英文病历书写范例

英语病历作文格式模板英文回答：Medical History Template。

Patient Information。

Name:Date of Birth:Address:Phone Number:Email:Insurance Information:Chief Complaint。

A brief summary of the patient's primary reason for the visit.Example: "The patient presents with a 3-day history of fever and chills."History of Present Illness。

A detailed description of the patient's symptoms, including:Onset: When did the symptoms first appear?Duration: How long have the symptoms been present?Severity: How severe are the symptoms?Location: Where are the symptoms located?Associated symptoms: Any other symptoms that are present, such as nausea, vomiting, or headache.Past Medical History。

A list of any previous medical conditions, surgeries, or hospitalizations.Example: "The patient has a history of hypertension and hyperlipidemia."Family History。

HUAZHONG UNIVERSITY OF SCIENCE AND TECHNOLOGYTONGJI MEDICAL COLLEGE ACCESSORY TONGJI HOSPITALHospitalizatio n Records for Non e-operati on Divisio nDivisi on: _________ Ward: __________ Bed: _________ Case No. ____________Name: ______________Sex: __________ Age: ___________ Nati on: ___________ Birth Place: ________________________________Marital Status: ____________ Work-orga nizati on & Occupati on: _____________________________________ Livi ng Address & Tel: ________________________________________________ Date of admissi on: ______ Date of history taken: ______ Informant:__________Chief Complaint: ____________________________________________History of Prese nt III ness:Past History:Gen eral Health Status: l.good 2.moderate 3.poorDisease history: (if any, please write dow n the date of on set, brief diag no sticand therapeutic course, and the results.)Respiratory system:1. None2.Repeated pharyngeal pain3.chronic cough4.expectoration:5. Hemoptysis6.asthma7.dyspnea8.chest painCirculatory system:1.No ne2.Palpitatio n3.exerti onal dysp nea4..cya no sis5.hemoptysis6.Edema of lower extremities7.chest pain8.s yn cope9.hypertensionDigestive system:1.None2.Anorexia3.dysphagia4.sour regurgitation5.eructation6.nausea7.Emesis8.melena9.abdominal pain 10.diarrhea11.hematemesis 12.Hematochezia 13.ja un diceUrinary system:1.N one2.Lumbar pain3.uri nary freque ncy4.uri nary urge ncy5.dysuria6.oliguria7.polyuria8.retention of urine9.ineontinence of urine10.hematuria ll.Pyuria 12.n octuria 13.puffy faceHematopoietic system:1.N one2.Fatigue3.dizz in ess4.gi ngival hemorrhage5.epistaxis6.subcuta neous hemorrhageMetabolic and en docri ne system:1.None2.Bulimia3.anorexia4.hot intoleranee5.cold intoleranee6.hyperhidrosis7.Polydipsia8.amenorrhea9.tremor of hands 10.character cha nge II.Marked obesity12.marked emaciati on 13.hirsutism 14.alopecia15.Hyperpigme ntatio n 16.sexual fun cti on cha ngeNeurological system:1.N one2.Dizz in ess3.headache4.paresthesia5.hypo mn esis6. Visual disturbanee7.lnsomnia8.somnolence9.s yn cope 10.c onv ulsi on II.Disturba nee of con scious ness12.paralysis 13. vertigoReproductive system:1.No ne2.othersMusculoskeletal system:1.None2.Migrating arthralgia3.arthralgia4.artrcocele5.arthremia6.Dysarthrosis7.myalgia8.muscular atrophyIn fectious Disease:1.N one2.Typhoid fever3.Dyse ntery4.Malaria 4.Schistosomiasis4. Leptospirosis 7.Tuberculosis 8.Epidemic hemorrhagic fever9.othersVacci ne ino culati on:1.No ne2.Yes3.Not clearVacci ne detail _________________________________________ Trauma an d/or operatio n history: Operati ons:1.No ne2.YesOperati on details: ______________________________________ Traumas:1.No ne2.YesTrauma details: _________________________________________ Blood tran sfusi on history:1.None2.Yes ( 1.Whole blood 2.Plasma3.Ingredient transfusion)Blood type: ___________ Tran sfusi on time: _________Tran sfusi on react ion1.None2.YesCli nic manifestation: ____________________________ Allergic history:1.No ne2.Yes3.Not clearallergen: _______________________________________________cli nical manifestation: ____________________________________Pers onal history:Custom livi ng address: ____________________________________________ Reside nt history in en demic disease area:Smoki ng: 1.No 2.YesAverage pieces per day; about yearsGivi ng-up 