Medical Records for Admisson

Medical Number: 696235

General information

Name: Zhang Yi

Age: thirteen

Sex: Female

Race: Han

Nationality: China

Address: NO.23, Yunchun Road,

Jiefang Rvenue, Hankou, Hubei. Tel:

85763723 Parents Name: father Zhang Hesheng Mother Yang Chiulian Date of admission: May 8th, 2001 Date of record: 11Am, May 8th, 2001 Complainer of history: patient’s mother Reliability: Reliable

Chief complaint: Pharyngalgia and fever for four days.

Present illness:

The patient felt pharyngalgia and weak about four days ago. She ate some medicine (not clear), but it do nothing. Then she found ulcer in her mouth and fever all along, but she felt no nausea and never vomited. So her parents took her to Wuhan Children’s Hospital, there she received treatment of antibiotics, but her symptoms didn’t abate. So her parents took her to our hospital, she was admitted with a diagnosis of “fever of unknown”

Since onset, her appetite was not good, and both her spiritedness and physical energy are bad. Defecation and urination are normal.

Past history

The patient is healthy before.

No history of “measles” or “pertussis” etc and no contact history with T.B or other infective diseases. No allergy history of food but she was allergy to sulfa.

Personal history

1.Natal: First birth born, uneventfully and on full term with birth weight

2.7 Kg. The state of her at birth was good, no cyanosis, apnea, convulsion or bleeding.

2.Development: Able to raise head at second month. The first tooth erupted at 6th. She began to walk at one. Her intelligence was normal.

3.Nutrition: She was only feeded with breast milk before she was 6 months old. Then the additives were added. She was weaned from the breast at 14th month.

4.Immunization: Inoculated on schedule after birth (such as B.C.G, D.P.T and smallpox voccination).

Physical examination

T 39.5℃, P 120/min, R 30/min, BP 110/90mmHg. She is well developed and moderately nourished. Active position. The skin was not stained yellow. No cyanosis. No pigmentation. No skin eruption. Spider angioma was not seen. No pitting edema. Superficial lymph nodes were found enlarged in her neck, but no flare and tenderness.

Head

Cranium: Hair was black and well distributed. No deformities. No scars. No masses. No tenderness.

Ear: Bilateral auricles were symmetric and of no masses. No discharges were found in external auditory 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 nares flaring. No tenderness in nasal sinuses.

Eye: Bilateral eyelids were not swelling. No ptosis. No entropion. Conjunctiva was not congestive. Sclera was anicteric. Eyeballs were not projected or depressed. Movement was normal. Bilateral pupils were round and equal in size. Direct and indirect pupillary 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 midline.

Chest

Chestwall: Veins could not be seen easily. No subcutaneous emphysema. Intercostal space was neither narrowed nor widened. No tenderness. Thorax: Symmetric bilaterally. No deformities.

Breast: Symmetric bilaterally.

Lungs: Respiratory movement was bilaterally symmetric with the frequency of 30/min. thoracic expansion 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 impulse was in 5th left intercostal space inside of the mid clavicular line and not diffuse. No pericardial friction sound. Border of the heart was normal. Heart sounds were strong and no splitting. Rate 120/min. Cardiac rhythm was regular. No pathological murmurs.

Abdomen: Flat and soft. No bulge or depression. No abdominal wall varicosis. Gastralintestinal type or peristalses were not seen. There was not tenderness and rebound tenderness on abdomen or renal region. Liver was touched 1.5cm under the right costal margin. Spleen was 0.5 cm under the left. No masses. Fluidthrill negative. Shifting dullness negative. Borhorygmus 5/min. No vascular murmurs.

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 exaned

Investigation

Impression: Fever of Unkown

Acute Lymphocyte leukaemia?

Signature: He Lin (95-10033)

第二篇：英文病历对照

住院病历的英汉对照分享 宋丽秀 21:06分享 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:泌尿系统Lumbago frequent micturition urgent micturition urodynia 腰痛 尿频 尿急 尿痛dysuria hematuria nocturia polyuria oliguria facial edema排尿困难 血尿 夜尿 多尿 少尿 面部水肿Hematopoietic system造血系统Fatigue dizziness blurred vision gingival bleedig 乏力 头昏 牙龈出血subcutaneous hemorrhage ostealgia epistaxis 皮下出血 骨痛 鼻衄 Metabolic and endocrine system:代谢及内分泌系统Excessive appetite anorexia sweats cold intolerance 食欲亢进 食欲减退 多汗 畏寒polydipsia tremor hands change of character obvious obesity 多饮 双手震颤 性格改变 显著肥胖emaciation hirsutism hair losing pigmentation 消瘦 多毛 毛发脱落 色素沉着 chang of sexual function amenorrhea 性功能改变 闭经 Musculoskeletal system 肌肉骨骼系统Floating arthralgia arthraliga swelling of joints 游走性关节痛 关节痛 关节红肿deformiteies of jionts myalgia atrophy of muscle 关节变形 肌肉痛 肌肉萎缩 Nervous system神经

系统Dizziness headache vertigo syncope degeneration of memory 头昏 头痛 眩晕 晕厥 记忆力减退visual disturbance insomnia disturbance of consciousness 视力障碍 失眠 意识障碍tremor spasm paralysis paresthesia颤动 抽搐 瘫痪 感觉异常 Personal history:个人史Birthplace Occupation sexual history smoking N Y 出生地 职业 冶游史 吸烟 无 有about years average pieces per day ceased for years 约 年 平均 支/日 戒烟 年alcohol intake N occasional frequent about years 嗜酒 无 偶有 经常 约为 年average ml per day others 平均 ml/日 其他 Marital history:婚姻史：Marrying age companion’s state of health结婚年龄 配偶健康状况Menorrhea and Childbearing:月经及生育史Menarche age cycle lasting for days date of last period 初潮 每次持续时间 末次月经时间(age of menopause)绝经年龄Amount of flow: little normal large menstrual pain: N Y 经量 少 正常 多 痛经 无 有cycle: regular irregular pregnancy times natural labor经期 规则 不规则 妊娠 次 顺产times abortions times premature delivery times 胎 流产 胎 早产 胎stillbirths times difficult labor and its condition死产 胎 难产及病情Familly history (pay attention to the congenital diseases and communicable diseases and communicable dieases related to the paitent家族史 （注意与患者现病有关的遗传病和传染性疾病）Father: still alive illness died cause of deaths mother: 父：健在 患病 已故 死因 母 still alive illness died cause of death siblings: others:健在 患病 已故 死因 兄弟姐妹 子女其他Physical examination体格检查Vital signs生命体征: Temperature体温pulse脉搏 /min次/分 respiration呼吸 /min次/分 B.P血压 mmHgGeneral Appearance一般状况:Development发育: ortho-sthenic type正常 asthenic type不良 sthenic type超常nutrition营养: well良好 fairly中等poor不良 cachexia恶病质Facial features面容: normal无病容 acute急性 chronic慢性病容 others其他Expression表情: natural自知 painful痛苦 anxious忧虑 dreadful恐惧 indifferent淡漠Position: active semi-recumbent others体位： 自主 半卧位 其他Gait: normal abnormal 步态 正常 不正常Conciousness: aware somnolence confusion stupor coma 神志 清楚 嗜睡 模糊 昏睡 昏迷 delirium coppperatio; well badly谵妄 配合检查 合作 不合作Mucocutaneous color: normal red pale cyaosis stainted 皮肤粘膜 色泽 无病容 潮红 苍白 紫绀 yellow pigmentation lesions:N Y (type and distribution)黄染 色素沉着 皮疹 无 有（类型及分布）Subcutaneous hemorrhange: N Y(type and distribution) 皮下出血 无 有（类型及分布）Hair: normal reduced edema: N Y(position and degree)头发分布 正常 减退 水肿 无 有（部位及程度）Hepatic palm:

N Y spider angionma:N Y（position numbers ） others:肝掌 无 有 蜘蛛痣 无有(部位 数目) 其他Lymphnodes:淋巴结Superficial lymph nodes: non-swelling swelling(position and characteristics)全身淋巴结肿大 无肿大 肿大（部位及特征）Head : cranium : size : normal large small deformity: 头部 头颅 大小 正常 大 小 畸形N Y(coxycephaly squared skull deforming skull)无 有（尖颅 方颅 变形颅 ）Others: tenderness mass sunk (position)其他异常：压痛 包块 凹陷（部位）Eyes eyelid: normal edema ptosis trichiasis conjunctive : 眼睑 正常 水肿 下垂 倒睫 结膜normal hyperemia edema hemrrhage正常 充血 水肿 出血 eye ball: normal proptosis depression tremor 眼球 正常 突出 凹陷 震颤 motion dysfunction(left right)运动障碍Sclera :normal yellow cornea : normal abnormal ( left right )巩膜 无黄染 有黄染 角膜 正常 异常 （左 右 ）Pupils: equal roundness same size unequal left cm瞳孔 等圆 等大 不等 左 cm reaction to light: normal delay (left right) disappear (left right) 对光反射 正常 迟钝（左 右） 消失 （左 右）Others:其他Ears: auricle :normal deformity fistula others (left right )耳 耳廓 正常 畸形 瘘管 其他 （左 右）excretions of external auditory canal: N Y (left right feature)外耳道分泌物 无 有（左 右 性质）Tenderness of mastoid : N Y audation dysfunction: N Y (left right)乳突压痛 无 有 听力粗试障碍 无 有（左 右）Nose: shape : normal: abnormal ( ) other abnormalities:N Y 鼻 外形 正常 异常 （ ） 其他异常 无 有Nosalala flap obsruction excretions nasal sinus tenderness: 鼻翼扇动 鼻塞 分泌物 鼻旁窦压痛N Y (position )无 有（部位）Mouth lips :red syanosis pale herpes fissure mucosa :normal口唇 红润 发绀 苍白 疱疹 皲裂 粘膜 正常abnormal ( pale petechia)异常 （苍白 出血点）Opening of parotid gland duct: normal abnormal (swelling 腮腺导管开口 正常 异常 （肿胀suppurative excretions)脓性分泌物）Tongue:normal abnormal (coverings tremor leaning to left or right)舌 正常 异常 （舌苔 伸舌震颤 向左、向右偏斜）Gums: normal swelling pus overflow hemorrhage pigments 牙龈 正常 肿胀 溢脓 出血 色素沉着lead line tooth:regular edentulous carious teeth铅线 牙列 齐 缺牙—|— 龋齿—|—Tonsils: pharynx: voice: normal hoarse扁桃体 咽 声音 正常 嘶哑Neck:resistence:N Y carotid artery pulsation: normal increased 颈部 抵抗感 无 有 颈动脉搏动 正常 增强decreased (left right) jugular vein:normal distention 减弱 （ 左 右 ） 颈静脉 正常 充盈high distention trachea:middle deviation to (left right)怒张 气管 正中 偏移 （向左 向右）Hepatojugular reflux:(-) (+) thyroid: normal swelling degree 肝颈静脉回流征： （

-）（+） 甲状腺 正常 肿大 度 Symmetry 对称Dominance in one side: spreading nodular:soft hard others :N Y 侧为主 弥漫性 结节性 质软 质硬 其他 无 有(tenderness tremor bruits)（压痛 震颤 血管杂音）Chest topography:normal barrel chest pigeon chest funnel chest 胸部 胸廓 正常 桶状胸 鸡胸 漏斗胸flat chest bulging or retraction (left right )扁平胸 膨隆或凹陷 （左 右 ）bulging in the precordial region tenderness of sternum心前区膨隆 胸骨压痛Breast: normal symmetrical abnormal : left right(gynecomastia 乳房 正常对称 异常 左 右（男乳女化mass tenderness excretions of nipples)包块 压痛 乳头分泌物）Lung 肺Inspection : movement of respiration : normal abnormal : left 视诊 呼吸运动 正常 异常 左right( increased decreased)右 （增强 减弱 ）Intercostal space :normal wide narrow(position)肋间隙 正常 增宽 变窄（ 部位 ）Palpation : vocal fremitus:normal abnormal :left right (increased 触诊 ： 语颤 正常 异常 左 右 （增强decreased ) pluernal friction rubs: N Y（position）减弱 胸膜摩擦感： 无 有（部位）Subcutaneous crepitus: N Y(posotion) percussion: resonance 皮下捻发感 无 有（部位） 叩诊 正常清音abnormal dullness flatness hyperresonance tympany异常叩诊音 浊音 实音 过清音 鼓音Lower borders:scapular line: right intercostal space, left 肺下界 肩胛线 右肋间 左intercostal space Range of mobility: right cm , left cm肋间 移动度 右 cm， 左 cmDusculation: breath regular irregular听诊 呼吸 规整 不规整Breath sound: normal abnormal( feature, position )呼吸音 正常 异常 （性质， 部位描写）Rale: N Y ：ronchi: sonorous sibilant啰音：无 有： 干性 鼾音 哨笛音Moist rales: coarse medium fine rales crepitus湿性 大 中 小水泡音 捻发音Vocal conduction: normal abnormal: reduced increased(position)语音传导 正常 异常 减弱 增强 （部位） Plueral friction rubs: N Y (position)胸膜摩擦音 无 有（部位）Heart 心Inspection:bulging in precordial region : N Y apex impulse: 视诊 心前区隆起 无 有 心尖搏动normal unseen increased diffusing position: normal 正常 未见 增强 弥散 心尖搏动位置 正常deviation ( the distance from midclavicular line cm)移动 （距左锁骨中线内外 厘米）Other precordial pulsations: N Y (position)其他部位搏动 无 有（部位）Palpation:apex impulse:normal increased thrust unclear 触诊 心尖搏动 正常 增强 抬举感 触不清thrills :N Y (position period) percardial friction rubs:N Y震颤 无 有（部位 时期 ） 心包摩擦感 无 有Percussion:relative cardiac outline: normal shrink extant (right left )叩诊 相对浊音界 正常 缩小 扩大（右 左 ）Ausculation: heart rate bpm/min rhythm(regular irregular

听诊 心率 次/分 心律 （齐 不齐 ） absolutly irrgelar) heart sound:S1 normal increased decreased 绝对不齐 心音 S1 正常 增强 减弱split S2 normal increased decreased split分裂 S2 正常 增强 减弱 分裂S3 N Y S4 N Y A2 P2S3 无 有 S4 无 有 A2 P2Extra heart sound N gallop (diastolic presystotic summalion 额外心音 无 奔马律（舒张期 收缩前期 重叠gallop) opening snap others murmurs: N Y (degree conduction)开瓣音 其他 杂音 无 有（图示并描述传导）Pericardial friction rubs N Y心包摩擦音 无 有Peripheral vessals: normal pistal shot of big arteries周围血管 无异常血管征 大血管枪击音Duroziez’s sign water hammer pulse capillary pulsation 二重杂音 水冲脉 毛细血管搏动pulse deficit paradoxical pulse pulsus alternans other脉搏短绌 奇脉 交替脉 其他Abdoman 腹部Inspection: shape normal distention frog abdomen( size cm) 视诊 外形 正常 膨隆 蛙腹 （腹围 厘米）scaphoid apical abdomen gastral pattern intestinal pattern舟腹 尖腹 胃型 肠型peristalsis abdominal respiration:existance disappear umbilicus: 蠕动波 腹式呼吸 存在 消失 脐normal protruding excretions others: N Y(venous distention of 正常凸出 分泌物 其他异常 无 有（腹壁静脉曲张abdoman purple striae surgical scars hernia)条纹 手术疤痕 疝）Palpation: soft muscle tension position tenderness N Y 触诊 柔软 腹肌紧张 部位 压痛 无 有rebound tenderness N Y fluidthtill N Y succussions plash N Y反跳痛 无 有 液波震颤 无 有 振水音 无 有Mass N Y(position size) discription of feature liver:can’t be 腹部包块 无 有（部位 大小） 特征描述 肝 未触及 touched can be touched :subcostal cm under xipfoid process可触及 肋下 厘米 剑突下 discription of feature gallbladder: can’t be touched can be touched特征描述 胆囊 未触及 可触及size cm tenderness N Y Murphy’s sign spleen: can’t be 大小 厘米 压痛 无 有 Murphy征 脾 未触及 touched can be touched distance from costal margin cm可触及 肋下 厘米Kideny:can’t be touched can be touched size consistency 肾 未触及 可触及 大小 硬度tenderness mobility tenderness of ureters: N Y (position)压痛 移动度 输尿管压痛点 无 有（部位）percussion: borders of liver dull(existance shrink obliteration )叩诊 肝浊音界 （存在 缩小 消失 ）Upper borders of liver on right midclavicular line intercostal space 肝上界位于右锁骨中线 肋间shifting dullness N Y tenderness in renal region N Y (right left )移动性浊音 无 有 肾区叩痛 无 有（右 左）ausculation : borhorygmus normal increased decreased听诊 肠鸣音 正常 增强 减弱disappear gurgling N Y vessal bruits N Y (position)消失 气过水声 无 有 血管杂音 无 有 （部位）Genitalia :not examined normal abnor

mal Rectum and Anus :生殖器 未查 正常 异常 肛门直肠not examined normal abnormal 未查 正常 异常 Spine and Extremities 脊柱四肢 Spine : normal deformities (lateral anterior posterior protruding)脊柱 正常 畸形 （侧 前 后凸 ）Spinous process : tenderness pain while percussed ( position ) 棘突 压痛 叩痛 （部位）Mobility : normal restricted extremeties: normal abnormal 移动度 正常 受限 四肢 正常 异常deformity swelling of joints joints stiffness 畸形 关节红肿 关节强直 tenderness of muscles atrophy of muscles肌肉压痛 肌肉萎缩Venous distention of lower limbs (position and feature ) acropachy下肢静脉曲张 （部位及特征） 杵状指Nervus System神经系统Abdominal wall reflex ( normal ) muscle tone ( normal )腹壁反射 （正常） 肌张力 （正常）Myodynamia ( degree ) paralysis of limbs N Y (left right 肌力 （ 级 ） 肢体瘫痪 无 有（左 右upper lower) biceps reflex left (normal) right (normal) 上 下 ） 肱二头肌反射 左（正常） 右 （正常 ） knee jerk left (normal) right( normal) achilles jerk left 膝健反射 左（正常） 右 （正常） 跟腱反射 左(normal) right ( normal ) 正常 右 （正常）Hoffmann’s dign left (+)(-) right(+)(-)Hoffmann征 左（+）(-) 右（+）（-）Babinski’s sign left(+)（-） right(+)(-) Babinski 左（+）（-） 右（+）（-）Kernig’s sign left(+)（-）right(+)(-) othersKernig征 左（+）（-） 右（+）（-） 其他Laboratory findings实验室及器械检查结果（The important laboratory examination .X-ray . ECG and other result areincluded） (重要的化验、X线、心电图及其他有关化验) Nunber of X-rayX线片号Abstract病历摘要Diagnosis(impressions)入院诊断Recorder病史记录者Examiner并使审阅者Date of record记录日期