Questions
Directions: Single best answer questions consist of numbered items or
incomplete statements followed by answers or by completions of the
statement. Select the ONE lettered answer or completion that is BEST in
each case.
第1题：A 19-year-old woman presents to the emergency department
with a new onset of right lower quadrant abdominal pain. On
physical examination, the patient has a temperature of 38.5℃
(101.3℉) and a WBC count of 13,000/mm3. Which of the following
symptoms is also most likely present in this patient?
A. Abdominal distention
B. Hunger
C. Nausea and vomiting
D. Profuse watery diarrhea
E. Vaginal bleeding
第2题：A mother brings in her 5-month-old infant because the
infant is bowlegged. The mother is interested in finding out
surgical treatment options. Examination reveals minimal
bowlegs without other abnormalities. Radiograph shows only a
mild bowleg deformity without other bony abnormalities. What
is the best therapeutic option for the infant?
A. Observation
B. Leg splints
C. High-dose oral calcium
D. Open surgical fixation
E. Cast application
第3题：An abdominal CT scan demonstrates a polypoid mass of the gallbladder protruding into the lumen, diffuse thickening of
the gallbladder wall, and enlarged lymph nodes. This patient
most likely has a history of which of the following?
A. Ascaris lumbricoides
B. Cigarette smoking
C. Gallstones
D. Schistosoma haematobium
E. Tuberculosis
第4题：Which of the following is least likely to occur in starvation?
A. Weight loss
B. Reduced basal metabolic rate
C. Amenorrhea in a female
D. Decreased glucagon levels
E. Diarrhea
第5题：Which vitamin deficiency is most likely in a vegan (one who eats no animal products whatsoever)?
A. Vitamin B1
B. Vitamin B3
C. Vitamin B6
D. Vitamin B12
E. Vitamin D
第6题：In which condition is a nontender, palpable gallbladder most likely?
A. Pancreatic cancer
B. Chronic cholecystitis
C. Cholelithiasis
D. Acute cholecystitis
E. Cholangitis
第7题：A 56-year-old woman undergoes neurologic evaluationfor recent onset of seizures and a gradually worsening tingling sensation in her right arm. Examination reveals mild loss of strength in the right upper extremity. CT scan and MRI show a
5-cm dural-based mass in the left frontoparietal region. The
mass is well demarcated and compresses the underlying parenchyma. Ti-weighted MRI scans after gadolinium enhancement show marked contrast enhancement within the lesion associated with a characteristic "dural tail." There is prominent
thickening of the overlying calvarial bone. Which of the
following is the most likely diagnosis?
A. Glioblastoma multiforme (GBM)
B. Langerhans cell histiocytosis
C. Meningioma
D. Metastasis
E. Paget disease
F. Schwannoma
G. Tuberculoma
第8题：Which of the following is least likely to cause pancreatitis?
A. Hypocalcemia
B. Coxsackievirus infection
C. Dideoxyinosine
D. Sulfonamides
E. Familial hypertriglyceridemia
第9题：Which of the following is least likely to cause high amylase levels?
A. Mumps
B. Perforated peptic ulcer
C. Intestinal infarction
D. Renal failure
E. Hypoglycemia
第10题：What is the most likely presenting sign or symptom of renal cell carcinoma?
A. Hematuria
B. Palpable flank mass
C. Cough secondary to lung metastasis
D. Hypertension
E. Renal failure
第11题：A 25-year-old man comes to the physician because of the
rapid onset of pain and swelling of his left knee, which began
24 hours ago. His temperature is 38.5°C (101.3 F), blood
pressure is 125/70 mmHg, pulse is 95/min, and respirations are
20/min. His personal history is significant for IV drug abuse.
He denies a history of sexually transmitted diseases. The left
knee is tender, swollen, and warm to the touch. Chest
auscultation is normal Which of the following is the most appropriate next step in management?
A. Blood studies including complete blood count (CBC)
B. HIV testing prior to instituting any treatment
C. Plain x-ray films of the joint
D. Nonsteroidal anti-inflammatory and empiric antibiotic
therapy
E. Diagnostic arthrocentesis
第12题：A 24-year-old woman comes to the emergency department because of abdominal pain, nausea, and anorexia for 24 hours.
She is sexually active but does not take oral contraceptives.