1.No 2.Yes (Time: )Drinking: 1.No 2.YesAverage grams per day; about yearsGivi ng-up 1.No 2.Yes(Time: ) Drug abuse: 1.No 2.YesDrug names: ______________________________________ Marital and obstetrical history:Married age: _________ years old Pregnancy ___________ t imesLabor ______________ times(1.Natural labor: ______ times 2.0perative labor: __________ times3. __________________ Natural abortion: _______________ times4.Artificial abortion: ____ times5. _______________________ Premature labor: _________ times6.stillbirth _________________ times)Health status of the Mate:1.Well2.Not fineDetails: _______________________________________________ Men strual history:Menarchal age: _______ Duration ________ d ay Interval ____ daysLast menstrual period: ____________ Menopausal age: ______ y ears oldAmount of flow: 1.small 2. moderate 3. largeDysme no rrheal: 1. prese nee 2.abse ncMe nstrual irregularity 1. No 2.Yes Family history: (especially pay atte ntio n to the in fectious and hereditary diseaserelated to the present illness)Father: l.healthy 2.ill: _________ 3.deceased cause: ____________________ Mother :1.healthy 2.ill: ________ 3.deceased cause: ____________________ Others: ________________________________________________________The an terior stateme nt was agreed by the in forma nt.Sig nature of in forma nt: Datetime:Physical Exam inationVital sig ns:Temperature: ______ C Blood pressure: ______ / ______ mmHg Pulse: ____ bpm (l.regular 2.irregular ) Respiration: __ bpm (l.regular 2.irregular )Gen eral con diti ons:Development: I.Normal 2.Hypoplasia 3.HyperplasiaNutrition : l.good 2.moderate 3.poor 4.cachexiaFacial expressi on: 1.no rmal 2.acute 3.chr onic other ___________________ Habitus: l.asthenic type 2.sthenic type 3.ortho-thenic typePositi on: l.active 2.positive pulsive 4.other _______________________ Consciousness: l.clear 2.somnolence 3.confusion 4.stupor 5.slight coma6. mediate coma7.deep coma8.deliriumCooperation: 1Yes 2.No Gait: 1.normal 2.abnormal _____Skin and mucosa:Color: 1.normal 2.pale 3.red ness 4.cya no sis 5.ja un dice 6.pigme ntatio nSk in erupti on: 1.No 2.Yes( type: _________ d istribution: _________________ )Subcuta neous bleed ing: 1.no 2.yes (type:______ distribution: ____________ ) Edema:1. no 2.yes ( locati on and degree ________________________________ ) Hair: 1.no rmal 2.abnormal(details ____________________________________ ) Temperature and moisture: normal cold warm dry moist dehydration Liver palmar :1.no2.yes Spider angioma (location: ________________________________ )Others: _________________________________________________________Lymph no des: enl argeme nt of superficial lymph no de:1. no2.yesDescripti on: ________________________________________________Head:Skull size:〔.normal 2.abnormal (description: __________________________ ) Skull shape: 1.no rmal 2.abnormal(description: _________________________ ) Hair distributio n :1. no rmal 2.abnormal(description: ____________________ ) Others: __________________________________________________________ Eye: exophthalmos: _________ eyelid: ___________ conjunctiva: _________ sclera: _______________ Cornea: _____________________Pupil: l.equally round and in size 2.un equal (R _____ mm L _______ m m)Pupil reflex:〔.normal 2.delayed (R __ s L _ s ) 3.abse nt (R _ L ___ )others: ______________________________________________________ Ear: Auricle〔.normal 2.desformation (description: ______________________ ) Discharge of exter nal auditory can al:1. no 2.yes (l.left 2.right quality: ___ )Mastoid tendern ess 1.no 2.yes (l.left 2.right quality: _________________ )Disturba nee of auditory acuity:1. no 2.yes(1」eft 2.right description: ___ ) Nose: Flaring of alae nasi :1.no 2.yes Stuffy discharge 1.no 2.yes(quality ____ ) Tendern ess over para nasal sinu ses:1. no 2.yes (location: ____________ ) Mouth: Lip ______________ Mucosa ____________ Tongue ________________ Teeth:1.normal 2.Agomphiasis 3. Eurodontia 4.others: _____________________Gum :1. normal 2.ab no rmal (Descripti on_________________________ )Tonsil: __________________________ P harynx: _____________________Sound: 1.no rmal 2.hoarse