英文病历样本.docVIP

General information Name Age Sex Race Nationality Address Occupation Marital status Date of admission Date of record Complainer of history Reliability: Reliable Chief complaint The patient has a cough producing thick rusty sputum and a high fever that is accompanied by shaking chills. He has a right chest pain when breathing. History of present illness The patient has had a cold after swimming in the cold water recently. He had a cough with thick rusty sputum. He had shaking chills and felt a chest pain on the right side. He saw a doctor. A week after, he thought he was over it and didn’t pay attention to it, went swimming again. Now the condition is more serious. He has a high fever with 39℃ that is accompanied by shaking chills. He has a bad cough with no-blood sputum. When he takes a deep breath, it even hurts. Past medical history The patient is health before. No history of infective disease. No allergy history of food and drugs. No operative history. No disease history in other system. Personal history He was born in XXX on XXXX and almost always lives in XXX. His living conditions were good. No bad personal habits and customs. Menstrual history: He is a male patient. Family history: His parents are both alive. Physical examination General: T P R BP W H. The patient is a well-developed, well-nourished adult male. HEENT: PERRL, EMOI, small oral aperture. Neck: JVP to angle of jaw, 2+ carotid pulses, full range of motion. Cardiac: RRR, normal S1,S2, distant heart sounds. Chest wall: No subcutaneous emphysema. No tenderness. Thorax: Symmetric bilaterally. Breast: Symmetric bilaterally. Lungs: Respiratory movement is bilaterally asymmetric with the frequency of 24/min. We can hear coarse breathing when listening to a portion of the chest with a stethoscope. There are moist rales on bilateral inferior lung. He