英文病历模板

MedicalRecordsforAdmissonMedicalNumber:1247717GeneralinformationName:CaiChunwangAge:47yDateofbirth:1965.2.16Sex:maleRace:HanNationality:ChinaMarriage:marriedOccupation:workerIdentificationNo.:422103196502260876Address:Huanggangcity,HubeiPhoneNo.:13857657835Complainerofhistory:CaiChunwangReliability:HimselfDateofrecord:2013.2.27Chiefcomplaint:Pancytopeniafor2yearPresentillness:ThepatientfoundPancytopeniaat2011,andheusedtobeinhospitaltotakeaphysicalexaminationwhichwasconsideredintoMyelodysplasticsyndromewithalargeprobability.Thepatienthadreexaminedhemogram,withobviouspancytopenia.SohegotintothehospitaltodotheBonemarrowcytologyandImmunetyping,whichshowedthatMDShadaggravatedintoAML.Now,hehasnoanybleedingspotintheskin,withoutheadache、melena、stomachacheandsoon.Theclinicmadeit“AML”tobetreatedinhospital.Duringtheperiodoftheillness,hismentalstateisbad,withafairappetiteandsleep.Thestoolandurinationarebothnormal,withahyposthenia.Weightisthesameasbefore.Pasthistory:generalsituationisbadSystemreview:Respiratorysystem:No.Circulatorysystem:NoAlimentarysystem:NoGenitourinarysystem:NoHematopoieticsystem:NoEndocrinesystem:NoKineticsystem:NoNeuralsystem:NoInfectioushistory:DeniedAllergichistory:.NoOperativehistory:Hewasonceoperatedonancholecystectomy.Taumahistory:Denied.Historyofallergy:Denied.Historyofpreventiveinoculation]:thenationalplanforvaccinationPersonalhistoryMenstrualhistory:MaleObstetricalhistory:NoMarriage:marriedonce.Familyhistory:Hisfatherandmotherarealiveandhealthy.Deniesgeneticandinfectiousdiseasesinhisfamily.PhysicalexaminationT37℃,P95/min,R20/min,BP124/78mmHg.Heiswelldevelopedandmoderatelynourished.Activeposition.Theskinwasnotstainedyellow.Cyanosis.Nopigmentation.Noskineruption.Spiderangiomawasnotseen.Nopittingedema.Superficiallymphnodeswerenotfoundenlargedinhisneck.HeadCranium:size:normallargesmalldeformity.Nocoxycephalysquaredskulldeformingskull.Notendernessmasssunk.Ear:Auricleisnormal.Noexcretionsofexternalauditorycanal.NoTendernessofmastoid.Nose:Shapeisnormal.Nonosalalaflapobsructionexcretionsnasalsinustenderness.Eye:Eyeseyelid、eyeball、Sclera、Pupilsandreactiontolightarenormal.Mouth:Mouthlipsisnormal.Openingofparotidglandduct:normal.Tongue:normal.Gums:normal.leadlinetooth:regular.Tonsils:pharynx:voice:normal.Neck:Noresistence.Hepatojugularreflux:(-).thyroid:normal.ChestChestwall:normalThorax:normal.Breast:normalsymmetricalLungs:Inspection:movementofrespiration:normal.Intercostalspace:normal.Palpation:vocalfremitus:normal.pluernalfrictionrubs:No.Subcutaneouscrepitus:No.percussion:resonance.Dusculation:breathregular.Breathsound:normal.Rale:No.Vocalconduction:norma.Plueralfrictionrubs:No.Heart:Inspection:bulginginprecordialregion:No.apeximpulse:normal.position:normal.Palpation:apeximpulse:normal.Thrills:No.Percardialfrictionrubs:NO.Percussion:relativecardiacoutline:normal.Ausculation:heartrate95bpm/min,rhythm:regular.Heartsound:S1normal.S2normal.S3No.S4no.ExtraheartsoundNo.Openingsnapothersmurmurs:N.Pericardialfrictionrubsno.Peripheralvessals:normal.Abdomen:Inspection:shapenormal.Abdominalrespiration:existence.Umbilicus:normalprotrudingexcretionsothers:NO.Palpation:soft.Tenderness:NO.MassNO.liver:can’tbetouched.gallbladder:can’tbetouched.tendernessNo.spleen:can’tbetouched.Kideny:can’tbetouched.tendernessmobilitytendernessofureters:No.Percussion:bordersofliverdull:existence.pperbordersofliveronrightmidclavicularlineintercostalspaceshiftingdullnessNo.tendernessinrenalregionNo.Ausculation:borhorygmusnormal.GurglingNo.vessalbruitsNo.Extremities:Spine:normal.Spinousprocess:no.Mobility:normal.Extremeties:normal.Neuralsystem:notfoundanyabnormality.Genitourinarysystem:notexamined.Rectum:notexaminedHistorysummary1.Generalinformation:CaiChunwang,male,47y.2.Chiefcomplaint:Pancytopeniafor2year.3.pasthistory:generalsituationisbad,Infectioushistory:Denied.Allergichistory:.No.Operativehistory:Hewasonceoperatedonancholecystectomy.Taumahistory:Denied.Historyofallergy:Denied.Historyofpreventiveinoculation]:thenationalplanforvaccination4.Physicalexamination:T37℃,P95/min,R20/min,BP124/78mmHg.hismentalstateisbad.Superficiallymphnodeswerenotfoundenlargedinhisneck.heartrate95bpm/min,rhythm:regular.Heartsound:S1normal.S2normal.S3No.S4no.shapenormal.Abdominalrespiration:existence.Umbilicus:normalprotrudingexcretionsothers:NO.Palpation:soft.Tenderness:NO.MassNO.liver:can’tbetouched.gallbladder:can’tbetouched.tendernessNo.spleen:can’tbetouched.Kideny:can’tbetouched.tendernessmobilitytendernessofureters:No.Percussion:bordersofliverdull:existence.pperbordersofliveronrightmidclavicularlineintercostalspaceshiftingdullnessNo.tendernessinrenalregionNo.Ausculation:borhorygmusnormal.GurglingNo.vessalbruitsNo.movementofrespiration:normal.Intercostalspace:normal.Palpation:vocalfremitus:normal.pluernalfrictionrubs:No.Subcutaneouscrepitus:No.percussion:resonance.Dusculation:breathregular.Breathsound:normal.Rale:No.Vocalconduction:norma.5.Specialistcase：seriousanemia.Theskinwasnotstainedyellow.Cyanosis.Nopigmentation.Noskineruption.Spiderangiomawa