ness 3.others: ___________________________Neck:Neck rigidity 1. no 2.yes ( tra nsvers fin gers)Carotid artery: 1.normal pulsation 2.increased pulsation 3.marked distentionTrachea location: l.middle 2.deviation (〔.leftward ________ 2.rightward _____ ) Hepatojugular vein reflux: 1. n egative 2.positiveThyroid: 1.normal 2.enlarged ________ 3.bruit (1.no 2.yes ________________ ) Chest:Chest wall: 1.no rmal 2.barrel chest 3.pro minence or retractio n:(left _______ right ________ Precordial prominence _________ )Percussi on pai n over sternum 1.No 2.Yes Breast:〔.Normal 2.ab no rmal __ Lung: Inspection: respiratory movement〔.normal 2.abnormal ____________ Palpati on: vocal tactile fremitus:1. no rmal 2.ab no rmal ____________ pleural rubb ing sen sati on :1. no 2.yes __________________Subcuta neous crepitus sen sati on :1. no 2.yes ____________ Percussion:1. resonance 2. Hyperresonance &location _____________3 Flatness&location ________________________________4. dulln ess & location: _____________________________5. tympa ny &location: ______________________________lower border of lung: (detailed percussi on in respiratory disease) midclavicular line : R: ____ in tercostae L: ____ in tercostaemidaxillary line: R: ____ in tercostae L: ____ in tercostaescapular li ne: R: _______ in tercostae L: ____ in tercostaemoveme nt 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.diffuseSubxiphoid pulsation: 1.no 2.yesLocati on of apex beat: 1. no rmal 2.shift ( ____ in tercosta,dista nee away from left MCL ____ cm) Palpati on:Apical pulsation:1. normal 2.lifting apex impulse 3.negative pulsationThrill:1. no 2.yes(location: __________ phase: ________________ )Percussi on: relative dull ness border: 1.no rmal 2.ab no rmal(Dista nee betwee n An terior Medli ne and left MCL _____ cm) Auscultation: Heart rate: __ bpm Rhythm:1.regular 2.irregular ______ Heart sound: 1.no rmal 2.abnormal ______________________Extra sound: 1.no 2.S3 3.9 4. opening snapP2 _____________ A _________ Pericardial frictio n soun d:1. no 2.yesMurmur: 1.no 2.yes (location __________ phase _____________quality _____ intensity ________ t ran smissio n _________effects of position ________________________________effects of respiration _____________________________ Peripheral vascular sig ns :1.N one2.paradoxical pulse3.pulsus alter nans4. Water hammer pulse5.capillary pulsati on6.pulse deficit7.Pistol shot sound8.Duroziezsig nAbdome n:Inspection: Shape: 1.normal 2.protuberanee 3.scaphoid 4.frog-belly Gastric patter n 1. no 2.yes In test inal pattern 1. no 2.yesAbdo minal vein varicosis 1.no 2.yes(direction: ______________ )Operatio n scarl. no 2.yes _______________________________ Palpation: l.soft 2. tensive (location: ______________________________ )Tendern ess: 1.no 2.yes(location: ______________________ )Rebo und tendern ess:1. no 2.yes(location: _____________ ) Fluctuatio n: l.prese nt 2.absce ntSuccussi on splash: 1.n egative 2.positiveLiver: ______________________________________________Percussion: Liver dullness border: 1.normal 2.decreased 3.absentUpper hepatic border:Right Midclavicular Line _______ In tercostaShift dullness:1.negative 2.positive Ascites: _____________ degreePai n on percussi on in costovertebral area: 1.n egative 2.positve __ Auscultation: Bowel sounds : 1.normal 2.hyperperistalsis 3.hypoperistalsis4.abse nee Gurgli ng soun d:1. no 2.yesVascular bruit 1.no 2.yes (location ____________________ ) Gen ital orga n: 1.un exam ined 2.no rmal 3.ab no rmalAnus and rectum: 1.un exam ined 2.no rmal 3.ab no rmalSpine and extremities:Spi ne: 1.no rmal 2.deformity (l.kyphosis 2.lo rdosis 3.scoliosis)3.Tenderness(location ____________________________ )Extremities: 1.no rmal 2.arthremia & arthrocele (location __________________ )3.A nkylosis (location _________ )4.Aropachy: 1.no 2.yes5.Muscular atrophy (location ______________________ )Neurological system: 1.no rmal 2.abnormal _____________________________ Importa nt exam in ati on results before hospitalizedSummary of the history: ______________________________________ Initial diagnosis: ____________________________________________Recorder:Corrector:。