Her last menstrual period was 2 weeks ago. Her temperature is
38.0 °C (100.4 F). The pain is constant and localized in the
right lower abdomen,where palpation elicits guarding and rebound tenderness. Pain in the right lower quadrant of the abdomenis also provoked by palpation of the left lower quadrant.Bowel sounds are absent. Pelvic examination is https://www.doczj.com/doc/cc12299091.html,boratory investigations show moderate neutrophilicleukocytosis and 13-hCG within normal limits. Urinalysis shows 2 erythrocytes per high power field. Which of the following is the most appropriate next step in management?
A. Antibiotic therapy
B. Barium enema
C. Ultrasonography of urinary tract
D. Dilatation and curettage
E. Appendectomy
第13题：A 59-year-old woman with four children reports involuntary loss of urine when coughing, sneezing, or lifting. What is the most likely mechanism for the woman's incontinence?
A. Stress incontinence
B. Urge incontinence
C. Overflow incontinence
D. Neurogenic bladder dysfunction
E. Psychogenic incontinence
第14题：A 31-year-old man presents with acute pain in the right testicle. He says the pain came on gradually over the last several hours. The patient denies any history of sexually transmitted disease but admits to being promiscuous. Physical examination reveals a temperature of 37.9°C（100.1 °F）, a tender right testicle, and mild erythema of the scrotal skin overlying the testicle. The testicular pain is relieved by
elevation of the testicle. An ultrasound study reveals
increased blood flow into the right testicle. What is likely
to be the most effective treatment for the most likely
condition?
A. Immediate surgical exploration and orchiopexy of the
affected testicle
B. Immediate surgical exploration and orchiopexy of both
testicles
C. Unilateral orchiectomy
D. Doxycycline
E. Penicillin
第15题：A mother brings her young child in for a routine
well-child visit. This child has been developmentally normal
so far. In reviewing the developmental milestones, the mother states the child has recently mastered the following; coos, smiles, laughs, raises body on hands, rolls over front to back, grasps a rattle, and can control its head well. Based on these milestones, which of the following would you also expect this child to have mastered?
A. Cruises and takes steps alone
B. Drinks from cup
C. May be cutting first tooth
D. Pulls to stand
E. Reaches for objects and bats them
第16题：A 64-year-old man with a long smoking history is found to have a 2-cm lung nodule on chest radiograph. A CT scan of the chest shows a suspicious-looking lung nodule as well as
multiple enlarged mediastinal lymphnodes. A biopsy of the lung nodule reveals a small cell lung carcinoma. What is the best
current single therapeutic option in terms of improving
survival?
A. Surgical pneumonectomy of the affected lung
B. Surgical lobectomy of the affected lobe
C. Radiation therapy
D. Chemotherapy
E. Hormonal therapy with an estrogen-containing compound
第17题：A 30-year-old man is recovering from abdominal trauma and now develops multiple bruises all over his body. He has
completed a 2-week course of antibiotics and has also been receiving nutrition parenterally for 21 days. He is otherwise
healthy and has never been on medications prior to this admission. On physical examination, his vital signs are
stable. He has multiple ecchymoses on his abdomen. The heart
is regular in rate and rhythm. His prothrombin time is
elevated. His hematocrit and platelet count are normal. Which
of the following is the most likely cause of his easy
bruising?
A. Calcium deficiency
B. Disseminated intravascular coagulation (DIC)
C. Magnesium deficiency
D. Sepsis
E. Vitamin K deficiency
第18题：A 29-year-old black woman presents for a routine checkup. She has a medical history significant only for asthma during childhood, which she claims to have "outgrown." She does not smoke, drink alcohol, or use drugs. She is sexually active and
has not seen a physician in 6 years. She is 4, feet 11 inches
(150 cm) tall and weighs 247.5 lb (112.5 kg). Physical
examination is unremarkable other than obesity. Which of the following is true?
A. The patient has a body mass index of 50 kg/m2.
B. The patient, given her age, has no outstanding
health maintenance issues other than anticipatory
guidance.
C. Given her race and sex, the patient's obesity is of
little concern at this age.
D. The patient should be referred promptly for gastric
bypass surgery.
E. The patient should be prescribed a β2-agonist because
people do not "outgrow" asthma.
第19题：Which of the following scenarios would be considered a coronary disease risk factor when deciding treatment goals for cholesterol-lowering therapy?
