英文病历标准模版.docVIP

Complete History ? Name:Si Ruihua????????????????? Department:Lumber?electric power bureau Sex: female????????????????????????? Present address: electric power bureau Age:80 years???????????????????????? Date of admission:2003-5-17 Nationality: China xinjiang????????Date of record:2003-5-17 Marital status: be married??????????Reliability:reliable Occupation: family numbers???????History of allergy:deny Chief complaints:??Palpitation and breathlessnss for 1 hour Present illness:??The patient complained of palpitation with no precipitating factors an hour ago , at the same time she still feel breahlessness and precardial pain which didn’t radiated to other parts of body. This discomfort can’t be relieved by take a rest.As couldn’t suffer from that she had to came to hospital for help. In the course of the?illness, he had no syncope, no cough, no headache, no diarrhea and vomiting. Her appetite, sleep, voiding and stool were normal. Past history:??The patient deny the hypertension ,diabetes mellitus,obesity and valvular heart disease history.deny the allegies to pollen,dust medications or food.Deny the surgical procedures and injuries. Review of systems: Respiratory system:??no pharyngalgia; no chromic cough or hemoptysis; no dyspnea and thoracalgia;no afternoon fever or night sweats. Circulatory system:??no palpitation and breathlessness on exertion: no precordial pain, dizziness and persistent headache; no syncope and hypertension. Digestive system:??no sour regurgitation and dysphagia: no chronic abdominal ache, diarrhea and vomiting: no jaundice, hematemesis and melena. Urinary system:??no past history of edema and proteinuria; no pollakiuria; no urgency and painful micturition; no visible hematuria and hypertension. Endocrine and metabolic system:??no irritability, hidrosis or profound fatigue and headache; no impaired vision, exceeding thirsty and polyuria; no excessive hairiness or hair loss; no pigmentation and sexuality change. Hematopoietic system:??no pale