內(nèi)科英文病歷實(shí)用模板

1、實(shí)用HUAZHONG UNIVERSITY OF SCIENCE AND TECHNOLOGYTONGJI MEDICAL COLLEGE ACCESSORY TONGJI HOSPITALHospitalization Records for None-operation DivisionDivision:Ward:Bed:Case No.Name:Sex:Age:Nation: Birth Place:Marital Status: Work-organization & Occupation:Living Address & Tel:Date of admission:D

2、ate of history taken:Informant:Chief Complaint: History of Present Illness:文檔Past History:General Health Status: l.good 2.moderate 3.poorDisease history: (if any, please write down the date of onset, brief diagnostic and therapeutic course, and the results.)Respiratory system:1. None 2.Repeated phar

3、yngeal pain 3.chronic coughd.expectoration:5. Hemoptysis 6.asthma 7.dyspnea 8.chest painCirculatory system:1 .None 2.Palpitation 3.exertional dyspnea 4.cyanosis 5.hemoptysis6.Edema of lower extremities 7.chest pain 8.syncope 9.hypertensionDigestive system:I.None 2.Anorexia 3.dysphagia 4.sour regurgi

4、tation 5.eructation6.nausea 7.Emesis 8.melena 9.abdominal pain 10.diarrhea ll.hematemesis 12.Hematochezia13.jaundiceUrinary system:I.None 2.Lumbar pain 3.urinary frequency 4.urinary urgency 5.dysuria6.oliguria 7.polyuria 8.retention of urine 9.incontinence of urine10.hematuria ll.Pyuria 12.nocturia

5、13.puffy faceHematopoietic system:I.None 2.Fatigue 3.dizziness 4.gingival hemorrhage 5.epistaxis6.subcutaneous hemorrhageMetabolic and endocrine system:I.None 2.Bulimia 3.anorexia 4.hot intolerance 5.cold intolerance6.hyperhidrosis 7.Polydipsia 8.amenorrhea9.tremor of hands 10.character change II.Ma

6、rked obesity 12.marked emaciation 13.hirsutism 14.alopecia 15.Hyperpigmentation 16.sexual function changeNeurological system:I.None 2.Dizziness 3.headache 4.paresthesia 5.hypomnesis 6.Visual disturbance 7.Insomnia 8.somnolence 9.syncope 10.convulsion "Disturbance of consciousness 12.paralysis13

7、. vertigoReproductive system:I.None 2.othersMusculoskeletal system:I.None 2.Migrating arthralgia 3.arthralgia 4.artrcocele 5.arthremia6.Dysarthrosis 7.myalgia 8.muscular atrophyInfectious Disease:1.None 2.Typhoid fever 3.Dysentery 4.Malaria 4.Schistosomiasis4.Leptospirosis 7.Tuberculosis 8.Epidemic

8、hemorrhagic fever 9.othersVaccine inoculation:1.None 2.Yes 3.Not clearVaccine detailTrauma 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:Trans

9、fusion time:Transfusion reaction1.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 yearsGiving-up 1.No 2.Yes (Tim

10、e:)Drinking: 1.No 2.Yes Average grams per day; about yearsGiving-up 1.No 2.Yes(Time:)Drug abuse: 1.No 2.Yes Drug names:Marital and obstetrical history:Married age: years old Pregnancy timesLabor times(I.Natural labor:times 2.Operative labor:times3.Natural abortion:timesd.Artificial abortion:times5.P

11、remature labor:times 6.stillbirth times)Health status of the Mate:I.Well 2.Not fineDetails:Menstrual history:Menarchal age: Duration day Interval days Last menstrual period: Menopausal age:years old Amount of flow: l.small 2. moderate 3. largeDysmenorrheal: 1. presence 2.absencMenstrual irregularity

12、 1. No 2.YesFamily history: (especially pay attention to the infectious and hereditary diseaserelated to the present 川ness)Father: l.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:Ph

13、ysical ExaminationVital signs:Temperature:0cBlood pressure:/mmHgPulse:bpm (l.regular 2.irregular)Respiration: bpm (l.regular 2.irregular)General conditions:Development: I.Normal 2.Hypoplasia 3.HyperplasiaNutrition : l.good 2.moderate 3.poor 4.cachexiaFacial expression: l.normal 2.acute 3.chronic oth