A. A 44-year-old woman on hormone replacement therapy
B. A male patient with an aunt who had a myocardial
infarction at age 42
C. A female patient who used to smoke but successfully
quit a few months ago
D. A female patient taking a calcium channel blocker for
high blood pressure
E. A male patient whose father died of a myocardial
infarction at the age of 62
第20题：In the United States, which form of acute hepatitis is most likely in an adult who is not sexually active, has never received a blood transfusion, and has never used intravenous drugs?
A. Hepatitis A
B. Hepatitis B
C. Hepatitis C
D. Hepatitis D
E. Hepatitis E
第21题：A 52-year-old man with a 30-pack-year smoking history presents to his primary care physician for a yearly physical examination. He was diagnosed with emphysema at the age of 47 and continues to smoke without modification. Chest X-ray
reveals lung hyperinflation. He is at much higher risk for
which of the following?
A. Bacterial endocarditis
B. Cor pulmonale
C. Deep venous thrombosis
D. Mitral valve prolapse
E. Pulmonary embolus
第22题：A 19-year-old woman comes to the office requesting birth control. She says she is not sure which method would be best
for her but says that her previous and current boyfriends did
not like to use condoms She has no plans of having children "anytime soon" but wants them eventually. She admits to being promiscuous and is not currently looking for a monogamous relationship. Other than "occasional" smoking, drinking, and marijuana use, her health history is unremarkable. Which of
the following methods of contraception would be least
appropriate for her?
A. Intrauterine device
B. Birth control pills
C. Long-acting medroxyprogesterone depot injections
D. Long-acting levonorgestrel implant
E. Diaphragm with spermicide
第23题：A 27-year-old female attorney presents with a chief complaint of severe "cramps" around the time of menstruation each month. She describes colicky, midline lower abdominal pain that begins just before her menstrual flow begins and lasts for 2 days "like clock-work" every month. She takes acetaminophen, which she says is not helping. Physical examination, including a full pelvic examination, is unremarkable. Which of the following is the most appropriate empirical therapy for the most likely condition?
A. A cyclooxygenase inhibitor
B. A gonadotropin-releasing hormone analogue
C. A corticosteroid
D. A synthetic testosterone analogue
E. A cephalosporin
第24题：A mother brings in her 7-month-old infant because she is concerned that the baby cries frequently for no apparent
reason. You have never seen the infant before because the
family has just moved here from another town. The infant last
saw a physician 3 months ago for routine vaccinations. The infant, the woman's first, cries at least twice a day,
sometimes for 15 minutes at a time. The woman says she tries
to soothe the infant, but the infant often continues crying
for several minutes. The woman admits that the crying has
gotten better since the infant was a newborn. Physical examination is unremarkable, and the infant seems alert and responsive. What is the best way to proceed in the management
of the infant?
A. Perform ultrasound of the abdomen.
B. Order an MRI of the brain.
C. Take routine blood tests including complete blood
count and chemistries.
D. Ask the woman if she ever strikes the child.
E. Give anticipatory guidanc and administer routine
immunizations.
第25题：A 2-yea r-old boy is brought into the emergency department by his mother, who has noted blood in the stools and abdominal distension. The child's laboratory tests are all within limits. A barium enema is done, revealing a
sausage-shaped structure near the ileum. What is the most likely explanation of these findings?
A. Colonic volvulus
B. Intussusception
C. Meckel's diverticulum
D. Rotavirus infection
E. Normal variant
第26题：A 63-year-old woman is brought to the emergency department with severe back pain. She also has a history of easy bruising and has cutaneous striae over the lower abdomen. Magnetic resonance imaging (MRI) of the spine reveals a
compression fracture of L1. During her hospital course, she ultimately expired owing to septic shock. Autopsy revealed adrenal atrophy. Which of the following explains these findings?
A. Corticosteroid therapy
B. Cretinism
C. Cushing's disease
D. Diabetes
E. Osteoporosis
第27题：A 29-year-old woman presents to her primary care physician complaining of generalized malaise and intermittent itchiness. Her family history is positive for blood disorders, particularly hemolytic anemia. Physical examination reveals scleral icterus, and her skin appears jaundiced. Cardiac and pulmonary examinations are within normal limits. The spleen tip is palpable. Laboratory studies are obtained and reveal a total bilirubin of 6 and an indirect bilirubin of 4.9.
