英文病历书写范例(内科)

英文病历书写范例（内科）

Medical Records for Admisson

Medical Number: 701721

General information

Name: Liu Side

Age: Eighty

Sex: Male

Race: Han

Nationality: China

Address: NO.35, Dandong Road, 857307523

Occupation: Retired

Marital status: Married

Date of admission: Aug 6th, 2001

Jiefang Tel: Rvenue, Hankou, Hubei.

Date of record: 11Am, Aug 6th, 2001

Complainer of history: patient's son and wife

Reliability: Reliable

Chief complaint: Upper bellyache ten days, haematemesis, hemafecia and unconsciousness for four hours.

Present illness:

The patient felt upper bellyache about ten days ago. He didn't pay attention to it and thought he had ate something wrong. At 6 o'clock this morning he fainted and rejected lots of blood and gore. Then hemafecia began. His family sent him to our hospital and received emergent treatment. So the patient was accepted because of \"upper gastrointestine hemorrhage and exsanguine shock\".

Since the disease coming on, the patient didn't urinate.

Past history

The patient is healthy before.

No history of infective diseases. No allergy history of food and drugs.

Past history

Operative history: Never undergoing any operation.

Infectious history: No history of severe infectious disease.

Allergic history: He was not allergic to penicillin or sulfamide.

Respiratory system: No history of respiratory disease.

Circulatory system: No history of precordial pain.

Alimentary system: No history of regurgitation.

Genitourinary system: No history of genitourinary disease.

Hematopoietic system: No history of anemia and mucocutaneous bleeding.

Endocrine system: No acromegaly. No excessive sweats.

Kinetic system: No history of confinement of limbs.

Neural system: No history of headache or dizziness.

Personal history

He was born in Wuhan on Nov 19th, 1921 and almost always lived in Wuhan. His living conditions were good. No bad personal habits and customs.

Menstrual history: He is a male patient.

Obstetrical history: No

Contraceptive history: Not clear.

Family history: His parents have both deads.

Physical examination

T 36.5℃, P 130/min, R 23/min, BP 100/60mmHg. He is well developed and moderately nourished. Active position. His consciousness was not clear. His face was cadaverous and the skin was not stained yellow. No cyanosis. No pigmentation. No skin eruption. Spider angioma was not seen. No pitting edema. Superficial lymph nodes were not found enlarged.

Head

Cranium: Hair was black and white, well distributed. No deformities. No scars. No masses. No tenderness.

Ear: Bilateral auricles were symmetric and of no masses. No discharges were found in external auditory canals. No tenderness in mastoid area. Auditory acuity was normal.

Nose: No abnormal discharges were found in vetibulum nasi. Septum nasi was

in midline. No nares flaring. No tenderness in nasal sinuses.

Eye: Bilateral eyelids were not swelling. No ptosis. No entropion. Conjunctiva was not congestive. Sclera was anicteric. Eyeballs were not projected or depressed. Movement was normal. Bilateral pupils were round and equal in size. Direct and indirect pupillary reactions to light were existent.

Mouth: Oral mucous membrane was not smooth, and there were ulcer can be seen. Tongue was in midline. Pharynx was congestive. Tonsils were not enlarged.

Neck: Symmetric and of no deformities. No masses. Thyroid was not enlarged. Trachea was in midline.

Chest

Chestwall: Veins could not be seen easily. No subcutaneous emphysema. Intercostal space was neither narrowed nor widened. No tenderness.

Thorax: Symmetric bilaterally. No deformities.

Breast: Symmetric bilaterally.

Lungs: Respiratory movement was bilaterally symmetric with the frequency of 23/min. thoracic expansion and tactile fremitus were symmetric bilaterally. No pleural friction fremitus. Resonance was heard during percussion. No abnormal breath sound was heard. No wheezes. No rales.

Heart: No bulge and no abnormal impulse or thrills in precordial area. The point of maximum impulse was in 5th left intercostal space inside of the mid clavicular line and not diffuse. No pericardial friction sound. Border of the heart was normal. Heart sounds were strong and no splitting. Rate 150/min. Cardiac rhythm was not regular. No pathological murmurs.

Abdomen: Flat and soft. No bulge or depression. No abdominal wall varicosis. Gastralintestinal type or peristalses were not seen. Tenderness was obvious around the navel and in upper abdoman. There was not rebound tenderness on abdomen or renal region. Liver and spleen was untouched. No masses. Fluidthrill negative. Shifting dullness negative. Borhorygmus not heard. No vascular murmurs.

