英文病历模版.doc

Name: ______________ Sex: __________ Age: ___________ Nation: ___________
Birth Place: ________________________________ Marital Status:____________
Work-organization & Occupation: _______________________________________
Living Address & Tel: _________________________________________________
Date of admission: _______Date of history taken:_______ Informant:__________

Chief plaint: ___________________________________________________
History of Present Illness: ______________________________________________________________________________________________________________________________
Past History:
General Health Status: 1.good 2.moderate 3.poor
Disease history: (if any, please write down the date of onset, brief diagnostic and therapeutic course, and the results.)
Respiratory system:
1. None 2.Repeated pharyngeal pain 3.chronic cough 4.expectoration:
5. Hemoptysis 6.asthma 7.dyspnea 8.chest pain
_______________________________________________________________
Circulatory system:
1.None 2.Palpitation 3.exertional dyspnea 4..cyanosis 5.hemoptysis
6.Edema of lower extremities 7.chest pain 8.syncope 9.hypertension
_______________________________________________________________
Digestive system:
1.None 2.Anorexia 3.dysphagia 4.sour regurgitation 5.eructation 6.nausea 7.Emesis 8.melena 9.abdominal pain 10.diarrhea 11.hematemesis 12.Hematochezia 13.jaundice
_______________________________________________________________
Urinary system:
1.None 2.Lumbar pain 3.urinary frequency 4.urinary urgency 5.dysuria 6.oliguria 7.polyuria 8.retention of urine 9.incontinence of urine 10.hematuria 11.Pyuria 12.nocturia 13.puffy face
_______________________________________________________________
Hematopoietic system:
1.None 2.Fatigue 3.dizziness 4.gingival hemorrhage 5.epistaxis 6.subcutaneous hemorrhage
_______________________________________________________________
Metabolic and endocrine system:
1.None 2.Bulimia 3.anorexia 4.hot intolerance 5.cold intolerance
6.hyperhidrosis 7.Polydipsia 8.amenorrhea
9.tremor of hands 10.character change 11.Marked obesity 12.marked emaciation 13.hirsutism 14.alopecia
15.Hyperpigmentation 16.sexual function change
________________________________
Neurological system:
1.None 2.Dizziness 3.headache 4.paresthesia 5.hypomnesis 6. Visual disturbance 7.Insomnia 8.somnolence 9.syncope 10.convulsion 11.Disturbance of consciousness 12.paralysis 13. vertigo
__________________________________
Reproductive system:
1.None 2.others
_______________________________________________________________

Musculoskeletal system:
1.None 2.Migrating arthralgia 3.arthralgia 4.artrcocele 5.arthremia
6.Dysarthrosis 7.myalgia 8.muscular atrophy
________
Infectious Disease:
1.None 2.Typhoid fever 3.Dysentery 4.Malaria 4.Schistosomiasis 4.Leptospirosis 7.Tuberculosis 8.Epidemic hemorrhagic fever 9.others
_______________________________________________________________
Vaccine inoculation:
1.None 2.Yes 3.Not clear
Vaccine detail __________________________________________
Trauma and/or operation history:
Operations:
1.None 2.Yes
Operation details:_______________________________________
Traumas:
1.None 2.Yes
Trauma details:_________
Blood transfusion history:
1.None 2.Yes ( 1.Whole blood 2.Plasma 3.Ingredient transfusion)
Blood type:____________ Transfusion time:___________
Transfusion reaction
1.None 2.Yes
Clinic manifestation:________________
Allergic history:
1.None 2.Yes 3.Not clear
allergen:________________________________________________
clinical manifestation:_____________________________________

Personal history:
Custom living address:____________________________________________
Resident history in endemic disease area:_____________________________
Smoking: 1.No 2.Yes
Average ___pieces per day; about___years
Giving-up 1.No 2.Yes (Time:_______________________)
Drinking: 1.No 2.Yes
Average ___grams per day; about ___years
Giving-up 1.No 2.Yes(Time:________________________)
Drug abuse:1.No 2.Yes
Drug names:_______________________________________
_______________________________________________________________

Marital and obstetrical history:
Married age: __________years old Pregnancy ___________times
Labor _______________times
(1.Natural labor: _______times 2.Operative labor: ________times
3.Natural abortion: ______times 4.Artificial abortion: _______times
5.Premature labor:__________times 6.stillbirth__________times)
Health status of the Mate:
1.Well 2.Not fine
Details: _____________________________________
Menstrual history:
Menarchal age: _______ Duration ______day Interval ____days
Last menstrual period: ____________ Menopausal age: ____years old
Amount of flow: 1.small 2. moderate 3. large
Dysmenorrheal: 1. presence 2.absence Menstrual irregularity 1. No 2.Yes
Family history: (especially pay attention to the infectious and hereditary disease related to the present illness)
Father: 1.healthy 2.ill:________ 3.deceased cause: ___________________
Mother:1.healthy 2.ill:________ 3.deceased cause: ___________________
Others: ____________________________________

The anterior statement was agreed by the informant.
Signature of informant: Datetime:

Physical Examination
Vital signs:
Temperature:______0C Blood pressure:_______/_______mmHg
Pulse: _____ bpm (1.regular 2.irregular_____________________________)
Respiration: ___bpm (1.regular 2.irregular____________________________)
General conditions:
Development: 1.Normal 2.Hypoplasia 3.Hyperplasia
Nutrition: 1.good 2.moderate 3.poor 4.cachexia
Facial expression: 1.normal 2.acute 3.chronic other______
Habitus: 1.asthenic type 2.sthenic type 3.ortho-thenic type
Position: 1.active 2.positive 3.pulsive 4.other_______________________
Consciousness: 1.clear 2.somnolence 3.confusion 4.stupor 5.slight a 6.mediate a 7.deep a 8.delirium
Cooperation: 1Yes 2.No Gait: 1.normal 2.abnormal______

Skin and mucosa:
Color: 1.normal 2.pale 3.redness 4.cyanosis 5.jaundice 6.pigmentation
Skin eruption:1.No 2.Yes( type: __________distribution:__________________)
Subcutaneous bleeding: 1.no 2.yes (type:_______distribution:______________)
Edema:1. no 2.yes ( location and degree________________________________)
Hair: 1.normal 2.abnormal(details_____________________________________)
Temperature and moisture: normal cold warm dry moist dehydration
Liver palmar : 1.no 2.yes Spider angioma (location:________________)
Others: ________________
Lymph nodes: enlargement of superficial lymph node:
1. no 2.yes
Description: ________________________________________________
Head:
Skull size:1.normal 2.abnormal (description:____________________________)
Skull shape:1.normal 2.abnormal(description:___________________________)
Hair distribution :1.normal 2.abnormal(description:______________________)
Others:___________________________________________________________
Eye: exophthalmos:___________eyelid:____________conjunctiva:__________ sclera:________________Cornea:____________________
Pupil: 1.equally round and in size 2.unequal (R______mm L_______mm)
Pupil reflex: 1.normal 2.delayed (R___s L___s ) 3.absent (R___L___) others:______________________________________________________
Ear: Auricle 1.normal 2.desformation (description:_______________________)
Discharge of external auditory canal:1.no 2.yes (1.left 2.right quality:_____)
Mastoid tenderness 1.no 2.yes (1.left 2.right quality:__________________) Disturbance of auditory acuity:1.no 2.yes(1.left 2.right description:_______)
Nose: Flaring of alae nasi :1.no 2.yes Stuffy discharge 1.no 2.yes(quality______)
Tenderness over paranasal sinuses:1.no 2.yes (location:_______________)
Mouth: Lip______________Mucosa_____________Tongue________________
Teeth:1.normal 2. Agomphiasis 3. Eurodontia 4.others:____________________
Gum :1.normal 2.abnormal (Description____________________________) Tonsil:___________________________Pharynx:_____________________
Sound: 1.normal 2.hoarseness 3.others:_____________________________
Neck:
Neck rigidity 1.no 2.yes (______________transvers fingers)
Carotid artery: 1.normal pulsation 2.increased pulsation 3.marked distention
Trachea location: 1.middle 2.deviation (1.leftward_______2.rightward______)
Hepatojugular vein reflux: 1. negative 2.positive
Thyroid: 1.normal 2.enlarged _______ 3.bruit (1.no 2.yes ________________)