Hematocrit is 28%. What is the most appropriate treatment for this patient?
A. Phenobarbital
B. Dialysis
C. Liver transplant
D. Splenectomy
E. Quinidine
第28题：Which of the following is the most widely recommended annual screening procedure in adolescents?
A. Fasting lipid profile in teens with a positive family
history of cardiovascular disease
B. Prostate examination in black males
C. Tuberculosis skin test
D. Complete blood count or hemoglobin and hematocrit
levels in males
E. Gonorrhea and chlamydia cultures in females who are
sexually active
HUAZHONG UNIVERSITY OF SCIENCE AND TECHNOLOGY TONGJI MEDICAL COLLEGE ACCESSORY TONGJI HOSPITAL Hospitalization Records for None-operation Division Division: __________ Ward: __________ Bed: _________ Case No. ___________ 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: ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________
随着中外交流的加强，专业英语对医院也是越来越重要！花了点时间整理了下“住院病历的英汉对照”的格式，发上来和大家分享，希望对能用到的人有所帮助！ POMR (Problem-Oriented Medical Records)表格式住院病历 Biographical data: 一般项目： Name Age Sex Marital status Nativity Race 姓名年龄性别婚否籍贯民族 Occupation Date of admission Informant History 职业入院日期病史叙述者病史 Chief complaint 主诉 History of present illness 现病史 Past history 既往史： Previous health status: well ordinary bad Infectious diseases 平素健康状况：良好一般较差传染病史 Immunizations Allergies: N Y clinical manifestation 预防接种史过敏史无有临床表现 allergen: Trauma: Surgery: 过敏原外伤史手术史 Review of systems:(Tick if positive, cross out if negative. If postive, you should write down your disease history and brief course of diagnose and therapy) 系统回顾：(有打√无打×阳性病史应在下面空间内填写发病时间及扼要诊疗经过) Respiratory system: 呼吸系统 Sore throat chronic cough sputum hemoptysis wheezing 咽痛慢性咳嗽咳痰咯血哮喘 dyspnea chest pain 呼吸困难胸痛 cadiovascular system: 循环系统 Palpitation dyspnea on exertion hemoptysis syncope 心悸活动后气促咯血晕厥 edema of lower limbs precordial pain hypertention 下肢水肿心前区疼痛高血压 Digestive system: 消化系统 Anorexia sour regurgitation belching nausea vomitting
CASE REPORT FORM TEMPLATE Version: 6.0 (8 November 2012) PROTOCOL: [INSERT PROTOCOL NUMBER] [INSERT PROTOCOL TITLE] Participant Study Number: Study group:
BASELINE DATA General Instructions for Completion of the Case Report Forms (CRF) Completion of CRFs ? A CRF must be completed for each study participant who is successfully enrolled (received at least one dose of study drug) ?For reasons of confidentiality, the name and initials of the study participant should not appear on the CRF. General ?Please print all entries in BLOCK CAPITAL LETTERS using a black ballpoint pen. ?All text and explanatory comments should be brief. ?Answer every question explicitly; do not use ditto marks. ?Do not leave any question unanswered. If the answer t o a question is unknown, write “NK” (Not Known). If a requested test has not been done, write “ND” (Not Done). If a question is not applicable, write “NA” (Not Applicable). ?Where a choice is requested, cross (X) the appropriate response. Dates and Times ?All date entries must appear in the format DD-MMM-YYYY e.g. 05-May-2009. The month abbreviations are as follows: January = Jan May = May September = Sep February = Feb June = Jun October = Oct March = Mar July = Jul November = Nov April = Apr August = Aug December = Dec In the absence of a precise date for an event or therapy that precedes the participant’s inclusion into the study, a partial date may be recorded by recording “NK” in the fields that are unknown e.g. where the day and month are not clear, the following may be entered into the CRF: N K N K 2 0 0 9 DD MMM YYYY ?All time entries must appear in 24-hour format e.g. 13:00. Entries representing midnight should be recorded as 00:00 with the date of the new day that is starting at that time. Correction of Errors ?Do not overwrite erroneous entries, or use correction fluid or erasers. ?Draw a straight line through the entire erroneous entry without obliterating it. ?Clearly enter the correct value next to the original (erroneous) entry. ?Date and initial the correction. Protocol Number: Page 1 of 15
1 病历case histroy 一般事项date of admission /marital status /present address /correspondence / occupatio n 主诉chief complaints 现病史present illness / history of present illness 既往史past medical history 家族史family history 个人病史personal history / social history 曾用药物medications 过敏史allergies 系统回顾system review / review of system 体检physical examination 一般资料physical data 生理指标physical signs 一般状况或全身状况general appearance 头眼与耳鼻喉head ,eyes,ear,nose,throat ,略作heent. 胸部与心肺CHEST,heart,and lungs 腹部abodoms 四肢extremities 神经系统nervous system,Neurological,略作CNC或Neuro, 骨骼肌系统Musculoskeletal 泌尿生殖系统Genitourinary 化验室资料laboratory data/ studies /diagnosis 血液检查blood test 化学7项指标chem.-7 心脑电图electrocardiogram / electroencephalogram , 略作EKG/EEG X线检查与x光片X-ray examination, x-ray slides, 计算机X线断层扫描与核磁共振扫描资料computerized x-ray tomography and nuclear mag netic resonance spectroscopy dta. CT AND NMR 其他检查资料other lab data 印象与诊断impression and diagnosis 住院治疗情况hospital course 出院医嘱discharge instructions / recommendations 出院后用药discharge medications 2 看病时用英文 1) 一般病情: He feels headache, nausea and vomiting. (他覺得頭痛、噁心和想吐。) He is under the weather. (他不舒服，生病了。) He began to feel unusually tired. (他感到反常的疲倦。) He feels light-headed. (他覺得頭暈。) She has been shut-in for a few days. (她生病在家幾天了。) Her head is pounding. (她頭痛。) His symptoms include loss of appetite, weight loss, excessive fatigue, fever and chills. (他的症狀包括沒有食慾、體重減輕、非常疲倦、發燒和發冷。) He feels exhausted or fatigued most of the time. (他大部份時間都覺得非常疲倦。)
第二节心内科常用英文病历模板 熟练地阅读和书写英文病历是一名临床医师需要具备的基本外语技能。对英文病历的熟练掌握对于阅读英文文献和撰写英文论文都有很大的帮助。本章主要介绍心内科常见疾病英文病历的格式和基本模板。英文病历的书写格式大致与中文病历相似，主要包括以下部分： 1.General information（一般情况） 2.Chief complaint（主诉） 3.Present illness（现病史） 4.Past history（既往史） 5.Personal history（个人史） 6.Family history（家族史） 7.Physical examination（体格检查） 8.Investigation（辅助检查） 9.History summary（病史特点） 10.Impression（印象、初步诊断） 11.Signature（签名） 鉴于不同疾病的病历之间存在共性，本章按照病历的通用部分和心血管内科部分逐一进行介绍。 第一部分通用部分 1. General information（一般情况） 这一部分包括name（姓名），age（年龄），sex（性别），race（民族），nationality（国籍），address（地址和电话），occupation（职业），marital status（婚姻状况），date of admission（入院日期），date of record（记录日期），complainer of history（供史者）和reliability（可信度）等12项内容。基本格式如下：
Name:Liu Side Age: Eighty Sex: Male Race:Han Nationality:China Address: NO.35, Dandong Road, Jiefang Rvenue, Hankou, Hubei. Tel: 857307523 Occupation: Retired Marital status: Married Date of admission:Aug 6th, 2001 Date of record: 11Am, Aug 6th, 2001 Complainer of history: patient’s son and wife Reliability: Reliable 2. Past history（既往史） 这一部分应首先总结既往一般健康状况、Operative history（手术史）、Infectious history（传染病史）、Allergic history（过敏史）等，然后对各系统健康状况进行回顾，包括Respiratory system（呼吸系统）、Circulatory system （循环系统）、Alimentary system（消化系统）、Genitourinary system（泌尿生殖系统）、Hematopoietic system（血液系统）、Endocrine system（内分泌系统）、Kinetic system（运动系统）和Neural system（神经系统）。基本格式示例如下： 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
