英文病历模版

Name: ______________ Sex: __________ Age: ___________ Nation: ___________ Birth Place: ________________________________ Marital

Status:____________

Work-organization & Occupation:

_______________________________________

Living Address & Tel:

_________________________________________________

Date of admission: _______Date of history taken:_______

Informant:__________

Chief Complaint:

___________________________________________________

History of Present Illness:

__________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________

______________

Past History:

General Health Status: 1.good 2.moderate 3.poor

Disease history:(if any, please write down the date of onset, brief

diagnostic and therapeutic course, and the

results.)

Respiratory system:

1. None

2.Repeated pharyngeal pain

3.chronic cough

4.expectoration:

5. Hemoptysis

6.asthma

7.dyspnea

8.chest pain

_______________________________________________________________

Circulatory system:

1.None

2.Palpitation

3.exertional dyspnea

4..cyanosis

5.hemoptysis

6.Edema of lower extremities

7.chest pain

8.syncope

9.hypertension

______________________________________________________________

Digestive system:

1.None

2.Anorexia

3.dysphagia

4.sour regurgitation

5.eructation

6.nausea

7.Emesis

8.melena

9.abdominal pain 10.diarrhea 11.hematemesis

12.Hematochezia 13.jaundice

______________________________________________________________

Urinary system:

1.None

2.Lumbar pain

3.urinary frequency

4.urinary urgency

5.dysuria

6.oliguria

7.polyuria

8.retention of urine

9.incontinence of urine 10.hematuria 11.Pyuria

12.nocturia 13.puffy face

______________________________________________________________

Hematopoietic system:

1.None

2.Fatigue

3.dizziness

4.gingival hemorrhage

5.epistaxis

6.subcutaneous hemorrhage

______________________________________________________________

Metabolic and endocrine system:

1.None

2.Bulimia

3.anorexia

4.hot intolerance

5.cold

intolerance

6.hyperhidrosis

7.Polydipsia

8.amenorrhea

9.tremor of hands 10.character change 11.Marked

obesity 12.marked emaciation 13.hirsutism

14.alopecia

15.Hyperpigmentation 16.sexual function change

______________________________________________________________

Neurological system:

1.None

2.Dizziness

3.headache

4.paresthesia

5.hypomnesis

6. Visual disturbance

7.Insomnia

8.somnolence

9.syncope 10.convulsion 11.Disturbance of

consciousness 12.paralysis 13. vertigo

______________________________________________________________

Reproductive system:

1.None

2.others

_______________________________________________________________

Musculoskeletal system:

1.None

2.Migrating arthralgia

3.arthralgia

4.artrcocele

5.arthremia

6.Dysarthrosis

7.myalgia

8.muscular atrophy

______________________________________________________________

Infectious Disease:

1.None

2.Typhoid fever

3.Dysentery

4.Malaria

4.Schistosomiasis 4.Leptospirosis 7.Tuberculosis

8.Epidemic hemorrhagic fever 9.others

_______________________________________________________________

Vaccine inoculation:

1.None

2.Yes

3.Not clear

Vaccine detail

__________________________________________

Trauma and/or operation history:

Operations:

1.None

2.Yes

Operation

details:_______________________________________

Traumas:

1.None

2.Yes

Trauma

details:_________________________________________

Blood transfusion history:

1.None

2.Yes ( 1.Whole blood 2.Plasma

3.Ingredient

transfusion)

Blood type:____________ Transfusion time:___________

Transfusion reaction

1.None

2.Yes

Clinic

manifestation:_____________________________

Allergic history:

1.None

2.Yes

3.Not clear

allergen:______________________________________________ __

clinical

manifestation:_____________________________________

Personal history:

Custom living

address:____________________________________________

Resident history in endemic disease

area:_____________________________

Smoking: 1.No 2.Yes

Average ___pieces per day; about___years

Giving-up 1.No 2.Yes

(Time:_______________________)

Drinking: 1.No 2.Yes

Average ___grams per day; about ___years

Giving-up 1.No

2.Yes(Time:________________________)

Drug abuse:1.No 2.Yes

Drug names:_______________________________________ _______________________________________________________________

Marital and obstetrical history:

Married age: __________years old Pregnancy ___________times Labor _______________times

(1.Natural labor: _______times 2.Operative labor:

________times

3.Natural abortion: ______times

4.Artificial abortion:

_______times

5.Premature labor:__________times

6.stillbirth__________times)

Health status of the Mate:

1.Well

2.Not fine

Details:

_______________________________________________

Menstrual history:

Menarchal age:_______ Duration ______day Interval____days Last menstrual period: ____________ Menopausal age: ____years old

Amount of flow: 1.small 2. moderate 3. large

Dysmenorrheal: 1. presence 2.absence Menstrual irregularity 1. No

2.Yes

Family history: (especially pay attention to the infectious and

hereditary disease related to the present illness) Father: 1.healthy 2.ill:________ 3.deceased cause:

___________________

Mother:1.healthy 2.ill:________ 3.deceased cause:

___________________

Others: ________________________________________________________

The anterior statement was agreed by the informant.

Signature of informant: Datetime:

Physical Examination

Vital signs:

Temperature:______0C Blood pressure:_______/_______mmHg Pulse: _____ bpm (1.regular

2.irregular_____________________________)

Respiration: ___bpm (1.regular

2.irregular____________________________)

General conditions:

Development: 1.Normal 2.Hypoplasia 3.Hyperplasia

Nutrition: 1.good 2.moderate 3.poor 4.cachexia

Facial expression: 1.normal 2.acute 3.chronic

other_____________________

Habitus: 1.asthenic type 2.sthenic type 3.ortho-thenic type

Position: 1.active 2.positive https://www.360docs.net/doc/cf14924877.html,pulsive

4.other_______________________

Consciousness: 1.clear 2.somnolence 3.confusion 4.stupor

5.slight coma

6.mediate coma

7.deep coma

8.delirium

Cooperation: 1Yes 2.No Gait: 1.normal 2.abnormal______

Skin and mucosa:

Color:1.normal 2.pale 3.redness 4.cyanosis 5.jaundice 6.pigmentation Skin eruption:1.No 2.Yes( type:

__________distribution:__________________)

Subcutaneous bleeding: 1.no 2.yes

(type:_______distribution:______________)

Edema:1. no 2.yes ( location and

degree________________________________)

Hair: 1.normal

2.abnormal(details_____________________________________)

Temperature and moisture: normal cold warm dry moist dehydration

Liver palmar : 1.no 2.yes Spider angioma

(location:________________)

Others: __________________________________________________________ Lymph nodes: enlargement of superficial lymph node:

1.no

2.yes

Description:

________________________________________________

Head:

Skull size:1.normal 2.abnormal

(description:____________________________)

Skull shape:1.normal

2.abnormal(description:___________________________)

Hair distribution :1.normal

2.abnormal(description:______________________)

Others:__________________________________________________________ _

Eye:

exophthalmos:___________eyelid:____________conjunctiva:_____

_____ sclera:________________Cornea:_______________________ Pupil: 1.equally round and in size 2.unequal (R______mm

L_______mm)

Pupil reflex: 1.normal 2.delayed (R___s L___s ) 3.absent (R___L___)

others:_____________________________________________________

Ear: Auricle 1.normal 2.desformation

(description:_______________________)

Discharge of external auditory canal:1.no 2.yes (1.left 2.right quality:_____)

Mastoid tenderness 1.no 2.yes (1.left 2.right

quality:__________________) Disturbance of auditory

acuity:1.no 2.yes(1.left 2.right description:_______) Nose: Flaring of alae nasi :1.no 2.yes Stuffy discharge 1.no

2.yes(quality______)

Tenderness over paranasal sinuses:1.no 2.yes

(location:_______________)

Mouth: Lip______________Mucosa_____________Tongue________________ Teeth:1.normal 2. Agomphiasis 3. Eurodontia

4.others:____________________

Gum :1.normal 2.abnormal

(Description____________________________)

Tonsil:___________________________Pharynx:___________________

Sound: 1.normal 2.hoarseness

3.others:_____________________________

Neck:

Neck rigidity 1.no 2.yes (______________transvers fingers)

Carotid artery: 1.normal pulsation 2.increased pulsation 3.marked distention

Trachea location: 1.middle 2.deviation

(1.leftward_______2.rightward______)

Hepatojugular vein reflux: 1. negative 2.positive

Thyroid: 1.normal 2.enlarged _______ 3.bruit (1.no 2.yes

________________)

Chest:

Chest wall: 1.normal 2.barrel chest 3.prominence or retraction: ( left________right_________Precordial

prominence__________)

