英文病历模版.docx
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英文病历模版.docx
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英文病历模版
Name:
Sex:
Age:
Nation:
BirthPlace:
Marital
Status:
Work-organization&Occupation:
LivingAddress&Tel:
Dateofadmission:
Dateofhistorytaken:
Informant:
ChiefComplaint:
HistoryofPresentIllness:
PastHistory:
GeneralHealthStatus:
1.good2.moderate3.poor
Diseasehistory:
(ifany,pleasewritedownthedateofonset,briefdiagnosticandtherapeuticcourse,andtheresults.)
Respiratorysystem:
1.None2.Repeatedpharyngealpain3.chroniccough
4.expectoration:
5.Hemoptysis6.asthma7.dyspnea8.chestpain
Circulatorysystem:
1.None2.Palpitation3.exertionaldyspnea4..cyanosis
5.hemoptysis
6.Edemaoflowerextremities7.chestpain8.syncope
9.hypertension
Digestivesystem:
1.None2.Anorexia3.dysphagia4.sourregurgitation
5.eructation6.nausea7.Emesis8.melena
9.abdominalpain10.diarrhea11.hematemesis
12.Hematochezia13.jaundice
Urinarysystem:
1.None2.Lumbarpain3.urinaryfrequency4.urinaryurgency
5.dysuria6.oliguria7.polyuria8.retentionofurine
9.incontinenceofurine10.hematuria11.Pyuria
12.nocturia13.puffyface
Hematopoieticsystem:
1.None2.Fatigue3.dizziness4.gingivalhemorrhage5.epistaxis
6.subcutaneoushemorrhage
Metabolicandendocrinesystem:
1.None2.Bulimia3.anorexia4.hotintolerance5.coldintolerance
6.hyperhidrosis7.Polydipsia8.amenorrhea
9.tremorofhands10.characterchange11.Markedobesity12.markedemaciation13.hirsutism
14.alopecia
15.Hyperpigmentation16.sexualfunctionchange
Neurologicalsystem:
1.None2.Dizziness3.headache4.paresthesia5.hypomnesis
6.Visualdisturbance7.Insomnia8.somnolence9.syncope10.convulsion11.Disturbanceofconsciousness12.paralysis13.vertigo
Reproductivesystem:
1.None2.others
Musculoskeletalsystem:
1.None2.Migratingarthralgia3.arthralgia4.artrcocele5.arthremia
6.Dysarthrosis7.myalgia8.muscularatrophy
InfectiousDisease:
1.None2.Typhoidfever3.Dysentery4.Malaria
4.Schistosomiasis4.Leptospirosis7.Tuberculosis
8.Epidemichemorrhagicfever9.others
Vaccineinoculation:
1.None2.Yes3.Notclear
Vaccinedetail
Traumaand/oroperationhistory:
Operations:
1.None2.Yes
Operation
details:
Traumas:
1.None2.Yes
Trauma
details:
Bloodtransfusionhistory:
1.None2.Yes(1.Wholeblood2.Plasma3.Ingredienttransfusion)
Bloodtype:
Transfusiontime:
Transfusionreaction
1.None2.Yes
Clinicmanifestation:
Allergichistory:
1.None2.Yes3.Notclearallergen:
clinicalmanifestation:
Personalhistory:
Customlivingaddress:
Residenthistoryinendemicdiseasearea:
Smoking:
1.No2.YesAverage___piecesperday;about___yearsGiving-up1.No2.Yes
(Time:
)
Drinking:
1.No2.YesAverage___gramsperday;about___yearsGiving-up1.No
2.Yes(Time:
)
Drugabuse:
1.No2.Yes
Drugnames:
Maritalandobstetricalhistory:
Marriedage:
yearsoldPregnancytimes
Labortimes
(1.Naturallabor:
times2.Operativelabor:
times
3.Naturalabortion:
times4.Artificialabortion:
times
5.Prematurelabor:
times
6.stillbirthtimes)
HealthstatusoftheMate:
1.Well2.Notfine
Details:
Menstrualhistory:
Menarchalage:
DurationdayIntervaldays
Lastmenstrualperiod:
Menopausalage:
years
old
Amountofflow:
1.small2.moderate3.large
Dysmenorrheal:
1.presenee2.abseneeMenstrualirregularity1.No
2.Yes
Familyhistory:
(especiallypayattentiontotheinfeetiousand
hereditarydiseaserelatedtothepresentillness)
Father:
l.healthy2.ill:
3.deeeasedcause:
Mother:
1.healthy2.ill:
3.deeeasedcause:
Others:
Theanteriorstatementwasagreedbytheinformant.