POMR (Problem-Oriented Medical Records)表格式住院病历 Biographical data: 一般项目： Name Age Sex Marital status Nativity Race 姓名年龄性别婚否籍贯民族 Occupation Date of admission Informant History 职业入院日期病史叙述者病史 Chief complaint 主诉 History of present illness 现病史 Past history 既往史： Previous health status: well ordinary bad Infectious diseases 平素健康状况：良好一般较差传染病史 Immunizations Allergies: N Y clinical manifestation 预防接种史过敏史无有临床表现 allergen: Trauma: Surgery: 过敏原外伤史手术史 Review of systems:(Tick if positive, cross out if negative. If postive, you should write down your disease history and brief course of diagnose and therapy) 系统回顾：(有打√无打×阳性病史应在下面空间内填写发病时间及扼要诊疗经过) Respiratory system: 呼吸系统 Sore throat chronic cough sputum hemoptysis wheezing 咽痛慢性咳嗽咳痰咯血哮喘 dyspnea chest pain 呼吸困难胸痛 cadiovascular system: 循环系统 Palpitation dyspnea on exertion hemoptysis syncope 心悸活动后气促咯血晕厥 edema of lower limbs precordial pain hypertention 下肢水肿心前区疼痛高血压 Digestive system: 消化系统 Anorexia sour regurgitation belching nausea vomitting 食欲减退反酸嗳气恶心呕吐 abdominal distention abdominal pain constipation diarrhea 腹胀腹痛便秘腹泻 hematemesis melena hematochezia jaundice 呕血黑便便血黄疸 Urinary system:
英文大病例写作示例 时间:2007-06-04 17:19来源:中国医师协会作者: 点击: 355 次 撰写大病例是实习医师与住院医师的日常工作，也是上级医师作进一步诊断治疗的原始依据，国外的英文大病例并无统一格式，但是基本内容大致相仿，本节介绍的许多医疗记录的词汇值得借鉴。 Details个人资料 Name: Joe Bloggs (姓名：乔。伯劳格斯) Date: 1st January 2000（日期：2000年1月1日） Time: 0720(时间：7时20分) Place: A&E（地点：事故与急诊登记处） Age: 47 years（年龄：47岁） Sex: male（性别：男） Occupation: HGV(heavy goods vehicle ) driver（职业：大型货运卡车司机） PC(presenting complaint)（主诉） 4-hour crushing retrosternal chest pain（胸骨后压榨性疼痛４小时） HPC(history of presenting complaint)（现病史） Onset: 4 hours of “crushing tight” retrosternal chest pain, radiating to neck and both arms, gradual onset over 5-10 minutes.（起病特征：胸骨后压榨性疼痛４小时，向颈与双臂放 https://www.doczj.com/doc/cc12299091.html,，5-10分钟内渐起病） Duration: persistent since onset（间期：发病起持续至今） Severe: “worst pain ever had”（严重性：“从未痛得如此厉害过）
CASE Medical Number: 682786 General information Name:Wang Runzhen Age: Forty three Sex: Female Race:Han Occupation: Teacher Nationality:China Marital status: Married Address: NO.38, Hangkong Road, Jiefang Rvenue, Hankou, Hubei. Tel: 82422500 Date of admission:Jan 11st, 2001 Date of record: 11Am, Jan 11st, 2001 Complainer of history: the patient herself Reliability: Reliable Chief complaint: Right breast mass found for more than half a month. Present illness: Half a month ago, the patient suddenly felt pain in her right chest when she put up her hand. After touching it, she found a mass in her right breast, but no tendness, and the patient didn’t pay attention it. Then the pain became more and more serious, so the patient went to tumour hospital and received a pathology centesis. Her diagnosis was breast cancer. Then she came to our hospital and asked for an operation. Since onset, her appetite was good, and both her spiritedness and physical energy are normal. Defecation and urination are normal, too. Past history Operative history: Never undergoing any operation. Infectious history:No history of severe infectious disease.
