大病历模板(英文)

Union Hospital affiliated to Huazhong University of Science and Technology

Admission Record 0000337023

Department: Respiratory Medicine Area:J17 Respiratory Medicine Bed No.109031 Case No. 1565825

Name: HouDeguang Gender:Male Date of Birth:15/9/ 1936Age:78Nationality: China

ID No. 420102************ Ethnicity: Han Occupation: other Marital status: Married

Address: Nanchong，Sichuan Tel No.138********

Source of History: Patient herself Reliability: Reliable

Admission Date & Time: 4/11/2014 14:36

Chief Complaint: Found pleural effusion for about 2 months.

Present Illness: The patient received the chest CT scan in the Wuhan Traditional Medicine Hospital two months ago and found right-side pleural effusion, right-side pulmonary atelectasis. After that,

he was hospitalized in the EndocrinologyDept of our hospital for poor management of blood

glucose level. On this admission, He received the thoracocentesis, and the laboratory

examination results indicated the large possibility of tuberculous pleural effusion. No special

treatment was given at that time. The patient was aware of a sense ofpolypnea after long walk,

without cough, expectoration, night sweats, chest distress, thoracalgia, wheeze, dyspnea and

can lie down to sleep at night. The return-visit in the clinic at October 13th showed that there

were a few pleural effusion on the right side and is hard to be localized. Now the patient came

to our hospital for further treatment and was admitted as “Pleural effusion origin unknown”.

Since the onset of the disease, the patient’s spirit, appetite and sleep are normal. Nocturia for 1

time per night.Stool are as usual. No obvious weight and physical strength change.

Past History: General Health Status: Relatively bad;Respiratory Syste m: Chronic bronchitis for about 10 years;Circulatory System: Hypertension for about 20 years, highest reached 180/95mmHg, took

Amlodipine orally 5mg qd, BP management is good. Diagnosed of coronary heart disease in

2007, underwent intracoronary stent implantation in 2008, 3 stents wereimplanted; Digestive

Systems: None; Urinary System: Benign prostatic hyperplasiafor about 5 years, Diabetic

nephropathy for 3 years; Hematologic System: Thrombocytopeniafor 2 years; Endocrine

System: None. Nervous System: Lacunar infarction in 2011; Motor System:None; Infection

History: No infection of hepatitis and TB. Others: None special;Preventive Inoculation: In

accordance with the stateplan; Operation History:underwent intracoronary stent implantation

in 2008, 3 stents was implantated;Blood Transfusion History: None;Traumatic History:

None;Allergic History: None;

Personal History: Habitual Residence: Hubei; Residential Environment: No exposure history to toxic substances and infected water; Travelling History: None; Smoking History:Smoking for

about 40 years, 3 cigarettes per day. Quit smoking in 2008; Drinking History:Drinking for 40

years, 150g-350g per day, Quit drinking in 2008;

Marital History: Married,

Menstrual History: Male

Family History: Father is deceased, mother is deceased. No other infective and hereditary diseases.

Physical Examination

Vital Signs: T:36.5℃. P:86bpm, regular. R: 20min, regular. BP: 132/74 mmHg. Height: 164cm. Weight: 64kg.

Expression: Normal. Development: Well. Nutritional status: Fairly. Consciousness: Conscious. Spirit: Well. Gait: Normal. Position: Active. Coordination with Examination: Cooperative.

Skin and Lymph Nodes: No jaundice. Some scattered scratch in hands and abdomen,No subcutaneous

bleeding, edema, nodules or unusual pigmentation. Liver palm(-). Spider angioma(-). No

swelling of general superficial lymph nodes.

HEENT(Head, Eye, Ear, Nose, Throat): Normal skull. No baldness, no scars. Eyes: No ptosis. Conjuctiva normal.

The pupils are round, symmetric and responsive to light and accommodation is normal. Ears:

Externally normal. Canals clear. Drums normal. Noses: No abnormalities noted. Month and

Throat: lips red, tongue red, no swelling of tonsils.