角膜炎病历书写范文英文回答：Patient Name: John Smith.Age: 35。

Date of Admission: 10/15/2021。

Chief Complaint:The patient presents with redness, pain, and blurred vision in the right eye for the past 3 days.History of Present Illness:The patient reports a gradual onset of symptoms, including eye pain, light sensitivity, and excessive tearing. He denies any trauma or foreign body sensation in the eye. The symptoms have not improved with over-the-counter eye drops.Past Medical History:The patient has a history of seasonal allergies and occasional dry eye symptoms. He denies any previous eye infections or surgeries.Medications:The patient takes over-the-counter allergy medication as needed.Family History:Non-contributory.Social History:The patient is a non-smoker and denies alcohol or drug use.Review of Systems:Negative for fever, chills, headache, or changes in vision in the left eye.Physical Examination:Visual acuity 20/30 in the right eye, 20/20 in the left eye. Slit-lamp examination reveals corneal opacity, conjunctival injection, and decreased corneal sensation in the right eye. The left eye examination is unremarkable.Diagnosis:Right eye keratitis, likely due to bacterial or viral etiology.Plan:The patient will be started on topical antibiotic eye drops and will be scheduled for a follow-up appointment in 3 days to monitor the response to treatment.英文回答结束。

英文病历书写范例（内科）Medical Records for AdmissonMedical Number: 701721General informationName: Liu SideAge: EightySex: MaleRace: HanNationality: ChinaAddress: NO.35, Dandong Road, Jiefang Rvenue, Hankou, Hubei.Tel: 857307523Occupation: RetiredMarital status: MarriedDate of admission: Aug 6th, 2001Date of record: 11Am, Aug 6th, 2001Complainer of history:patient’s son and wifeReliability: ReliableChief complaint: Upper bellyache ten days, haematemesis, hemafecia and unconsciousness for fo ur hours.Present illness:The patient felt upper bellyache about ten days ago. He didn’t pay attention to it and thought heha date something wrong. At 6 o’cloc k this morning he fainted and rejected lots of blood and gore. T hen hemafecia began. His family sent him to our hospital and received emergent treatment. So the patient was accepted because of “upper gastrointestine hemorrhage and exsanguine shock”. Since the disease coming on, the patient didn’t urinate. Past historyThe 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 s evere infectious disease. Allergic history: He was not allergic to penicillin or sulfamide. Respirator y system: No history of respiratory disease. Circulatory system: No history of precordial pain. Ali mentary system: No history of regurgitation.Genitourinary system: No history of genitourinary disease.Hematopoietic system: No history of anemia and mucocutaneous bleeding. Endocrine system: No acromegaly. No excessive sweats. Kinetic system: No history of confinement of limbs. Neural sys tem: No history of headache or dizziness. Personal historyHe was born in Wuhan on Nov 19th, 1921 and almost always lived in Wuhan. His living condition s were good. No bad personal habits and customs.Menstrual history: He is a male patient. Obstetrical history: NoContraceptive history: Not clear.Family history: His parents have both deads. Physical examinationT 36.5℃, P 130/min, R 23/min, BP 100/60mmHg. He is well developed and moderately nourished.Active position. His consciousness was not clear. His face was cadaverous and the skin was not sta ined yellow. No cyanosis. No pigmentation. No skin eruption. Spider angioma was not seen. No pi tting edema. Superficial lymph nodes were not found enlarged. HeadCranium: Hair was black and white, well distributed. No deformities. No scars. No masses. No ten derness.Ear: Bilateral auricles were symmetric and of no masses. No discharges were found in external au ditory canals. No tenderness in mastoid area. Auditory acuity was normal.Nose: No abnormal discharges were found in vetibulum nasi. Septum nasi was in midline. No nare s flaring. No tenderness in nasal sinuses. Eye: Bilateral eyelids were not swelling. No ptosis. No e ntropion. Conjunctiva was not congestive. Sclera was anicteric. Eyeballs were not projected or dep ressed. Movement was normal. Bilateral pupils were round and equal in size. Direct and indirect p upillary reactions to light were existent.Mouth: Oral mucous membrane was not smooth, and there were ulcer can be seen. Tongue was in midline. Pharynx was congestive. Tonsils were not enlarged.Neck: Symmetric and of no deformities. No masses. Thyroid was not enlarged. Trachea was in mi dline. ChestChestwall: Veins could not be seen easily. No subcutaneous emphysema. Intercostal space was nei ther narrowed nor widened. No tenderness.Thorax: Symmetric bilaterally. No deformities. Breast: Symmetric bilaterally.Lungs: Respiratory movement was bilaterally symmetric with the frequency of 23/min. thoracic e xpansion and tactile fremitus were symmetric bilaterally. No pleural friction fremitus. Resonance was heard during percussion. No abnormal breath sound was heard. No wheezes. No rales. Heart: No bulge and no abnormal impulse or thrills in precordial area. The point of maximum imp ulse was in 5th left intercostal space inside of the mid clavicular line and not diffuse. No pericardi al friction sound. Border of the heart was normal. Heart sounds were strong and no splitting. Rate 150/min. Cardiac rhythm was not regular. No pathological murmurs.Abdomen: Flat and soft. No bulge or depression. No abdominal wall varicosis. Gastralintestinal ty pe or peristalses were not seen. Tenderness was obvious around the navel and in upper abdoman. T here was not rebound tenderness on abdomen or renal region. Liver and spleen was untouched. No masses. Fluidthrill negative. Shifting dullness negative. Borhorygmus not heard. No vascular mur murs. Extremities: No articular swelling. Free movements of all limbs.Neural system: Physiological reflexes were existent without any pathological ones. Genitourinary system: Not examed. Rectum: not exanedInvestigationBlood-Rt: Hb 69g/L RBC 2.70T/L WBC 1. 1G/L PLT 120G/L History summary1. Patient was male, 80 years old2. Upper bellyache ten days, haematemesis, hemafecia and unconsciousness for four hours.3. No special past history.4. Physical examination: T 37.5℃, P 130/min, R 23/min, BP 100/60mmHg Superficial lymph node s were not found enlarged. No abdominal wall varicosis. Gastralintestinal type or peristalses were not seen. Tenderness was obvious around the navel and in upper abdoman. There was not rebound tenderness on abdomen or renal region. Liver and spleen was untouched. No masses. Fluidthrill ne gative. Shifting dullness negative. Borhorygmus not heard. No vascular murmurs. No other positive signs. 5. investigation information:Blood-Rt: Hb 69g/L RBC 2.80T/L WBC 1.1G/L PLT 120G/LImpression: upper gastrointestine hemorrhage Exsanguine shock出院小结（DISCHARGE SUMMARY）， ===============Department of GastroenterologyChanghai Hospital，No.174 Changhai Road Shanghai, China Phone: 86-21-25074725-803 DISCHARGE SUMMARYDA TE OF ADMISSION: October 7th, 2005 DA TE OF DISCHARGE: October 12th, 2005 ATTE NDING PHYSICIAN: Yu Bai, MD PA TIENT AGE: 18ADMITTING DIAGNOSIS:V omiting for unknown reason: acute gastroenteritis?BRIEF HISTORYA 18-year-old female with a complaint of nausea and vomiting for nearly one month who was see n at Department of Gastroenterology in Changhai Hospital, found to have acute gastroenteritis and non-atrophic gastritis. The patient was subsequently recovered and discharged soon after medicati on.REVIEW OF SYSTEMShe has had no headache, fever, chills, diarrhea, chest pain, palpitations, dyspnea, cough, hemopty sis, dysuria, hematuria or ankle edema.PAST MEDICAL HISTORYShe has had no previous surgery, accidents or childhood illness.SOCIAL HISTORY: She has no history of excessive alcohol or tobacco use.FAMIL Y HISTORYShe has no family history of cardiovascular, respiratary and gastrointestinal diseases. PHYSICAL EXAMINA TIONTemperature is 37, pulse 80, respirations 16, blood pressure 112/70. General: Plump girl in no app arent distress. HEENT: She has no scalp lesions. Her pupils are equally round and reactive to light and accommodation. Extraocular movements are intact. Sclerae are anicteric. Oropharynx is clear. There is no thyromegaly. There is no cervical or supraclvicular lymphadenopathy. Cardiovascular: Regular rate andrhythm, normal S1, S2. Chest: Clear to auscultation bilateral. Abdomen: Bowel sounds present, no hepatosplenomagaly. Extremities: There is no cyanosis, clubbing or edema. Neurologic: Cranial n erves II-XII are intact. Motor examination is 5/5 in the bilateral upper and lower extremities. Sens ory, cerebellar and gait are normal.LABORATORY DATAWhite blood cells count 5.9, hemoglobin 111g/L, hematocrit 35.4. Sodium 142, potassium 4.3, chl oride 106, CO2 25, BUN 2.6mmol/L, creatinine 57μmol/L, glucose 4.1mmol/L, Albumin 36g/L. Endoscopic ExamChronic non-atrophic gastritisHOSPITAL COURSEThe patient was admitted and placed on fluid rehydration and mineral supplement. The patient im proved, showing gradual resolution of nausea and vomiting. The patient was discharged in stable c ondition.DISCHARGE DIAGNOSIS Acute gastroenteritisChronic non-atrophic gastritisPROGNOSISGood. No medications needed after discharge. But if this patient can not get used to Chinese food, she had better return to UK as soon as possible to prevent the relapse of acute gastroenteritis. The patient is to follow up with Dr. Bai in one week. ___________________________ Yu Bai, MD D: 12/10/2005。