General information Name Age Sex Race Nationality Address Occupation Marital status Date of admission Date of record Complainer of history Reliability: Reliable Chief complaint The patient has a cough producing thick rusty sputum and a high fever that is accompanied by shaking chills. He has a right chest pain when breathing. History of present illness The patient has had a cold after swimming in the cold water recently. He had a cough with thick rusty sputum. He had shaking chills and felt a chest pain on the right side. He saw a doctor. A week after, he thought he was over it and didn’t pay attention to it, w ent swimming again. Now the condition is more serious. He has a high fever with 39℃that is accompanied by shaking chills. He has a bad cough with no-blood sputum. When he takes a deep breath, it even hurts. Past medical history The patient is health before. No history of infective disease. No allergy history of food and drugs. No operative history. No disease history in other system. Personal history He was born in XXX on XXXX and almost always lives in XXX. His living conditions were good. No bad personal habits and customs. Menstrual history: He is a male patient. Family history: His parents are both alive. Physical examination General: T P R BP W H. The patient is a well-developed, well-nourished adult male. HEENT: PERRL, EMOI, small oral aperture. Neck: JVP to angle of jaw, 2+ carotid pulses, full range of motion. Cardiac: RRR, normal S1,S2, distant heart sounds. Chest wall: No subcutaneous emphysema. No tenderness. Thorax: Symmetric bilaterally. Breast: Symmetric bilaterally. Lungs: Respiratory movement is bilaterally asymmetric with the frequency of 24/min. We can hear coarse breathing when listening to a portion of the chest with a stethoscope. There are moist rales on bilateral inferior lung. Heart: Border of the heart is normal. Heart sounds are strong and no splitting. Rate 150/min. No pathological murmurs. Abdomen: Flat and soft. No abdominal wall varicose. There is no rebound tenderness on abdomen or renal region. Liver and spleen are untouched. Skin: No pigmentation. No pitting edema. No skin eruption. Extremities: No articular swelling. All limbs can free move. Genitourinary system: Not examed. Rectum: Not examed. Neural system: Physiological reflexes are existent without pathological ones. Investigation Chest X-ray: Lamellar shadow can be seen in middle and inferior lobe of right lung. The right lung is seriously infected. The volume of useful lung is reduced because of the collection of fluid around the lung.
Nanjing children’s hospital Medical Records for Admisson Ward:321 Bed Number:32178 Medical Number: 696235 General information Name:Son of *** Sex: Male Age: 3 h Birthplace: *** county,Anhui province Race:Han Address:***town,***county,Anhu i province Date of admission:3:31pm Oct 16th,2015 Date of record: 3:31pm Oct 16th,2015 Parents Name: father *** Mother *** Complainer of history: patient’s father Reliability: Reliable Chief complaint: Shortness of breath and moaning for 3h Present illness: The afflicted baby was delivered 3h ago and had instaneous shortness of breath along with obtuse response and moaning.No aspnea or seizure or scream were observed. In local Hospital he received treatment of “naloxone、mezlocillin and Vit K1”, but his symptoms didn’t abate. So the parents took him to our hospital, he was admitted with a diagnosis of “acute respiratory dyspnea syndrome” .Breast feed has not been initiated.He has not vomitted,defecated or urinated since he was born,.
Complete Medical History General information Name: Du Donghe Sex: male Profession : retired worker Age:53 years Native place: Tian Jin Address:shenghe Department pujijian Road hebei district tianjin Marital state: married Nationality: Han Date of admission: July 16th 2012 Date of history taking :July 16th 2012 Narrator: the patient's daughter Reliability of the history: reliable The History Chief Complaint: weakness for 1 year, more severe with edema in lower limbs for half a year. Present Illness:1 years ago ,without significant causes,the patient began to feel weakness. No headache, dizzy, palpitation, shortness, abdominal pain or diarrhea . The patient went to the hospital in his town, and checked his live function, shown the live is damaged,given liver-protecting treatment(the detail of drugs used is unclear). But the symptom is not obviously lightened. And half a year ago ,the symptom became more severe,with edema in lower limbs , abdominal distension and bulge.No headache, dizzy, palpitation, shortness, tightness, abdominal pain or diarrhea . So the patient
Medical Records for Admission Medical Number: 701721 General information Name:Liu Side Age: Eighty Sex: Male Race:Han Nationality:China Address: NO.**, Dandong Road, Jiefang Rvenue, Hankou, Hubei. Tel: ****** Occupation: Retired Marital status: Married Date of admission: Aug 6th, 2001 Date of record: 11Am, Aug 6th, 2001 Complainer of history: patient’s son and wife Reliability: Reliable Chief complaint: Upper abdominal pain for ten days, hematemesis, hematochezia and unconsciousness for four hours. Present illness: The patient felt upper abdominal pain for 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 as “upper gastrointestine hemorrhage and hemorrhagic 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. 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. Family history: His parents have both deads. Physical examination
Division: __________ Ward: __________ Bed: _________ Case No. ___________ 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: