眼科英文病例模板(myself)(可编辑).docx

眼科英文病例模板（ myself ） Medical Records for AdmissonMedical Number: 701721 General information Name: Liu Xiaojing Age:56 Sex: Male Nationality: China Motherland:Chongqing Address: Occupation: worker Marital status: Married Date of admission: Date of record: Complainer of history: himself Reliability: Reliable Chief complaint: Prese nt ill ness: Contain: main symptoms e g. The patie nt felt ?…; 、DM、symptomsfor differential diagnosis e g. without vomiting;examination and therapeutic proceduree g. drugs 、DM、 History of infective diseasee g. hepatitis B,TB ; History of HBP CHD; History of trauma and surgery; Allergy history of food and drugse g. penicillin 、 sulfamide; History of blood transfusion; History of vaccinatione g. he was inoculated according to the national plan Systems review: Head and neck: no history of deaf, tinnitus, vertigo, headache, epistaxis, gum hemorrhage and hoarseness. Respiratory system: No history of respiratory diseaseCirculatory system: No history of precordial pain. Alimentary system: No history of regurgitation. Genitourinary system: No history of genitourinary diseaseHematopoietic system: No history of anemia and mucocutaneous bleedingEndocrine system: No acromegaly. No diabetes mellitusKinetic system: No history of confinement of limbsNeural system: No history of headache or dizziness. Personal history: e g. Hewas born in Chongqing on Nov 19th, 1921 and lived in Chongqing. His living conditions were good. He has never been to malaria, paragonmiasis, and schistosoma prevalent areas. He works as worker, and has college education. He never smokes, drinks, or has any drug abuses.No bad personal habits and customs. Menstrual and Obstetrical history: He is a male patient. Family history: No history of special hereditary disease and infective disease are found in his family. His parents are both healthy. Physical examination T 36.5 °C ,P 80/min,R 20/min, BP 100/60mmHg He is well developed and moderately nourished. Active position. His consciousness