心内科英文病历Word下载.doc

心内科英文病历Word下载.doc

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Race:

Han

Nationality:

China

Address:

NO.35,DandongRoad,JiefangRvenue,Hankou,Hubei.Tel:

857307523

Occupation:

Retired

Maritalstatus:

Married

Dateofadmission:

Aug6th,2001

Dateofrecord:

11Am,Aug6th,2001

Complainerofhistory:

patient’ssonandwife

Reliability:

Reliable

Chiefcomplaint:

Upperbellyachetendays,haematemesis,hemafeciaandunconsciousnessforfourhours.

Presentillness:

Thepatientfeltupperbellyacheabouttendaysago.Hedidn’tpayattentiontoitandthoughthehadatesomethingwrong.At6o’clockthismorninghefaintedandrejectedlotsofbloodandgore.Thenhemafeciabegan.Hisfamilysenthimtoourhospitalandreceivedemergenttreatment.Sothepatientwasacceptedbecauseof“uppergastrointestinehemorrhageandexsanguineshock”.

Sincethediseasecomingon,thepatientdidn’turinate.

Pasthistory

Thepatientishealthybefore.

Nohistoryofinfectivediseases.Noallergyhistoryoffoodanddrugs.

Operativehistory:

Neverundergoinganyoperation.

Infectioushistory:

Nohistoryofsevereinfectiousdisease.

Allergichistory:

Hewasnotallergictopenicillinorsulfamide.

Respiratorysystem:

Nohistoryofrespiratorydisease.

Circulatorysystem:

Nohistoryofprecordialpain.

Alimentarysystem:

Nohistoryofregurgitation.

Genitourinarysystem:

Nohistoryofgenitourinarydisease.

Hematopoieticsystem:

Nohistoryofanemiaandmucocutaneousbleeding.

Endocrinesystem:

Noacromegaly.Noexcessivesweats.

Kineticsystem:

Nohistoryofconfinementoflimbs.

Neuralsystem:

Nohistoryofheadacheordizziness.

Personalhistory

HewasborninWuhanonNov19th,1921andalmostalwayslivedinWuhan.Hislivingconditionsweregood.Nobadpersonalhabitsandcustoms.

Menstrualhistory:

Heisamalepatient.

Obstetricalhistory:

No

Contraceptivehistory:

Notclear.

Familyhistory:

Hisparentshavebothdeads.

Physicalexamination

T36.5℃,P130/min,R23/min,BP100/60mmHg.Heiswelldevelopedandmoderatelynourished.Activeposition.Hisconsciousnesswasnotclear.Hisfacewascadaverousandtheskinwasnotstainedyellow.Nocyanosis.Nopigmentation.Noskineruption.Spiderangiomawasnotseen.Nopittingedema.Superficiallymphnodeswerenotfoundenlarged.

Head

Cranium:

Hairwasblackandwhite,welldistributed.Nodeformities.Noscars.Nomasses.Notenderness.

Ear:

Bilateralauriclesweresymmetricandofnomasses.Nodischargeswerefoundinexternalauditorycanals.Notendernessinmastoidarea.Auditoryacuitywasnormal.

Nose:

Noabnormaldischargeswerefoundinvetibulumnasi.Septumnasiwasinmidline.Nonaresflaring.Notendernessinnasalsinuses.

Eye:

Bilateraleyelidswerenotswelling.Noptosis.Noentropion.Conjunctivawasnotcongestive.Sclerawasanicteric.Eyeballswerenotprojectedordepressed.Movementwasnormal.Bilateralpupilswereroundandequalinsize.Directandindirectpupillaryreactionstolightwereexistent.

Mouth:

Oralmucousmembranewasnotsmooth,andtherewereulcercanbeseen.Tonguewasinmidline.Pharynxwascongestive.Tonsilswerenotenlarged.

Neck:

Symmetricandofnodeformities.Nomasses.Thyroidwasnotenlarged.Tracheawasinmidline.

Chest

Chestwall:

Veinscouldnotbeseeneasily.Nosubcutaneousemphysema.Intercostalspacewasneithernarrowednorwidened.Notenderness.

Thorax:

Symmetricbilaterally.Nodeformities.

Breast:

Symmetricbilaterally.

Lungs:

Respiratorymovementwasbilaterallysymmetricwiththefrequencyof23/min.thoracicexpansionandtactilefremitusweresymmetricbilaterally.Nopleuralfrictionfremitus.Resonancewasheardduringpercussion.Noabnormalbreathsoundwasheard.Nowheezes.Norales.

Heart:

Nobulgeandnoabnormalimpulseorthrillsinprecordialarea.Thepointofmaximumimpulsewasin5thleftintercostalspaceinsideofthemidclavicularlineandnotdiffuse.Nopericardialfrictionsound.Borderoftheheartwasnormal.Heartsoundswerestrongandnosplitting.Rate150/min.Cardiacrhythmwasnotregular.Nopathologicalmurmurs.

Abdomen:

Flatandsoft.Nobulgeordepression.Noabdominalwallvaricosis.Gastralintestinaltypeorperistalseswerenotseen.Tendernesswasobviousaroundthenavelandinupperabdoman.Therewasnotreboundtendernessonabdomenorrenalregion.Liverandspleenwasuntouched.Nomasses.Fluidthrillnegative.Shiftingdullnessnegative.Borhorygmusnotheard.Novascularmurmurs.

Extremities:

Noarticularswelling.Freemovementsofalllimbs.

Neuralsystem:

Physiologicalreflexeswereexistentwithoutanypathologicalones.

Genitourinarysystem:

Notexamed.

Rectum:

notexaned

Investigation

Blood-Rt