入院记录示例(国外英文资料).docVIP

入院记录示例 (the admission record example) Academy record First name: born: Sex: career: Age: admission time: People: record time: Marital status: history statement: Chief complaint: the discontinuous chest is held for 3 years, aggravating 4 hours. Hpi: patients with chest suffocated. Three years ago began to intermittent attacks appear in physical activity, more serious when sweating, without shoulder suppress trapped, shortness of breath, palpitation, dizziness, about 1-4 minutes each time, the rest can ease, every attack several times, did not pay attention to; This morning at 7 to urinate in the process of sudden onset sternum after middle period of sultry, heavy degree, with the left back suppress trapped, YanHei, sweating, dying, no syncope, shortness of breath, cough, hemoptysis, fever, vision and rotated, sublingual including the inefficiency of kyushin pills speed 10, the above symptoms do not ease, for further diagnosis and treatment to the hospital, the outpatient service in coronary heart disease (CHD) admitted to our department, since the patient is sick, poor spirit, sleep, appetite, urine normal. Previous history: the patient had high blood pressure for 13 years, the highest blood pressure 180, 120mmHg? The blood pressure was 140/80mmhg. Type 2 diabetes, the blood lipids anomaly the history of the history 4 years, self-service metformin, riguenet, lovastatin, blood sugar control, and blood lipids are unknown; No history of stroke, no history of infectious diseases such as hepatitis, tuberculosis, vaccination history is unknown, there is no history of surgery, trauma, there is no history of blood transfusion and transfusion of blood products, no food, drug allergies. Personal history: born and live in origin, denied out in recent history, deny that plague, epidemic area and water contact poison, dust, radioactive substances, no alcohol, tobacco, habits, there is no history of play. Marriage history: 24 years old marriage, 2 children 1 female, spouse body ji