英文病例写作范文阅读带翻译病例写作是医生日常的工作，英文的病例该如何写呢，接下来店铺为大家整理英文病例写作范文，希望对你有帮助哦!英文病例写作范文篇一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，向颈与双臂放射，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)Relieving/exacerbating factors缓解与恶化因素GTN(glyceryl trinitrate) provided no relief although normally relieves pain in minutes, no other relieving/exacerbating factors.(硝酸甘油平时能在数分钟内缓解疼痛，但本次无效，无其它缓解和恶化因素。

Admission RecordName：* Nativity: * district, * citySex:male Race: HanAge:55 Date of admission:2020-09-07 14:30 Marital status: be married Date of record:2020-09-07 15:23 Occupation:teacher Complainer:patient himself Medical record Number: * Reliability: reliablePresent address: NO*, building*, * village,* district, *city, *provinceChief complaint: cough and sputum for more than 6 years, worsening for 2 weeksHistory of present illness: The patient complained of having paroxysmal cough and sputum 6 years ago. At that time, he was diagnosed as “COPD” in another hospital and no regular treatment was applied. Cough and sputum worsened and were accompanied by tachypnea 2 weeks ago with no inducing factors. Small amounts of white and mucous sputum were hard to cough up. Compared to daytime, tachypnea worsened in the night or when sputum can’t be cough up. The patient can’t lie flat at the night because of prominent tachypnea and prefer a high pillow. He had no fever, no chest pain, no dizziness, no diarrhea, no abdominal pain, no obvious decrease of activity tolerance. On 20*-0*-*, the patient went to *Hospital for medical consultation. CT lung imaging indicated: lesion accompanied by calcification in the superior segment, the inferior lobe of the right lung, the possibility of obsolete tuberculosis; emphysema, bullae formation and sporadic inflammation of bilateral lung; calcified lesion in the inferior lobe of the left lung; arteriosclerosis of coronary artery.Pulmonary function tests indicated:d obstructive ventilation dysfunction; bronchial dilation test was negative2.moderate decrease of diffusion function, lung volume, residual volume and the ratio of lungvolume; residual volume were normalThe patient was diagnosed as “AECOPD” and prescribed cefoxitin to anti-infection for a week, Budesonide and Formoterol to relieve bronchial muscular spasm and asthma,amb roxol to dilute sputum, and traditional Chinese medicine (specific doses were unknown).The patient was discharged from the hospital after symptoms of cough and sputum slightly relieved with a prescription of using Moxifloxacin outside the hospital for 1 week. Cough and sputum were still existing, thus the patient came to our hospital for further treatment and the outpatient department admitted him in the hospital with “COPD”. His mental status, appetite, sleep, voiding, and stool were normal. No obvious decrease or increase of weight.Past history: The patient was diagnosed as type 2 diabetes 1 years ago and take Saxagliptin (5mg po qd) without regularly monitoring the levels of blood sugar. The patient denies hepatitis, tuberculosis, malaria, hypertension, mental illness, and cardiovascular diseases. Denies surgical procedures, trauma, transfusion, food allergy and drug allergy. The history of preventive inoculation is not quite clear.Personal history: The patient was born in *district, * city and have lived in * since birth. He denies water contact in the schistosome epidemic area. Smoking 10 cigarettes a day for 20 years and have stopped for half a month. Denies excessive drinking and contact with toxics.Marital history: Married at age of 27 and have two daughters. Both the mate and daughters are healthy.Family history: Denies familial hereditary diseases.Physical ExaminationT: 36.5℃ P：77bpm R: 21 breaths/min BP：148/85mmHgGeneral condition：normally developed, well-nourished, normal facies, alert, active position, cooperation is goodSkin and mucosa: no jaundiceSuperficial lymph nodes: no enlargementHead organs: normal shape of headEyes:no edema of eyelids; no exophthalmos; eyeballs move freely; no bleeding spots of conjunctiva; no sclera jaundice; cornea clear; pupils round, symmetrical in size and acutely reactive to light.Ears: no deformity of auricle; no purulent secretion of the external canals; no tenderness over mastoidsNose: normal shape; good ventilation;no nasal ale flap; no tenderness over nasal sinus; Mouth: no cyanosis of lips; no bleeding spots of mouth mucosa; no tremor of tongue; glossy tongue in midline; no pharynx hyperemia; no enlarged tonsils seen and no suppurative excretions; Neck: supple without rigidity, symmetrical; no cervical venous distension; Hepatojugular reflux is negative; no vascular murmur; trachea in midline; no enlargement of thyroid glandChest: symmetrical; no deformity of thoraxLung:Inspection：equal breathing movement on two sidesPalpation: no difference of vocal fremitus over two sides;Percussion: resonance over both lungs;Auscultation: decreased breath sounds over both lungs; no dry or moist rales audible; no pleural friction rubsHeart:Inspection: no pericardial protuberance; Apex beat seen 0.5cm within left mid-clavicular at fifth intercostal space;Palpation: no thrill felt;Percussion: normal dullness of heart bordersAuscultation: heart rate 78bpm; rhythm regular; normal intensity of heart sounds; no murmurs or pericardial friction sound audiblePeripheral vascular sign: no water-hammer pulse; no pistol shot sound; no Duroziez’s murmur; no capillary pulsation sign; no visible pulsation of carotid arteryAbdomen:Inspection: no dilated veins; no abnormal intestinal and peristaltic waves seenPalpation: no tenderness or rebounding tenderness; abdominal wall flat and soft; liver and spleen not palpable; Murphy's sign is negativePercussion: no shifting dullness; no percussion tenderness over the liver and kidney regionAuscultation: normal bowel sounds.External genitalia: uncheckedSpine: normal spinal curvature without deformities; normal movementsExtremities: no clubbed fingers(toes); no redness and swelling of joints; no edema over both legs; no pigmentation of skins of legsNeurological system: normal muscle tone and myodynamia; normal abdominal and bicipital muscular reflex; normal patellar and heel-tap reflex; Babinski sign(-);Kerning sign(-) ; Brudzinski sign(-)Laboratory DataKey Laboratory results including CT imaging and pulmonary function test have been detailed in the part of history of present illness.Abstract*, male, 55 years old. Admitted to our hospital with the chief complaint of cough and sputum for more than 6 years, worsening for 2 weeks. Cough and sputum worsened and were accompanied by tachypnea 2 weeks ago. The patient can’t lie flat in the night because of prominent tachypnea and prefer a high pillow.Physical Examination: T: 36.5℃,P: 77bpm, R: 21 breaths per minute, BP:148/85mmHg. Decreased breath sounds over both lungs; no dry or moist rales audible.Laboratory data: CT lung imaging indicates: lesion accompanied by calcification in superior segment, inferior lobe of right lung, possibility of obsolete tuberculosis; emphysema, bullae formation and sporadic inflammation of bilateral lung; calcified lesion in inferior lobe of left lung. Pulmonary function tests indicate: mild obstructive ventilation dysfunction, bronchial dilation test was negative moderate decrease of diffusion function.Primary Diagnosis:1.AECOPD2.Type 2 Diabetes3.Primary Hypertension Doctor’s Signature:。

