大病历模板(英文)

1UnionHospitalaffiliatedtoHuazhongUniversityofScienceandTechnologyAdmissionRecord0000337023Department:RespiratoryMedicineArea:J17RespiratoryMedicineBedNo.109031CaseNo.1565825Name:HouDeguangGender:MaleDateofBirth:15/9/1936Age:78Nationality:ChinaIDNo.420102193609150819Ethnicity:HanOccupation:otherMaritalstatus:MarriedAddress:Nanchong，SichuanTelNo.13871426922SourceofHistory:PatientherselfReliability:ReliableAdmissionDate&Time:4/11/201414:36ChiefComplaint:Foundpleuraleffusionforabout2months.PresentIllness:ThepatientreceivedthechestCTscanintheWuhanTraditionalMedicineHospitaltwomonthsagoandfoundright-sidepleuraleffusion,right-sidepulmonaryatelectasis.Afterthat,hewashospitalizedintheEndocrinologyDeptofourhospitalforpoormanagementofbloodglucoselevel.Onthisadmission,Hereceivedthethoracocentesis,andthelaboratoryexaminationresultsindicatedthelargepossibilityoftuberculouspleuraleffusion.Nospecialtreatmentwasgivenatthattime.Thepatientwasawareofasenseofpolypneaafterlongwalk,withoutcough,expectoration,nightsweats,chestdistress,thoracalgia,wheeze,dyspneaandcanliedowntosleepatnight.Thereturn-visitintheclinicatOctober13thshowedthattherewereafewpleuraleffusionontherightsideandishardtobelocalized.Nowthepatientcametoourhospitalforfurthertreatmentandwasadmittedas“Pleuraleffusionoriginunknown”.Sincetheonsetofthedisease,thepatient’sspirit,appetiteandsleeparenormal.Nocturiafor1timepernight.Stoolareasusual.Noobviousweightandphysicalstrengthchange.PastHistory:GeneralHealthStatus:Relativelybad;RespiratorySystem:Chronicbronchitisforabout10years;CirculatorySystem:Hypertensionforabout20years,highestreached180/95mmHg,tookAmlodipineorally5mgqd,BPmanagementisgood.Diagnosedofcoronaryheartdiseasein2007,underwentintracoronarystentimplantationin2008,3stentswereimplanted;DigestiveSystems:None;UrinarySystem:Benignprostatichyperplasiaforabout5years,Diabeticnephropathyfor3years;HematologicSystem:Thrombocytopeniafor2years;EndocrineSystem:None.NervousSystem:Lacunarinfarctionin2011;MotorSystem:None;InfectionHistory:NoinfectionofhepatitisandTB.Others:Nonespecial;PreventiveInoculation:Inaccordancewiththestateplan;OperationHistory:underwentintracoronarystentimplantationin2008,3stentswasimplantated;BloodTransfusionHistory:None;TraumaticHistory:None;AllergicHistory:None;PersonalHistory:HabitualResidence:Hubei;ResidentialEnvironment:Noexposurehistorytotoxicsubstancesandinfectedwater;TravellingHistory:None;SmokingHistory:Smokingforabout40years,3cigarettesperday.Quitsmokingin2008;DrinkingHistory:Drinkingfor40years,150g-350gperday,Quitdrinkingin2008;MaritalHistory:Married,2MenstrualHistory:MaleFamilyHistory:Fatherisdeceased,motherisdeceased.Nootherinfectiveandhereditarydiseases.PhysicalExaminationVitalSigns:T:36.5℃.P:86bpm,regular.R:20min,regular.BP:132/74mmHg.Height:164cm.Weight:64kg.Expression:Normal.Development:Well.Nutritionalstatus:Fairly.Consciousness:Conscious.Spirit:Well.Gait:Normal.Position:Active.CoordinationwithExamination:Cooperative.SkinandLymphNodes:Nojaundice.Somescatteredscratchinhandsandabdomen,Nosubcutaneousbleeding,edema,nodulesorunusualpigmentation.Liverpalm(-).Spiderangioma(-).Noswellingofgeneralsuperficiallymphnodes.HEENT(Head,Eye,Ear,Nose,Throat):Normalskull.Nobaldness,noscars.Eyes:Noptosis.Conjuctivanormal.Thepupilsareround,symmetricandresponsivetolightandaccommodationisnormal.Ears:Externallynormal.Canalsclear.Drumsnormal.Noses:Noabnormalitiesnoted.MonthandThroat:lipsred,tonguered,noswellingoftonsils.Neck:Motionfree.Thyroidisnotenlarged.Noabnormalpulsations.Tracheainmiddle.Carotid:Pulseisnormal.Hepatojugularrefluxsign(-).Vascularbruit:None.ChestandLung:Normalcontour.Breastnormal.Inspection:respiratorymovementsymmetricandregular.Palpation:Normalandsymmetric.Nopleuralfrictionfremitus.Percussion:bothsidesresonance.Auscultation:right-sidebreathsoundsweaken,left-sideisnormal.Nomoistordryrales.Nopleuralfrictionrubs.Heart:Noprotrusionofprecordium.Normalapicalimpulse.Nothrill.Noenlargedcardiacdullnessborder.Heartrate:88bpm,rhythmnormal.Noabnormalandextracardiacsoundsorcardiacmurmurs.Noperipheralvascularsigns.Abdomen:Flatabdomen.Nogastricorintestinalpattern.Novisibleperistalsis.Normalbowelsound.Norigidity.Nomasspalpable.Notendernessandreboundtenderness.Liverandspleenarenotpalpable.Kidneysarenotpalpable.Nopercussiontendernessoverkidneyregions.Noshiftingdullness.Rectum:Normalanusandperineum.GenitourinarySystem:Normal.NeuralSystem:Normal.Extremities:Nojointdisease.Musclestrengthnormal.Pathologicalreflex(-).SpecialtyExamination:Right-sidebreathsoundsweaken,leftsidenormal.Nomoistordryrales,Noswellingofgeneralsuperficiallymphnodes.Noedemainneitherlowerextremities.AccessoryExamination:DischargerecordofEndocrinologyDept.ofourhospitalatSeptember2014;ClinicexaminationatOctober13th:afewpleuraleffusionontherightsideandishardtobelocalized.3Historysummary:1.HouDeguang,male,78yr.2.Admittedfor”Foundplauraleffusionforabout2months”.3.T:36.5℃.P:86bpm,regular.R:20min,regular.BP:132/74mmHg.Expression:Normal.Spiritclear.Cardiacsoundsnormal,HR:72bpm,rhythmnormal,Noabn