Signatureofinformant:
Datetime:
PhysicalExamination
Vitalsigns:
Temperature:
°CBloodpressure:
/mmHg
Pulse:
bpm(l.regular
2.irregular)
Respiration:
bpm(l.regular
2.irregular)
Generalconditions:
Development:
I.Normal2.Hypoplasia3.Hyperplasia
Nutrition:
l.good2.moderate3.poor4.eaehexia
Facialexpression:
1.normal2.aeute3.ehronic
other
Habitus:
l.asthenictype2.sthenictype3.ortho-thenictype
Position:
l.aetive2.positive3.eompulsive
4.other
Conseiousness:
l.elear2.somnolence3.eonfusion4.stupor
5.slightcoma6.mediatecoma7.deepcoma8.delirium
Cooperation:
1Yes2.NoGait:
1.normal2.abnormal
Skinandmucosa:
Color:
1.normal2.pale3.redness4.cyanosis5.jaundice6.pigmentation
Skineruption:
1.No2.Yes(type:
distribution:
)
Subcutaneousbleeding:
1.no2.yes
(type:
distribution:
)
Edema:
1.no2.yes(locationanddegree)
Hair:
1.normal
2.abnormal(details)
Temperatureandmoisture:
normalcoldwarmdrymoistdehydration
Liverpalmar:
1.no2.yesSpiderangioma
(location:
)
Others:
Lymphnodes:
enlargementofsuperficiallymphnode:
1.no2.yesDescription:
Head:
Skullsize:
1.normal2.abnormal
(description:
)
Skullshape:
1.normal
2.abnormal(description:
)
Hairdistribution:
1.normal
2.abnormal(description:
)
Others:
Eye:
exophthalmos:
eyelid:
conjunctiva:
sclera:
Cornea:
Pupil:
1.equallyroundandinsize2.unequal(Rmm
Lmm)
Pupilreflex:
1.normal2.delayed(R___sL___s)3.absent
(R___L___)
others:
Ear:
Auricle1.normal2.desformation
(description:
)
Dischargeofexternalauditorycanal:
1.no2.yes(1.left2.rightquality:
)
Mastoidtenderness1.no2.yes(1.left2.rightquality:
)Disturbanceofauditory
acuity:
1.no2.yes(1.left2.rightdescription:
)
Nose:
Flaringofalaenasi:
1.no2.yesStuffydischarge1.no
2.yes(quality)
Tendernessoverparanasalsinuses:
1.no2.yes
(location:
)
Mouth:
LipMucosaTongue
Teeth:
1.normal2.Agomphiasis3.Eurodontia4.others:
Gum:
1.normal2.abnormal(Description)
Tonsil:
Pharynx:
Sound:
1.normal2.hoarseness
3.others:
Neck:
Neckrigidity1.no2.yes(transversfingers)
Carotidartery:
1.normalpulsation2.increasedpulsation3.markeddistention
Trachealocation:
1.middle2.deviation
(1.leftward2.rightward)
Hepatojugularveinreflux:
1.negative2.positive
Thyroid:
1.normal2.enlarged3.bruit(1.no2.yes
)
Chest:
Chestwall:
1.normal2.barrelchest3.prominenceorretraction:
(leftrightPrecordial
prominence)
Percussionpainoversternum1.No2.Yes
Breast:
1.Normal2.abnormal
Lung:
Inspection:
respiratorymovement1.normal2.abnormal
Palpation:
vocaltactilefremitus:
1.normal2.abnormal
pleuralrubbingsensation:
1.no
2.yes
Subcutaneouscrepitussensation:
1.no
2.yes
Percussion:
1.resonance2.Hyperresonance
&location3
Flatness&location
4.dullness&
location:
5.tympany
&location:
lowerborderoflung:
(detailedpercussionin
respiratorydisease)
midclavicularline:
R:
intercostae
L:
intercostae
midaxillaryline:
R:
intercostae
L:
intercostae
scapularline:
R:
intercostae
L:
intercostae
movementoflowerborders:
R:
cmL:
cm
Auscultation:
Breathingsound:
:
1.normal2.abnormal
Rales:
1.no
2.yes
Heart:
Inspection:
Apicalpulsation:
1.normal2.unseen3.increase
4.diffuseSubxiphoidpulsation:
1.no2.yesLocationofapexbeat:
1.normal2.shift(
intercosta,
distaneeawayfromleft
MCLcm)
Palpation:
Apicalpulsation:
1.normal2.liftingapeximpulse
3.negativepulsation
Thrill:
1.no2.yes(location:
phase:
)
Percussion:
relativedullnessborder:
1.normal2.abnormal
Right(cm)
Anteriormidline
Left(cm)
II
III
IV
V
(DistaneebetweenAnteriorMedlineandleftMCL
cm)
Auscultation:
Heartrate:
bpmRhythm:
1.regular
2.irregular
Heartsound:
1.normal
2.abnormal
Extrasound:
1.no2.S33.S44.openingsnap
P2A2Pericardialfrictionsound:
1.no
2.yes
Murmur:
1.no2.yes(locationphase
qualityintensity
transmission
effectsofposition
effectsofrespiration
Peripheralvascularsigns:
1.None2.paradoxicalpulse3.pulsusalternans4.Waterhammerpulse5.capillarypulsation6.pulsedeficit7.Pistolshotsound8.Duroziezsign
Abdomen:
Inspection:
Shape:
1.normal2.protuberance3.scaphoid
4.frog-belly
Gastricpattern1.no2.yesIntestinalpattern
1.no2.yes
Abdominalveinvaricosis1.no
2.yes(direction:
)
Operationscar1.no2.yes
Palpation:
1.soft2.tensive
(location:
)
Tenderness:
1.no
2.yes(location:
)
Reboundtenderness:
1.no
2.yes(location:
)
Fluctuation:
1.present2.abscentSuccussionsplash:
1.negative2.positive
Liver:
Gallbladder:
Murphy
sign:
Spleen:
Kidneys:
Abdominal
Others:
Percussion:
Liverdullnessborder:
1.normal2.decreased
3.absent
Upperhepaticborder:
RightMidclavicularLineIntercosta
Shiftdullness:
1.negative2.positiveAscites:
degree
Painonpercussionincostovertebralarea:
1.negative2.positve
Auscultation:
Bowelsounds:
1.normal2.hyperperistalsis
3.hypoperistalsis4.absenceGurglingsound:
1.no2.yesVascularbruit1.no2.yes
(location)
Genitalorgan:
1.unexamined2.normal3.abnormal
Anusandrectum:
1.unexamined2.normal3.abnormal
Spineandextremities:
Spine:
1.normal2.deformity(1.kyphosis2.lordosis
3.scoliosis)
3.Tenderness(location)
Extremities:
1.normal2.arthremia&arthrocele
(location)3.Ankylosis
(location)4.Aropachy:
1.no2.yes
5.Muscularatrophy
(location)
Neurologicalsystem:
1.normal
2.abnormal
Importantexaminationresultsbeforehospitalized
Summaryofthe
history:
Initial
diagnosis:
Recorder:
Corrector:
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