英文病例模版.doc

？为了什么？

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3岁的3360?什么样的？八月？6号？2001年地点：重庆日？什么样的？记录：上午11点？八月？6号？2001年的？3360现状？已婚投诉者？什么样的？3360历史？病人（可靠)地址：重庆渝北黄泥浜龙头金源？tel:酋长？投诉：一个月一个月。

礼物？疾病：在四个月前，病人认为，在长期、渐进地变得更糟，甚至变得更大之后，他会自动放弃阴道，但不会变得更明白。我会在休息后回来，而且不经常性的出现大面积的疼痛，疼痛性的疼痛。无下腹部和腰骶部疼痛，无腹胀和摩擦，白细胞破裂正常。但是不要做那件事。病人对第三个人的行为持怀疑态度（数据不清楚),他被建议不要做手术，但是不要做手术。前一天，病人在医院接受了放射治疗。妇科门诊：阴道前壁阴道投影；宫颈3360低度糜烂，坠入阴道口；子宫体：中位，稍小。所以呢。那个？病人？曾经是。

接受吗？因为什么？" Descensusuteri度，和前沃洛夫切夫吉项目.

从什么时候开始？那个？疾病？来吗？来吧？那个？病人的精神和行为正常，大脑和大脑是自然的。

过去？历史：那个？病人？是吗？健康吗？之前。历史疫苗预防

不清楚，不是吗？历史？她的病人，结核病患者？有传染性吗？疾病。

没有吗？过敏？历史？什么样的？食物？然后呢。毒品。从来没有？经历什么？有吗？操作

或者融合。

系统回顾呼吸？系统3360?没有吗？历史？什么样的？哮喘、咯血、呼吸困难、咳嗽、咳痰和胸痛。

循环系统？系统3360?没有吗？历史？发热、胸痛、呼吸短促、咳嗽、咯血、水肿、晕厥、头晕。

消化道？系统3360?没有吗？历史？什么样的？慢性腹泻和狭窄、无症状性腹泻或高血压、无反流或腹泻、恶心和腹泻、无病史性贫血、黑便和黄疸。

泌尿生殖系统？系统3360?没有吗？历史？什么样的？腰痛、尿频、尿痛、尿痛、排尿困难、尿量减少、血尿、夜尿增多。造血？系统3360?没有吗？历史？什么样的？长期疲劳，头晕，眼花，从来没有牙龈

Endocrine?system:?No?historyofappetitehyperfunction,heatintolerance,

excessivesweeting,polydipsia,chilly.Notrembleoftowhands,changeofmind,remarkableobesityorwasting.

Kinetic?system:?No?history?of?jointpain,numbness,redandswollen,

metallaxis,myalgiaormyophagism.

Neural?system:?No?history?of?long-termheadache,dizzinessandvertigo,

insomnia.Nevercoma.Nodeteriorationofthememory,visualdisorder,disturbanceofconsciousness.Nohistoryofparalysis,hyperspasmiaandabnormalsensation.

Personal?history：He?was?born?inChongqing?and?almost?always?lived?in?Chongqing.

?No?bad?personal?habits?and?customs.Menstrual?history:?Ageofmenarcheis14year，3-5/28-30days,passthemenopauseage46.Maritalhistory：She’smarriedChildbearinghistory：naturallabourtwice,andtheyareheathy.

Family?history:?Shehasdenyedthattherewereanyinfectiousorgeneticdisease.Physical?examination

T?36.8℃,?P?74/min,?R?21/min,?BP?120/70mmHg

Generalcondition：He?is?well?developed?and?moderately?nourished.?Active?position.?

Consciousness?is?clearandwellcooperation.Theanswerswerepertinenttothequestions.Nounusualfacies.Expressionisfreelyandthetreadisnormal.

Skinandmucosa：His?mouthandlipsisnot?cyanosis.Thecolouroftheskinisnormal.No?skin?eruptionandsubcutaneoushemorrhage.?No?pigmentationorjaundice.?Spider?angioma?andliverpalmswas?not?seen.?No?pitting?edema.?

Superficiallymphnodes：Superficial?lymph?nodes?were?not?found?enlarged.

Head:Cranium:?Hair?was?black?and?white,?well?distributed.No?deformities.?No?scars.Nopainwhenwepresson.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:Theappearanceisnormal,aerationiswell.No?abnormal?

discharges?were?found?invetibulum?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?normal.?Tongue?was?in?midline.?Teethandgumswas?normal.?Pharynx?wasnormal.Tonsils?were?not?enlarged.?

Neck:?Symmetric?and?of?no?deformities.Freedomofmovement.?No?masses.

?Arteriopalmuswasnormal.Thyroidwasnot?enlarged.No

vascularaccentuated.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.No?deformities.

Lungs:?inspection：intercostalspaceandrespiratorymovementwerenormal.

palpation：tactilefremitusisnormalandtherewasnosenseofpleuralfriction.

Percussion：Bilateralpercussionsoundsymmetricofresonance.

Auscultation：rhythmicbreathing,breathsoundsvoiceconductionwerenormal.Noraleandpleuralrale.

Heart:??inspection：precordiumisnotprotuberance,thesiteoftheapexbeatandstrengthwerenormal,therewerenounusualbeat.

palpation：thebeatofapexisregularly,andnotrembleorsenseofpericardialfriction.

Percussion：theborderofrelativedullnesswereregularly,asbelow:

RightLeft

2.1cmⅡ4.5cm

2.3cmⅢ6.9cm

2.5cmⅣ8.3cm

Ⅴ9.6cm

Thedistancebetweentheanteriormidlineandleftmid-calvicularlineis10cm

Auscultation：Heartratebeat/min,rhythmoftheheartisshipshape,S1,S2werenormal,S3,S4werenotbeenfound,therewerenoextra-heartsounds、murmurorpericardialfrictionsound.

Pripheralvessels:Pulsewasbeat/min,pulserhythmandthedegreeofstrengthwereregularly.apillarypulsationisnormal.Andtherewerenounusualvascularsigns，pistol-shotsound，Corriganpulseandsoon.

Abdomen:?inspection：bilateralsymmetry,abdominalflatness，bellybuttonandabdominalbreathingwerenormal,andwecann’tfandsubcutaneousvaricosveinofabdominalwall.palpation：thewalloftheabdominalwassoft,notendernessorreboundtenderness,nofluidthrillormass,live,spleen,kidney,cholecystwerenotbeentouched,theuretertendernesspointhasnothavetenderness.

Percussion：theborderoflivedullnesscanbetouched,andthesiteoftheupperboundwasrightmid-calvicularlineofthefifthintercostalspace,noshiftingdullness,nopainwhenrapthekidney.

Auscultation：normalbowelsound，aboutbeat/min,novascularaccentuated.

Anusandgenitalorgan：heexamhasnotdone.(Youcanknowthatinspecialitycheck