Chest:
Chest wall: 1.normal 2.barrel chest 3.prominence or retraction: ( left________right_________Precordial prominence__________)
Percussion pain over sternum 1.No 2.Yes
Breast: 1.Normal 2.abnormal _______________________________________
Lung: Inspection: respiratory movement 1.normal 2.abnormal_____________
Palpation: vocal tactile fremitus:1.normal 2.abnormal _____ pleural rubbing sensation:1.no 2.yes______________________
Subcutaneous crepitus sensation:1.no 2.yes________________
Percussion:1. resonance 2. Hyperresonance &location_____________ 3 Flatness&location_________________________________
4. dullness & location:_______________________________ 5.tympany &location:_______________________________
lower border of lung: (detailed percussion in respiratory disease)
midclavicular line : R:_____intercostae L:_____intercostae
midaxillary line: R:______intercostae L:_____intercostae
scapular line: R:______intercostae L:_____intercostae
movement 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.diffuse Subxiphoid pulsation: 1.no 2.yes
Location of apex beat: 1.normal 2.shift (______ intercosta,
distance away from left MCL______cm)
Palpation:
Apical pulsation:1. normal 2.lifting apex impulse 3.negative pulsation
Thrill:1.no 2.yes(location:___________ phase:_________________)
Percussion: relative dullness border: 1.normal 2.abnormal

Right(cm)
Anterior midline
Left(cm)

II

III

IV

V

(Distance between Anterior Medline and left MCL _______cm)
Auscultation: Heart rate:___bpm Rhythm:1.regular 2.irregular_______
Heart sound: 1.normal 2.abnormal________________________
Extra sound: 1.no 2.S3 3.S4 4. opening snap
P2_________ A2_________Pericardial friction sound:1.no 2.yes
Murmur: 1no 2.yes (location____________phase_____________ quality______intensity________ transmission___________
effects of position_________________________________ effects of respiration______________________________

Peripheral vascular signs:
1.None 2.paradoxical pulse 3.pulsus alternans 4. Water hammer pulse 5.capillary pulsation 6.pulse deficit 7.Pistol shot sound 8.Duroziez sign
Abdomen:
Inspection: Shape: 1.normal 2.protuberance 3.scaphoid 4.frog-belly
Gastric pattern 1.no 2.yes Intestinal pattern 1.no 2.yes
Abdominal vein varicosis 1.no 2.yes(direction:______________ )
Operation scar1.no 2.yes ________________________________
Palpation: 1.soft 2. tensive (location:____________________________)
Tenderness: 1.no 2.yes(location:_______________________)

Rebound tenderness:1.no 2.yes(location:________________)
Fluctuation: 1.present 2.abscent
Succussion splash: 1.negative 2.positive
Liver:_______________________________________________
Gallbladder: __________________Murphy sign:____________
Spleen:
Kidneys:____________________________________________
Abdominal mass:______________________________________
Others:______________________________________________
Percussion: Liver dullness border: 1.normal 2.decreased 3.absent
Upper hepatic border:Right Midclavicular Line ________Intercosta
Shift dullness:1.negative 2.positive Ascites:_____________degree
Pain on percussion in costovertebral area: 1.negative 2.positve ____
Auscultation: Bowel sounds : 1.normal 2.hyperperistalsis 3.hypoperistalsis 4.absence Gurgling sound:1.no 2.yes
Vascular bruit 1.no 2.yes (location_____________________)
Genital organ: 1.unexamined 2.normal 3.abnormal
Anus and rectum: 1.unexamined 2.normal 3.abnormal
Spine and extremities:
Spine: 1.normal 2.deformity (1.kyphosis 2.lordosis 3.scoliosis)
3.Tenderness(location______________________________)
Extremities: 1.normal 2.arthremia & arthrocele (location_________________) 3.Ankylosis (location__________) 4.Aropachy: 1.no 2.yes
5Muscular atrophy (location_______________________)
Neurological system:1.normal 2.abnormal_______________________________ _____________________________________________________________________
Important examination results before hospitalized
______________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
Summary of the history:__________________________