儿科英文病历模板.doc

Medical Records for Admisson Medical Number: 696235 General information Name: Zhang Yi Age: thirteen Sex: Female Race: Han Nationality: China Address: NO.23, Yunchun Road, Jiefang Rvenue, Hankou, Hubei. Tel:Parents Name: father Zhang Hesheng Mother Yang Chiulian Date of admission: May 8th, 2001 Date of record: 11Am, May 8th, 2001 Complainer of history: patient’s mother Reliability: Reliabl Chief complaint: Pharyngalgia and fever for four days. Present illness: The patient felt pharyngalgia and weak about four days ago. She ate some medicine (not clear), but it do nothing. Then she found ulcer in her mouth and fever all along, but she felt no nausea and never vomited. So her parents took her to Wuhan Children’s Hospital, there she received treatment of antibiotics, but her symptoms didn’t abate. So her parents took her to our hospital, she was admitted with a diagnosis of “fever of unknown” Since onset, her appetite was not good, and both her spiritedness and physical energy are bad. Defecation and urination are normal. Past history The patient is healthy before. No history of “measles” or “pertussis” etc and no contact history with T.B or other infective diseases. No allergy history of food but she was allergy to sulfa. Personal history Natal: First birth born, uneventfully and on full term with birth weight 2.7 Kg. The state of her at birth was good, no cyanosis, apnea, convulsion or bleeding. Development: Able to raise head at second month. The first tooth erupted at 6th. She began to walk at one. Her intelligence was normal. Nutrition: She was only feeded with breast milk before she was 6 months old. Then the additives were added. She was weaned from the breast at 14th month. Immunization: Inoculated on schedule after birth (such as B.C.G, D.P.T and smallpox vaccination). Physical examination T 39.5℃, P 120/min, R 30/min, BP 110/90mmHg. She is well developed and moderately nourished. Active position. The skin was not stai