Percussion pain over sternum 1.No 2.Yes

Breast: 1.Normal 2.abnormal

_______________________________________

Lung:Inspection: respiratory movement 1.normal

2.abnormal_____________

Palpation: vocal tactile fremitus:1.normal 2.abnormal

_______________ pleural rubbing sensation:1.no

2.yes______________________

Subcutaneous crepitus sensation:1.no

2.yes________________

Percussion:1. resonance 2. Hyperresonance

&location_____________ 3

Flatness&location________________________________

4. dullness &

location:_______________________________

5.tympany

&location:_______________________________

lower border of lung: (detailed percussion in

respiratory disease)

midclavicular line : R:_____intercostae

L:_____intercostae

midaxillary line: R:______intercostae

L:_____intercostae

scapular line: R:______intercostae

L:_____intercostae

movement of lower borders:R:_______cmL:__________cm Auscultation: Breathing sound : 1.normal 2.abnormal

_______________

Rales:1.no

2.yes__________________________________

Heart: Inspection:Apical pulsation: 1.normal 2.unseen 3.increase

4.diffuse Subxiphoid pulsation: 1.no 2.yes

Location of apex beat: 1.normal 2.shift (______

intercosta,

distance away from left

MCL______cm)

Palpation:

Apical pulsation:1. normal 2.lifting apex impulse

3.negative pulsation

Thrill:1.no 2.yes(location:___________

phase:_________________)

Percussion: relative dullness border: 1.normal 2.abnormal

_______cm)

Auscultation: Heart rate:___bpm Rhythm:1.regular

2.irregular_______

Heart sound: 1.normal

2.abnormal________________________

Extra sound: 1.no 2.S

3 3.S

4. opening snap

2_________ A

_________Pericardial friction sound:1.no

2.yes

Murmur: 1.no 2.yes

(location____________phase_____________

quality______intensity________

transmission___________

effects of

position_________________________________

effects of

respiration______________________________

Peripheral vascular signs:

1.None

2.paradoxical pulse

3.pulsus alternans

4. Water

hammer pulse 5.capillary pulsation 6.pulse

deficit 7.Pistol shot sound 8.Duroziez sign Abdomen:

Inspection: Shape: 1.normal 2.protuberance 3.scaphoid

4.frog-belly

Gastric pattern 1.no 2.yes Intestinal pattern

1.no

2.yes

Abdominal vein varicosis 1.no

2.yes(direction:______________ )

Operation scar1.no 2.yes

________________________________

Palpation: 1.soft 2. tensive

(location:____________________________)

Tenderness: 1.no

2.yes(location:_______________________)

Rebound tenderness:1.no

2.yes(location:________________)

Fluctuation: 1.present 2.abscent

Succussion splash: 1.negative 2.positive

Liver:__________________________________

_____________

Gallbladder: __________________Murphy

sign:____________

Spleen:_________________________________

_____________

Kidneys:____________________________________________

Abdominal

mass:___________________________________

___

Others:_________________________________

_____________

Percussion: Liver dullness border: 1.normal 2.decreased 3.absent

Upper hepatic border:Right Midclavicular Line

________Intercosta

Shift dullness:1.negative 2.positive

Ascites:_____________degree

Pain on percussion in costovertebral area: 1.negative 2.positve ____

Auscultation: Bowel sounds : 1.normal 2.hyperperistalsis

3.hypoperistalsis

4.absence

Gurgling sound:1.no 2.yes Vascular bruit 1.no 2.yes

(location_____________________)

Genital organ: 1.unexamined 2.normal 3.abnormal

Anus and rectum: 1.unexamined 2.normal 3.abnormal

Spine and extremities:

Spine: 1.normal 2.deformity (1.kyphosis 2.lordosis

3.scoliosis)

3.Tenderness(location______________________________)

Extremities: 1.normal 2.arthremia & arthrocele

(location_________________) 3.Ankylosis

(location__________) 4.Aropachy: 1.no 2.yes

5.Muscular atrophy

(location_______________________)

Neurological system:1.normal

2.abnormal_______________________________

_____________________________________________________________________ Important examination results before hospitalized

__________________________________________________________ _

Summary of the

history:______________________________________

__________________________________________________________ _

Initial

diagnosis:_____________________________________________

__________________________________________________________ _

Recorder:

Corrector: