原版英语病历.docVIP

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原版英语病历

正宗原版英文病历一份,与大家共勉 Sample History and Physical Note Charting Plus? - Electronic Medical Records converted by require more medical notes / medical records/ medical history/ progressing notes/ medical case/ case report/ admitting notes / dischanrge notes/ case referrence/ 英文病历/ 英语病历 / 病历?please contact medtran@ Note for Jane Doe on 4/8/03 - Chart 2646 Chief Complaint (1/1): This 19 year old female presents today complaining of acne from continually washing area, frequent phone use so the receiver rubs on face and oral contraceptive use. Location: She indicates the problem location is the chin, right temple and left temple locally. Severity: Severity of condition is worsening. Menses: Onset : 13 years old. Interval: 22-27 days. Duration: 4-6 days. Flow: light. Complications: none. Allergies: Patient admits allergies to penicillin resulting in difficulty breathing. Medication History: Patient is currently taking Alesse-28, 20 mcg-0.10 mg tablet usage started on 08/07/2001 medication was prescribed by Obstetrician-Gynecologist A. Past Medical History: Female Reproductive Hx: (+) birth control pill use, Childhood Illnesses: (+) chickenpox, (+) measles. Past Surgical History: No previous surgeries. Family History: Patient admits a family history of anxiety, stress disorder associated with mother. Social History: Patient admits caffeine use She consumes 3-5 servings per day, Patient admits alcohol use Drinking is described as social, Patient admits good diet habits, Patient admits exercising regularly, Patient denies STD history. Review of Systems: Integumentary: (+) periodic reddening of face, (+) acne problems, Allergic / Immunologic: (-) allergic or immunologic symptoms, Constitutional Symptoms: (-) constitutional symptoms such as fever, headache, nausea, dizziness. Physical Exam: Patient is a 19 year old female who appears pleasant, in no apparent distress, her given age, well developed, well nourished and with good attention to hygiene and body habitus. Skin: Exa

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