英文病历书写（中英） Medical Records for Admission Medical Number: 701721 Name: Liu Yun Age: Eighty Sex: Male Race: Han Nationality: China Address: NO.35, Dandong Road, Hankou, Hubei. Occupation: Retired Marital status: Married Date of admission: Aug 6th, 2001 Date of record: 11Am, Aug 6th, 2001 Complainer of history: patient’s son and wife Reliability: Reliable Chief complaint: Upper bellyache ten days, haematemesis, hemafecia and unconsciousness for four hours. Present illness: The patient felt upper bellyache about ten days ago. He didn’t pay attention to it and thought he had ate something wrong. At 6 o’clock this morning he fainted and rejected lots of blood and gore. Then hemafecia began. His family sent him to our hospital and received emergent treatment. So the patient was accepted because of “upper gastrointestine hemorrhage and exsanguine shock”. Since the disease coming on, the patient didn’t urinate. Past history The patient is healthy before. No history of infective diseases. No allergy history of food and drugs. Operative history: Never undergoing any operation. Infectious history: No history of severe infectious disease. Allergic history: He was not allergic to penicillin or sulfamide. Respiratory system: No history of respiratory disease. Circulatory system: No history of precordial pain. Alimentary system: No history of regurgitation. Genitourinary system: No history of genitourinary disease. Hematopoietic system: No history of anemia and mucocutaneous bleeding. Endocrine system: No acromegaly. No excessive sweats. Kinetic system: No history of confinement of limbs. Neural system: No history of headache or dizziness. Personal history He was born in Wuhan on Nov 19th, 1921 and almost always lived in Wuhan. His living conditions were good. No bad personal habits and customs. Contraceptive history: Not clear. Family history: His parents have both deads. Physical examination T 36.5℃, P 130/min, R 23/min, BP 100/60mmHg. He is well developed and moderately nourished. Active position. His consciousness was not clear. His face was cadaverous and 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 not found enlarged. Head Cranium: Hair was black and white, 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 23/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 150/min. Cardiac rhythm was not regular. No pathological murmurs. Abdomen: Flat and soft. No bulge or depression. No abdominal wall varicosis. Gastralintestinal type or peristalses were not seen. Tenderness was obvious around the navel and in upper abdoman. There was not rebound tenderness on abdomen or renal region. Liver and spleen was untouched. No masses. Fluidthrill negative. Shifting dullness negative. Borhorygmus not heard. 