传染英文病历模板.docVIP

Medical Record Name: Occupation: Sex: Address: Age: Date of admission: Marital status: Date of record: Native place: Presenter of the case: Race: Dependable degree: History Chief complaint: Tiredness and poor appetite for 20 days, dark urine and yellow eyes for 1 week. History of present illness: The patient had an onset of tiredness and poor appetite without any inducement 20 days ago, accompanying with nausea and vomit for twice. He paid no attention to it and continued to work. One week ago, he had dark urine like thick tea. His eyes and skin became yellow gradually. Then he went to the see a doctor in a local hospital. The “two and a half of viral hepatitis B” showed “HBsAg(+), HBeAg(+), Anti-HBc(+)”, and the liver function showed “ALT 2100 U/L, AST 1893 U/L, ALB 36.5 g/L, GLB 32 g/L, TBIL 182 umol/L, DBIL 102.8 umol/L”. He was admitted with the diagnosis of “chronic viral hepatitis B”. After one-week unknowable treatment, he had little improvement on his symptom, and the dark urine as well as the yellow eyes and skin became more and more serious. Then he left for further diagnosis and treatment in our hospital. Since the onset of his illness, he had no fever or cough, no abdominal pain or diarrhea, no abdominal distension or ankle edema, no lumber pain or dark urine like sauce, no itch of skin or pale feces, no lack bowel movement, no bleeding in nose or gum, no abnormal character or behavior. He had poor mental status and appetite, normal stool, and no obvious tabification. Past History: He had “HBsAg(+)” in 1990, and the liver function was normal every year. No tuberculosis, hypertension, heart attack, nephrosis or diabetes. No operations or injuries. No allergic reaction to food or medicine. Review of system: Respiratory System: No repeatedly pharyngalgia, chronic cough, expectoration, hemoptysis, asthma, dyspnoea or chest pain. Circulatory System:No palpitation, panting after activity, hemoptysis, edema of lower ext