三级甲等中病院针灸按摩科病例模板(国外英文资料).docVIP

三级甲等中医院针灸推拿科病例模板 The hospital in the city of xian Academy record The hospital number: 16148 Name: yu wenhai gender: male age: 45-year-old nation: han nationality Birthplace: hubei xiantao career: flexible employment status: married Family (household registration) address and telephone: three groups of CAI bang village, office of the longhua mountain in xiantao city. Telephone:Work unit and telephone: no Medical history and telephone:Morbidity: rain: April 25, 2012 at 9:40 p.m Patient complaint: pain in the left lumbar sacral department, restricted to 13 hours. Hpi: patients in clinical move the chair back pain after the day before, gradually increase, a special posture, slanting buttock claudication cannot lay down, also cannot sitting cannot stand upright. Forced to the semi-squat, the self-serving anti-inflammatory pain the strong pain-fixing tablet was invalid, then the two men helped the doctor, our outpatient clinic with the wrong seam income in the hospital. Hospital disease see: on the left side of the lumbar di ministry pain, limited activity, cant bend over and stand side lower limb weight, walking leg is difficult, to the hip and groin radiation pain worse. The tongue is dark purple, the moss is white, the pulse is tight. Since the beginning of the disease, the spirit, the spirit, the inferior, the sleep difference, the second normal, the weight has no apparent change. History of the past: no surgery, trauma, blood transfusion, history of infectious diseases, drug and food allergy history. Personal history: born local, not to the natural epidemic disease and endemic disease area, flexible employment, flat vegetable life is irregular, likes to sleep late. History of marriage: marriageable, spousal health. Family history: parent body health, no infection, no history of genetic disease. The history of the above medical records has been identified by the presenter, stating that the statement is signed by the presenter: time: 0/0/0/20