英文病历标准模版Patient ProfileName: Si RuihuaDepartment: ___ Power ___Sex: FemalePresent Address: Electric Power Bureau Age: 80 yearsDate of n: May 17.2003nality: Chinese XinjiangDate of Record: May 17.2003Marital Status: MarriedReliability: Reliablen: Family ___History of Allergy: None reportedChief Complaints___。

breathlessness。

and precordial pain for the last hour。

There were no precipitating factors。

and the fort could not be relieved by rest。

As a result。

she came to the hospital for help。

She did not experience syncope。

cough。

headache。

diarrhea。

or vomiting during the course of the illness。

Her appetite。

sleep。

voiding。

and stool were normal.Medical History___.______。

___ distress。

She had a heart rate of 120 beats per minute and a blood pressure of 160/90 mmHg。

Her respiratory rate was 28 breaths per minute。

and her oxygen n was 90% on room air。

美国门诊病历范文以下是一篇美国门诊病历范文：Patient Information:Name: John DoeAge: 35Gender: MaleAddress: 123 Main Street, Anytown, USAPhone: 555-555-5555Date of Visit: 05/10/2021Chief Complaint:The patient presents with a persistent cough that has lasted for the past two weeks.History of Present Illness:Mr. Doe reports a persistent cough that is dry in nature and has been present for the past two weeks. He has also experienced mild shortness of breath on exertion over the past few days. He denies any chest pain, fever, chills, or other symptoms.Medical History:Mr. Doe has a history of hypertension and takes medication to manage it. He is otherwise healthy and has no significant medical history.Social History:Mr. Doe is a non-smoker and does not drink alcohol. He works in an office and does not have any significant occupational exposures.Family History:There is no relevant family history.Physical Examination:On physical examination, Mr. Doe has clear lungs with good air entry bilaterally. His vital signs are within normal limits. He has no other notable findings.Assessment and Plan:Based on the patient's history and physical examination, the working diagnosis is likely a viral or respiratory infection. The patient will be advised to get a COVID-19 test, and if positive, he will need to quarantine and follow up via telemedicine. If negative, he will be advised to use over-the-counter cough medication and to rest and hydrate as needed. He will follow up in five days to reassess his symptoms.Prescription:The patient is advised to use over-the-counter cough medication as needed.Follow-up:The patient will follow up via telemedicine in five days to reassess his symptoms.。