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 examed Investigation Blood-Rt: Hb 69g/L RBC 2.70T/L WBC 1. 1G/L PLT 120G/L History summary 1. Patient was male, 80 years old 2. Upper bellyache ten days, haematemesis, hemafecia and unconsciousness for four hours. 3. No special past history. 4. Physical examination: T 37.5℃, P 130/min, R 23/min, BP 100/60mmHg Superficial lymph nodes were not found enlarged. No abdominal wall varicosis. Gastralintestinal type or peristalses were not seen. Tenderness was obvious around the navel and in upper abdoman. There was not rebound tenderness on abdomen or renal region. Liver and spleen was untouched. No masses. Fluidthrill negative. Shifting dullness negative. Borhorygmus not heard. No vascular murmurs. No other positive signs. 5. investigation information: Blood-Rt: Hb 69g/L RBC 2.80T/L WBC 1.1G/L PLT 120G/L Impression: upper gastrointestine hemorrhage Exsanguine shock 住院病历 病历号： 701721 名字： 刘云 年龄： 80 性别： 男 民族： 汉 国籍： 中国 地址： 湖北汉口丹东路35号 职业： 退休 婚姻状况： 已婚 入院日期： 2007年8月6日 记录日期： 2007年8月6日上午11点， 病史提供： 病人儿子和妻子 可靠性： 可靠 主 诉：上腹痛10 天，吐血，便血 ，意识丧失4 小时 。 现病史： 病人约10 天前感到上腹痛， 并未引起注意，以为吃错了东西。今晨6时昏迷并且大量呕血，然后开始便血。家人送到我院接受紧急治疗。因“上消化道出血和失血性休克”入院。发病至今病人无尿。 既往史： 病人以前健康。无传染病史。 对食品和药品无过敏史。 手术史： 未经历过任何手术。 感染史：无严重传染病史。 过敏史： 对青霉素或磺胺药无过敏反应。 呼吸系统： 无呼吸道病史。 循环系统： 无心前区疼痛史。 消化系统： 无返流 史。 生殖泌尿系统： 无生殖泌尿系病史。 造血系统： 无贫血及皮肤粘膜出血史。 内分泌系统： 无肢端巨大症 。无过度出汗。 运动系统 ： 无肢体受限史。 神经系统：无头痛或头晕史。 个人史： 1921年11月19日在大同出生并一直住在大同。生活条件尚好，个人无坏习惯和习俗。 避孕史： 不清楚。 家族史： 父母均不在世。 体检 体温36.5 ℃,脉搏 130 /分钟，呼吸23 /分钟，血压 100/60mmHg。发育良好，营养中等。自主体位，意识不清。面色苍白皮肤无黄染。无紫绀 。无色素沉着。无皮疹。未见蜘蛛痣。无凹陷性水肿。表浅淋巴结未发现肿大。 头 颅骨：头发黑白相间，分布良好。无畸形，无伤痕，无肿块，无触痛 。 耳朵：双侧耳廓对称无肿块，外耳道未见排出物。乳突 区无压，听敏度正常。 鼻子：鼻前庭未见异常分泌物。鼻中隔居中，无鼻翼扇动，鼻窦区无压痛。 眼睛：双侧眼睑无肿胀，无眼睑下垂，无睑内翻，结膜无充血，巩膜无黄染。眼球无突出或下陷，运动正常。双侧瞳孔等园， 直接和间接光反应存在。 嘴： 口腔粘膜不光滑，可见溃疡。舌居中。咽充血。扁桃体不肿大。 颈 匀称无畸形，无肿块。气管居中，甲状腺无肿扩大。 胸 胸壁：静脉不易看到，无皮下气肿。肋间隙等宽，无压痛。 胸廓：两侧匀称，无畸形。 乳房：两侧匀称。 肺： 呼吸23次 /分钟，双侧运动频率匀称。双侧扩张及触觉震颤对称。无胸膜摩擦音。叩诊可听到共振，无喘呜无罗音。 心： 心前区无膨胀，无异常脉冲或震颤。最大脉冲点位于锁骨中线第5肋间隙，无传导。无心包摩擦声音。心界正常，心音有力无分裂。心率150 /分钟，律不齐，无病理杂音。 腹部： 平坦柔软，无膨胀或凹陷。腹壁无异常静脉曲张。未见肠型或蠕动。上腹及脐周压痛明显。腹部或肾区无反跳痛。肝脾未触及，无肿块。液波震颤 阴性。移动浊音阴性。无血管杂音。 四肢： 关节无肿胀。四肢运动自如。 神经的系统：生理反射存在，无任病理所见。 生殖系统：未查。 直肠：未查。 实验室检查：血Rt： Hb 69 克/ L RBC 2.70 T/L WBC 1。 1 G/L PLT 120 G/L 历史摘要 1. 病人男性，80岁 2. 上腹痛10 天，呕血,便血，意识丧失4 小时。 3. 无特殊过去史。 4. 体检：体温36.5 ℃,脉搏 130 /分钟，呼吸23 /分钟，血压 100/60mmHg。未发现表浅淋巴结肿大，腹壁无异常静脉曲张。未见肠型或蠕动，上腹及脐周压痛明显，腹部或肾区无反跳痛。肝脾未触及，无肿块。液波震颤 阴性，移动浊音阴性，移动浊音阴性。无血管杂音，无其他阳性征。 5. 实验室信息： 血Rt： Hb 69 g/ L RBC 2.80 T/L WBC 1.1 G/L PLT 120 G/L 印象：上消化道出血 失血性休克