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1、英文病历范文Name（姓名）：zhangsanOccupation（职业）:teacher（教师）Gender（性别）:female（女）Address（通讯地址）：No167,BeilishiRoad,Beijing（mou路167号）ge（年龄）:30yearsold（30岁）Timeadmission（入院日期）:2014-2-1417:00Nationality（民族）:Han（汉）Timerecording（病史采集日期）:2014-2-1417:00Birthplace（出生地）:Beijing（北京）ReIiabiIity（可信度）：ReIiabIe（可靠）Maritalstat
2、us（婚姻状况）：married（已婚）Historyoffer（病史陈述者）：herself（患者本人）Chiefcomplaint（主诉）:Palpitationsfortwentyyearsandchills,fever,dyspneaandedemaoftheankleforhalfamonth心悸持续20年，寒战、发热、呼吸困难及踝部水肿15天Presentillness（现病史）：Abouttwentyyearsago,thepatientsufferedforthefirsttimefrompalpitationswhichoccurredaftershehaddonevigor
3、ousphysicalexercise,andwhichhavebeengraduallyworseningeversince.Tenyearsago,shebegantoexperiencedyspneawhilegoingupstairsordoingwork;therefore,shehadsoughtmedicaltreatment.cardiacmurmurwassubsequentlydiscoveredandadiagnosisofheartdiseasewasgiven,whichwasnottreated.Nevertheless,shehadbeencapableofdoi
4、nglightworkuntilhalfamonthago,whenshecaughtabadcold,whichwasaccompaniedbychills,coughnon-productiveofsputum.Inthelastfewdays,herconditionhasbeenaggravatedbyepigastricdistention,nausea,vomitingandedemaoftheankles;shewasthusunabletoliesupine.Palpitationsanddyspneawerefurtheraggravatedatthesametime.For
5、thisreason,shehadtocometothehospitalfortreatment.患者于20年前因剧烈运动开始出现从心悸症状，并逐渐恶化。于10年前开始出现上楼后及劳累后发作性呼吸困难，因此求医，遂查出心脏杂音，诊断为冠心病心脏病，未做治疗。此后仍可从事轻体力活动。15天前患重感冒，伴寒战、咳嗽无痰。近几日病情加重，出现脱腹胀满、恶心、呕吐和脚踝水肿，不能平卧，心悸和呼吸困难进一步加剧，为求诊治来我院就诊。Inthecourseofherillness,shehashadanorexiaandoliguriawithoutabnormalbowelmotions;shehasn
6、ottakendigoxinoritsequivalent;andshehasnotsufferedfromparoxysmalnocturnalasthma.发病以来，患者食欲下降、少尿，大便通畅。无地高辛类药物服用史。不伴阵发性夜间哮喘。Pasthistory（既往史）:Priormajorillnessandinjuries:shehasoftenhadIaryngalgiaandArthralgiasinceherchildhood.疾病和外伤史：自幼年经常喉痛和关节痛。Prioroperations（手术史）：Noprioroperations（无手术史）。Priorhospital
7、izations（住院史）:Nopriorhospitalizations（无住院史）。Allergies（过敏史）:Nofood,medications,chemicalsallergy（无食物、药物及化学品过敏史）。AgeappropriateimmunizationStatUS（免疫接种史）：Unknown（不详）。Reviewofsystems（系统回顾）：Respiratorysystem:Deniedhemoptysis,asthma,bronchitis,orthopnea,emphysema.呼吸系统：无咯血、哮喘、支气管炎、端坐呼吸和肺气肿。Cardiovascularsys
8、tem:Deniedparoxysmalnocturnaldyspnea,orthopnea,edema,butchestpain,palpitations.心血管系统：无夜间阵发性呼吸困难、端坐呼吸、水肿，有胸痛、心悸。Gastrointestinalsystem:Deniedrectalbleeding,vomitingblood,blacktarrystools,abdominalpain,jaundice,hepatitis,diarrhea,changeinbowelhabits,constipation.消化系统：无直肠出血、吐血、柏油样便、腹痛、黄疸、肝炎、腹泻、排便习惯改变、便
9、秘。Urinarysystem:Deniedpolyuria,dysuria,hematuria,incontinence,urinaryinfections,stones.泌尿系统：无多尿、排尿困难、血尿、尿失禁、尿路感染、尿结石。Hematologicsystem:Deniedanemia,easybruisingorbleeding.血液系统：无贫血、易发瘀斑及出血。Endocrinesystem:Deniedthyroidtrouble,heatorcoldintolerance,excessivesweating,diabetes,excessivethirst,hungerorur
10、ination.内分泌系统：无甲状腺功能异常、恶寒/热、多汗，无糖尿病、口渴、过饥及多尿。Musculoskeletalsystem:Deniedjointpainsorstiffness,arthritis,gout,backpain.Deniedmusclepainsandcramps.肌肉骨骼系统：无关节疼痛或僵硬、关节炎、痛风、背痛。无肌肉疼痛及痉挛。Neurologicalsystem:Deniedseizures,paralysis,localweakness,numbness,tremors,memoryproblems.神经系统：无癫痫发作、肌肉麻痹、局部肢体无力、麻木、震颤及
11、记忆障碍。Personalhistory（个人史）：Currentemployment（从事职业）：WOrker（工人）Useofdrugs（药物史）：Nomedicationsweredailyused（无药物滥用史）Useofalcohol（饮酒史）：Nodrinking（无饮酒史）Useoftobacco（吸烟史）：Nosmoking（无吸烟史）1.evelofeducation（教育背景）：college（本科）Maritalhistory（婚姻史）:Shegotmarriedattheageofnineteen.Herhusbandishealthy,andtheirrelation
12、shipisharmony.19岁结婚，配偶身体健康，夫妻关系和谐。MenstrualhistoryandChildbearinghistory（月经史及孕产史）：Hermenarchebeganwhenshewasfifteenanditwasregular.Ayearafterhermarriage,shenormallydeliveredababyboy,whoisnowtenyearsoldandhealthy.15岁月经初潮，经期正常。婚后1年内产一男婴，现已10岁，身体健康。Familyhistory（家族史）:Healthstatusorcauseofdeathofparents
13、,siblingsandchildren:Allarehealthy.父母、兄弟姐妹和子女健在（或死因无异常）。Specificdiseasesrelatedtoproblemsidentifiedinthechiefcomplaintorhistoryofthepresentillnessand/orsystemreview:None.无与主诉及现病史/系统回顾中相关疾病史（即无心脏病及相关性病史）。Diseasesoffamilymemberswhichmaybehereditaryorplacethepatientatrisk:Nohereditarydiseases.直系家属遗传病史或
14、潜在风险：无家族遗传疾病。Physicalexamination（体格检查）T38P108/minR:24/minBP:12080mmHgNormallydeveloped.Moderatelynourished.Mindclear.Inasemi-sittingposition.Acutelyill-looking,showingdyspnea,slightcyanosisandflushing.Superficiallymphnodesnotpalpable.Nojaundiceonskinorsclera.Pharynxslightlycongested.Necksoftandsuppl
15、e.Tracheainmidline.Nothyroidenlargement,butwithengorgementofjugularveins.Chestnotasymmetrical.Lungsclear.Apexbeatfeltin5thinter-costalspacealongleftmidclavicularline.Heartbeatfluctuatedbetween100/minand108/min,extrasystolesoccurring7-8/min.Arumbling,crescendodiastolicmurmurheardoverapex,ratherlocali
16、zed,andnottransmittedelsewhere.A2equaltoP2.Abdomenflatandsoft.Liverpalpable5cmbelowcostalmarginwithsoftconsistencyandfreefromtenderness.Hepatojugularrefluxpositive.Spleennotfelt.Abdomenfreeofanymassormobiledullness.Notendernessinkidney.Bowelsoundsnotabnormal.Nodeformityofspineorextremities.Markedpit
17、tingedemainlowerextremities.Kneejerkspresent.Nopathologicalreflex.Anusandexternalgenitalianotexamined.发育正常，营养中等，神志清楚，半坐位，急性病面容，呼吸困难，轻度发绡，面部潮红。浅表淋巴结未触及肿大。无巩膜及皮肤黄染。轻度咽部充血。颈软无抵抗。气管居中。甲状腺不大。颈静脉充盈。胸廓对称无畸形。肺部查体未见异常。心尖搏动处位于左锁骨中线第5肋间隙。心率波动在100-108次/分，每分钟早搏7-8次。心尖部可闻及舒张期隆隆样杂音，呈递增性，不传导。主动脉瓣第二心音等于肺动脉瓣第二心音。腹平软，
18、肝肋下5cm可触及，质软，边缘整齐，无压痛。肝颈静脉回流征阳性。脾肋下未及。腹部未触及包块，移动性浊音阴性。肾区无压痛。肠鸣音正常。脊柱及四肢无畸形。双下肢明显指凹性水肿。膝反射存在。病理反射未引出。肛门及外阴未查。1.aboratorydata（实验室检查）:1. ESR15mmh.血沉：15mmh2. ASO200U.抗链球菌溶血素0：200U3. Chestfluoroscopy:Leftatriumandrightventricleenlarged,withprominentpulmonaryartery,andesophagusdisplacedposteriorly,compati
19、blewithdiagnosisofmitralvalveheartdisease.胸片：左心房和右心室扩大，肺动脉段突出，食管后移，符合二尖瓣心脏病病变改变。4. ECGshows:a. ventricularprematurebeatb. widthofP0.12mm.RV1+SV5=1.5Mv心电图：a.室性早搏c. P波增宽，振幅0.12mm.RV1+SV5=1.5MvDiagnosis（诊断）:RheumaticHeartDisease（风湿性心脏病）MitralStenosis（二尖瓣狭窄）RightVentricularEnglargement（右心室增大）HeartFailure（心力衰竭）VentricularPrematureBeat（室性早搏）Signature（签名）Dr.XXXDate（日期）Feb14,2014