Neck: Motion free. Thyroid is not enlarged. No abnormal pulsations. Trachea in middle. Carotid: Pulse is normal.

Hepatojugular reflux sign(-). Vascular bruit: None.

Chest and Lung: Normal contour. Breast normal. Inspection: respiratory movement symmetric and regular.

Palpation: Normal and symmetric. No pleural friction fremitus. Percussion: both sides resonance.

Auscultation: right-side breath sounds weaken, left-side is normal. No moist or dry rales. No pleural friction rubs.

Heart: No protrusion of precordium. Normal apical impulse. No thrill. No enlarged cardiac dullness border. Heart rate:88bpm, rhythm normal. No abnormal and extra cardiac sounds or cardiac murmurs. No peripheral

vascular signs.

Abdomen: Flat abdomen. No gastric or intestinal pattern. No visible peristalsis. Normal bowel sound. No rigidity.

No mass palpable. No tenderness and rebound tenderness. Liver and spleen are not palpable. Kidneys

are not palpable. No percussion tenderness over kidney regions. No shifting dullness.

Rectum: Normal anus and perineum.

Genitourinary System: Normal.

Neural System: Normal.

Extremities: No joint disease. Muscle strength normal. Pathological reflex(-).

Specialty Examination:Right-side breath sounds weaken, left side normal.No moist or dry rales, No swelling of general superficial lymph nodes. No edema in neither lower extremities.

Accessory Examination:Discharge record of Endocrinology Dept. of our hospital at September 2014; Clinic

examination at October 13th: a few pleural effusion on the right side and is hard to be

localized.

History summary: 1. HouDeguang, male, 78 yr.

2. Admitted for ”Found plaural effusion for about 2 months”.

3. T:36.5℃. P:86bpm, regular. R: 20min, regular. BP: 132/74 mmHg. Expression: Normal. Spirit

clear. Cardiac sounds normal, HR: 72 bpm, rhythm normal, No abnormal and extra cardiac sounds

or cardiac murmurs. Right-side breath sounds weaken, left side normal. No moist or dry rales, no

pleural friction rubs. Flat abdomen. No rigidity.

4. Special examination: Trachea in middle. Contour symmetric. Respiratory movement regular.

Right-side breath sounds weaken, left side normal. No moist or dry rales, no pleural friction rubs.

5. Accessory Examination: Discharge record of Endocrinology Dept of our hospital at September

2014; Clinic examination at October 13th: a few pleural effusion on the right side and is hard to be

localized.

6. Past history: Respiratory Syste m: Chronic bronchitis for about 10 years; Circulatory System:

Hypertension for about 20 years, highest reached 180/95mmHg, took Amlodipine orally 5mg qd,

BP management is good. Diagnosed of coronary heart disease in 2007, underwent

intracoronary stent implantation in 2008, 3 stents was implantated; Digestive Systems: None;

Urinary System: Benign prostatic hyperplasiafor about 5 years, Diabetic nephropathy for 3 years;

Hematologic System: Thrombocytopeniafor 2 years; Endocrine System: None. Nervous

System: Lacunar infarction in 2011; Motor System:None; Infection History: No infection of

hepatitis and TB. Others: None special; Preventive Inoculation: In accordance with the stateplan;

Operation History:underwent intracoronary stent implantation in 2008, 3 stents was

implantated;Blood Transfusion History: None; Traumatic History: None; Allergic History:

None;

Impression: 1.Right-side pleural effusion origin unknown: TB? Tumor?

2. II diabetes mellitus, Diabetic nephropathy

3. Hypertension III, high risk

4. Coronary heart disease, post-intracoronary stent implantation

https://www.wendangku.net/doc/8810573336.html,cunar infarction

6.Thrombocytopenia

7.Benign prostatic hyperplasia

Recorder: Cheng Long

Date & Time: 4/11/2014 16:14

Checker: XuJuanjuan

Date & Time:5/11/2014 10:22