14、erHabitus: l.asthenic type 2.sthenic type 3.ortho-thenic typePosition: l.active 2.positive pulsive 4.otherConsciousness: l.clear 2.somnolence 3.confusion 4.stupor 5.slight coma6.mediate coma 7.deep coma 8.deliriumCooperation : 1Yes 2.No Gait: l.normal 2.abnormalSkin and mucosa:Color: .normal 2.pale

15、3.redness 4.cyanosis 5.jaundice 6.pigmentationSkin eruption: 1.No 2.Yes( type:distribution:)Subcutaneous bleeding: 1.no 2.yes (type:distribution:)Edema: 1. no 2.yes ( location and degree) Hair: l.normal 2.abnormal(details)Temperature and moisture: normal cold warm dry moist dehydration Liver palmar

16、: 1.no 2.yes Spider angioma (location:) Others:Lymph nodes: enlargement of superficial lymph node:1. no 2.yes Description:Head:Skull size: l.normal 2.abnormal (description:)Skull shape: l.normal 2.abnormal(description:)Hair distribution :1.normal 2.abnormal(description:)Others:Eye: exophthalmos:eyel

17、id:conjunctiva:sclera:Cornea:Pupil: l.equally round and in size 2.unequal (R mm L mm)Pupil reflex: l.normal 2.delayed (R s L s ) 3.absent (R L )others:Ear: Auricle l.normal 2.desformation (description:)Discharge of external auditory canal:1.no 2.yes (l.left 2.right quality:)Mastoid tenderness 1.no 2

18、.yes (l.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 TongueTeeth:1.normal 2. Agomphiasis 3. Eurodontia 4

19、.others:Gum :1.normal 2.abnormal (Description)Tonsil:Pharynx:Sound: l.normal 2.hoarseness 3.others:Neck:Neck rigidity 1.no 2.yes (transvers fingers)Carotid artery: l.normal pulsation 2.increased pulsation 3.marked distentionTrachea location: l.middle 2.deviation (l.leftward 2.rightward)Hepatojugular

20、 vein reflux: 1. negative 2.positiveThyroid: l.normal 2.enlarged 3.bruit (1.no 2.yes)Chest:Chest wall: .normal 2.barrel chest 3.prominence or retraction: (left right Precordial prominence)Percussion pain over sternum 1.No 2.YesBreast: I.Normal 2.abnormalLung: Inspection: respiratory movement l.norma

21、l 2.abnormalPalpation: 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 3Flatness&location4 . dullness & location:5 .tympany &location:lower border of lung: (

22、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:cmAuscultation: Breathing sound : l.normal 2.abnormalRales:1.no 2.yesHeart: Inspection

23、: Apical pulsation: l.normal 2.unseen 3.increase 4.diffuse Subxiphoid pulsation: 1.no 2.yesLocation of apex beat: l.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:) Percussio

24、n: relative dullness border: l.normal 2.abnormalRight(cm)Anterior midlineLeft(cm)IIIIIIVV(Distance between Anterior Medline and left MCL cm)Auscultation: Heart rate:bpm Rhythm:1.regular 2.irregularHeart sound: l.normal 2.abnormalExtra sound: 1.no 2.S3 3.S4 4. opening snapP2 A2 Pericardial friction s

25、ound:1.no 2.yesMurmur: 1.no 2.yes (location phasequality intensity transmissioneffects of positioneffects of respirationPeripheral vascular signs :I.None 2.paradoxical pulse 3.pulsus alternans 4. Water hammer pulse5.capillary pulsation 6.pulse deficit 7.Pistol shot sound8.Duroziez signAbdomen:Inspec

26、tion: Shape:.normal 2.protuberance 3.scaphoid 4.frog-bellyGastric pattern 1.no 2.yes Intestinal pattern 1.no 2.yesAbdominal vein varicosis 1.no 2.yes(direction:)Operation scar1.no 2.yesPalpation: l.soft 2. tensive (location:)Tenderness: 1.no 2.yes(location:)Rebound tenderness:1.no 2.yes(location:)Fluctuation:l.present 2.abscentSuccussion splash: l.negative 2.positive Liver:Gallbladder:Murphy sign:Spleen:Kidneys:Abdominal