement,butwithengorgementofjugu1arveins.Chestnotasymmetrica1.1ungsc1ear.Apexbeatfe1tin5thinter-costa1spacea1ong1eftmidc1avicu1ar1ine.Heartbeatf1uctuatedbetween100/minand108/min,extrasysto1esoccurring7-8/min.Arumb1ing,crescendodiasto1icmurmurheardoverapex,rather1oca1iz

16、ed,andnottransmittede1sewhere.A2equa1toP2.Abdomenf1atandsoft.1iverpa1pab1e5cmbe1owcosta1marginwithsoftconsistencyandfreefromtenderness.Hepatojugu1arref1uxpositive.Sp1eennotfe1t.Abdomenfreeofanymassormobi1edu11ness.Notendernessinkidney.Bowe1soundsnotabnorma1.Nodeformityofspineorextremities.Markedpittingedemain1owerextremities.Kneejerkspresent.No