Extremities: No articular swelling. Free movements of all limbs.

Neural system: Physiological reflexes were existent without any pathological ones.

Genitourinary system: Not examed.

Rectum: not exaned

Investigation

Blood-Rt: Hb 69g/L RBC 2.70T/L WBC 1. 1G/L PLT 120G/L

History summary

1. Patient was male, 80 years old

2. Upper bellyache ten days, haematemesis, hemafecia and unconsciousness for four hours.

3. No special past history.

4. Physical examination: T 37.5℃, P 130/min, R 23/min, BP 100/60mmHg Superficial lymph nodes were not found enlarged. No abdominal wall varicosis. Gastralintestinal type or peristalses were not seen. Tenderness was obvious around the navel and in upper abdoman. There was not rebound tenderness on abdomen or renal region. Liver and spleen was untouched. No masses. Fluidthrill negative. Shifting dullness negative. Borhorygmus not heard. No vascular murmurs. No other positive signs.

5. investigation information:

Blood-Rt: Hb 69g/L RBC 2.80T/L WBC 1.1G/L PLT 120G/L

Impression: upper gastrointestine hemorrhage

Exsanguine shock

出院小结（DISCHARGE SUMMARY），

===============

Department of Gastroenterology

Changhai Hospital，No.174 Changhai Road Shanghai, China

Phone: 86-21-25074725-803

DISCHARGE SUMMARY

DATE OF ADMISSION: October 7th, 2005

DATE OF DISCHARGE: October 12th, 2005

ATTENDING PHYSICIAN: Yu Bai, MD

PATIENT AGE: 18

ADMITTING DIAGNOSIS:

Vomiting for unknown reason: acute gastroenteritis?

BRIEF HISTORY

A 18-year-old female with a complaint of nausea and vomiting for nearly one month who was seen at Department of Gastroenterology in Changhai Hospital, found to have acute gastroenteritis and non-atrophic gastritis. The patient was subsequently recovered and discharged soon after medication.

REVIEW OF SYSTEM

She has had no headache, fever, chills, diarrhea, chest pain, palpitations, dyspnea, cough, hemoptysis, dysuria, hematuria or ankle edema.

PAST MEDICAL HISTORY

She has had no previous surgery, accidents or childhood illness.

SOCIAL HISTORY: She has no history of excessive alcohol or tobacco use.

FAMILY HISTORY

She has no family history of cardiovascular, respiratary and gastrointestinal diseases.

PHYSICAL EXAMINATION

Temperature is 37, pulse 80, respirations 16, blood pressure 112/70. General: Plump girl in no apparent distress. HEENT: She has no scalp lesions. Her pupils are equally round and reactive to light and accommodation. Extraocular movements are intact. Sclerae are anicteric. Oropharynx is clear. There is no thyromegaly. There is no cervical or supraclvicular lymphadenopathy. Cardiovascular: Regular rate and rhythm, normal S1, S2. Chest: Clear to auscultation bilateral. Abdomen: Bowel sounds present, no hepatosplenomagaly. Extremities: There is no cyanosis, clubbing or edema. Neurologic: Cranial nerves II-XII are intact. Motor examination

is 5/5 in the bilateral upper and lower extremities. Sensory, cerebellar and gait are normal.

LABORATORY DATA

White blood cells count 5.9, hemoglobin 111g/L, hematocrit 35.4. Sodium 142, potassium 4.3, chloride 106, CO2 25, BUN 2.6mmol/L, creatinine 57μmol/L, glucose 4.1mmol/L, Albumin 36g/L.

Endoscopic Exam

Chronic non-atrophic gastritis

HOSPITAL COURSE

The patient was admitted and placed on fluid rehydration and mineral supplement. The patient improved, showing gradual resolution of nausea and vomiting. The patient was discharged in stable condition.

DISCHARGE DIAGNOSIS

Acute gastroenteritis

Chronic non-atrophic gastritis

PROGNOSIS

Good. No medications needed after discharge. But if this patient can not get used to Chinese food, she had better return to UK as soon as possible to prevent the relapse of acute gastroenteritis.

The patient is to follow up with Dr. Bai in one week.

___________________________

Yu Bai, MD

D: 12/10/2005