Union Hospital affiliated to Huazhong University of Science and TechnologyAdmission Record 0000337023Department: Respiratory Medicine Area: J17 Respiratory Medicine Bed No. 109031 Case No. 1565825Name: Hou Deguang Gender: Male Date of Birth:15/9/ 1936 Age:78 Nationality: ChinaID No. 42021 Ethnicity: Han Occupation: other Marital status: MarriedAddress: Nanchong，Sichuan Tel No.Source of History: Patient herself Reliability: ReliableAdmission Date & Time: 4/11/2021 14:36Chief Complaint: Found pleural effusion for about 2 months.Present Illness: The patient received the chest CT scan in the Wuhan Traditional Medicine Hospital two months ago and found right-side pleural effusion, right-sidepulmonary atelectasis. After that, he was hospitalized in the EndocrinologyDept of our hospital for poor management of blood glucose level. On thisadmission, He received the thoracocentesis, and the laboratory examinationresults indicated the large possibility of tuberculous pleural effusion. Nospecial treatment was given at that time. The patient was aware of a sense ofpolypnea after long walk, without cough, expectoration, night sweats, chestdistress, thoracalgia, wheeze, dyspnea and can lie down to sleep at night. Thereturn-visit in the clinic at October 13th showed that there were a few pleuraleffusion on the right side and is hard to be localized. Now the patient came toour hospital for further treatment and was admitted as “Pleural effusionorigin unknown〞.Since the onset of the disease, the patient’s sp irit, appetite and sleep arenormal. Nocturia for 1 time per night. Stool are as usual. No obvious weightand physical strength change.Past History: General Health Status: Relatively bad; Respiratory Syste m: Chronic bronchitis for about 10 years; Circulatory System: Hypertension for about 20years, highest reached 180/95mmHg, took Amlodipine orally 5mg qd, BP managementis good. Diagnosed of coronary heart disease in 2007, underwentintracoronary stent implantation in 2021, 3 stents were implanted; DigestiveSystems: None; Urinary System: Benign prostatic hyperplasia for about 5 years,Diabetic nephropathy for 3 years; Hematologic System: Thrombocytopenia for 2years; Endocrine System: None. Nervous System: Lacunar infarction in 2021;Motor System: None; Infection History: No infection of hepatitis and TB. Others:None special; Preventive Inoculation: In accordance with the stateplan;Operation History:underwent intracoronary stent implantation in 2021, 3stents was implantated; Blood Transfusion History:None; Traumatic History:None; Allergic History: None;Personal History: Habitual Residence: Hubei; Residential Environment: No exposure history to toxic substances and infected water; Travelling History: None; Smoking History:Smoking for about 40 years, 3 cigarettes per day. Quit smoking in 2021;Drinking History: Drinking for 40 years, 150g-350g per day, Quit drinking in2021;Marital History: Married,Menstrual History: MaleFamily History:Father is deceased, mother is deceased. No other infective and hereditary diseases.Physical ExaminationVital Signs: T:℃. P:86 bpm, regular. R: 20min, regular. BP: 132/74 mmHg. Height: 164cm.Weight: 64kg. Expression: Normal. Development: Well. Nutritional status: Fairly.Consciousness: Conscious. Spirit: Well. Gait: Normal. Position: Active.Coordination with Examination: Cooperative.Skin and Lymph Nodes:No jaundice. Some scattered scratch in hands and abdomen, No subcutaneous bleeding, edema, nodules or unusual pigmentation. Liverpalm(-). Spider angioma(-). No swelling of general superficial lymphnodes.HEENT(Head, Eye, Ear, Nose, Throat): Normal skull. No baldness, no scars. Eyes: No ptosis.Conjuctiva normal. The pupils are round, symmetric and responsive to lightand accommodation is normal. Ears: Externally normal. Canals clear. Drumsnormal. Noses: No abnormalities noted. Month and Throat: lips red, tongue red,no swelling of tonsils.Neck: Motion free. Thyroid is not enlarged. No abnormal pulsations. Trachea in middle. Carotid: Pulse is normal. Hepatojugular reflux sign(-). Vascular bruit: None.Chest and Lung:Normal contour. Breast normal. Inspection: respiratory movement symmetric and regular. Palpation: Normal and symmetric. No pleural friction fremitus. Percussion: both sides resonance. Auscultation: right-side breath sounds weaken, left-side is normal. No moist or dry rales. No pleural friction rubs.Heart:No protrusion of precordium. Normal apical impulse. No thrill. No enlarged cardiac dullness border. Heart rate: 88bpm, rhythm normal. No abnormal and extra cardiac sounds or cardiac murmurs. No peripheral vascular signs.Abdomen:Flat abdomen. No gastric or intestinal pattern. No visible peristalsis. Normal bowel sound. No rigidity. No mass palpable. No tenderness and rebound tenderness. Liver and spleen are not palpable. Kidneys are not palpable. No percussion tenderness over kidney regions. No shifting dullness.Rectum: Normal anus and perineum.Genitourinary System: Normal.Neural System: Normal.Extremities: No joint disease. Muscle strength normal. Pathological reflex (-).Specialty Examination: Right-side breath sounds weaken, left side normal. No moist or dry rales, No swelling of general superficial lymph nodes. No edema inneither lower extremities.Accessory Examination:Discharge record of Endocrinology Dept. of our hospital at September 2021; Clinic examination at October 13th: a few pleural effusion on theright side and is hard to be localized.History summary: 1. Hou Deguang, male, 78 yr.2. Admitted for 〞Found plaural effusion for about 2 months〞.3. T:℃. P:86 bpm, regular. R: 20min, regular. BP: 132/74 mmHg.Expression: Normal. Spirit clear. Cardiac sounds normal, HR: 72 bpm, rhythmnormal, No abnormal and extra cardiac sounds or cardiac murmurs. Right-side breathsounds weaken, left side normal. No moist or dry rales, no pleural friction rubs.Flat abdomen. No rigidity.4. Special examination:Trachea in middle. Contour symmetric.Respiratory movement regular. Right-side breath sounds weaken, left side normal. Nomoist or dry rales, no pleural friction rubs.5. Accessory Examination: Discharge record of Endocrinology Dept of ourhospital at September 2021; Clinic examination at October 13th: a few pleuraleffusion on the right side and is hard to be localized.6. Past history: Respiratory Syste m: Chronic bronchitis for about 10years; Circulatory System: Hypertension for about 20 years, highest reached180/95mmHg, took Amlodipine orally 5mg qd, BP management is good. Diagnosed ofcoronary heart disease in 2007, underwent intracoronary stent implantation in2021, 3 stents was implantated; Digestive Systems: None; Urinary System: Benignprostatic hyperplasia for about 5 years, Diabetic nephropathy for 3 years;Hematologic System: Thrombocytopenia for 2 years; Endocrine System: None.Nervous System: Lacunar infarction in 2021; Motor System: None;InfectionHistory: No infection of hepatitis and TB. Others: None special; PreventiveInoculation: In accordance with the stateplan; Operation History:underwentintracoronary stent implantation in 2021, 3 stents was implantated; BloodTransfusion History: None; Traumatic History: None; Allergic History: None; Impression: 1. Right-side pleural effusion origin unknown: TB? Tumor?2. II diabetes mellitus, Diabetic nephropathy3. Hypertension III, high risk4. Coronary heart disease, post-intracoronary stent implantation5. Lacunar infarction6. Thrombocytopenia7. Benign prostatic hyperplasiaRecorder: Cheng LongDate & Time: 4/11/2021 16:14Checker: Xu JuanjuanDate & Time: 5/11/2021 10:22。